Post on 18-Jul-2020
HEDIS 101 forproviders 2019 improving quality of care
TNPEC-2878-19 September 2019
2
Topics covered
HIPAA 3
What is HEDISreg 4
What is your role in HEDIS 6
Annual HEDIS calendar 7
Types of reviews 8
Medical record request 9
Hybrid and administrative HEDIS measures 10-11
Questions and answers 12
Appendix oneA HEDIS hybrid measures and required documentationB HEDIS administrative measures
14-3637-47
Appendix two mdash HEDIS Physician Documentation Guidelines and Administrative Codes
48-49
Appendix three mdash survey data 50-54
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)
bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization
bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers
bull All of our health plan providersrsquo records are protected by this law
3
Health Insurance Portability and Accountability Act (HIPAA)
HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities
bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service
bull HEDIS is a retrospective review of services and performance of care
bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)
bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year
bull A subset of HEDIS measures is collected and reported for the Marketplace product lines
4
What is HEDIS
HEDIS (HĒ DIS)
Healthcare
Effectiveness
Data and
Information
Set
bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided
bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported
bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members
bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards
5
HEDIS results
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
2
Topics covered
HIPAA 3
What is HEDISreg 4
What is your role in HEDIS 6
Annual HEDIS calendar 7
Types of reviews 8
Medical record request 9
Hybrid and administrative HEDIS measures 10-11
Questions and answers 12
Appendix oneA HEDIS hybrid measures and required documentationB HEDIS administrative measures
14-3637-47
Appendix two mdash HEDIS Physician Documentation Guidelines and Administrative Codes
48-49
Appendix three mdash survey data 50-54
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)
bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization
bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers
bull All of our health plan providersrsquo records are protected by this law
3
Health Insurance Portability and Accountability Act (HIPAA)
HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities
bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service
bull HEDIS is a retrospective review of services and performance of care
bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)
bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year
bull A subset of HEDIS measures is collected and reported for the Marketplace product lines
4
What is HEDIS
HEDIS (HĒ DIS)
Healthcare
Effectiveness
Data and
Information
Set
bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided
bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported
bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members
bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards
5
HEDIS results
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization
bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers
bull All of our health plan providersrsquo records are protected by this law
3
Health Insurance Portability and Accountability Act (HIPAA)
HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities
bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service
bull HEDIS is a retrospective review of services and performance of care
bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)
bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year
bull A subset of HEDIS measures is collected and reported for the Marketplace product lines
4
What is HEDIS
HEDIS (HĒ DIS)
Healthcare
Effectiveness
Data and
Information
Set
bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided
bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported
bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members
bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards
5
HEDIS results
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service
bull HEDIS is a retrospective review of services and performance of care
bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)
bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year
bull A subset of HEDIS measures is collected and reported for the Marketplace product lines
4
What is HEDIS
HEDIS (HĒ DIS)
Healthcare
Effectiveness
Data and
Information
Set
bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided
bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported
bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members
bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards
5
HEDIS results
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided
bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported
bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members
bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards
5
HEDIS results
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull You play a central role in promoting the health of our members
bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned
members for your practice and scheduling annual well exams
o Providing the appropriate care within designated time frames
o Documenting all care in member medical recordso Accurately coding all claims
(Providing accurate information on a claim may reduce the number of records requested)
o Responding to our requests for medical records within five to seven business days
6
What is your role in HEDIS
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide during this process help us validate the quality of care provided to our members
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
7
Annual HEDIS calendar
January-May
Clinical Quality staff initiates medical record requests and collection from providers
June
Results are reported to NCQA
July-October
NCQA releases Quality Compassreg results nationwide
Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption
Quality Compassreg is a registered trademark of NCQA
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider
EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys
bull New for 2019 HEDIS Electronic Clinical Data System reporting
o Depression Screening and Follow-Up for Adolescents and Adults (DSF)
o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)
o Depression Remission or Response for Adolescents and Adults (DRR)
o Unhealthy Alcohol Use Screening and Follow-Up (ASF)
o Adult Immunization Status (AIS)
o Prenatal Immunization Status (PRS)
8
Types of reviews
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull Medical record requests are sent to providers
bull The request includes a member list identifying their assigned measures and the minimum information needed
bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site
9
Medical record requests
Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated
We recommend uploading records to our secure site to allow for better tracking of submitted information
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
10
Hybrid HEDIS measures
ABA Adult BMI Assessment IMA Immunizations for Adolescents
ADL Adolescent Preventive Care LSC Lead Screening in Children
AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)
CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care
CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)
CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life
COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)
W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
COL Colorectal Cancer Screening
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
11
Administrative HEDIS measures
AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis
FUH Follow‐Up After Hospitalization for MentalIllness
ADDFollow-Up Care for Children Prescribed ADHD Medication
IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment
AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain
ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With
Asthma
OMW Osteoporosis Management in WomenWho Had a Fracture SSD
Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request
bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office
bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation
bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)
bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg
12
Questions and answers
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
Appendix oneA HEDIS hybrid measures and required documentation
B HEDIS administrative measures
13
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
Appendix one section A
HEDIS hybrid measures and required documentation
14
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
15
ABA mdash Adult BMI Assessment
Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height
weight and BMI percentile on the date of visit
Common chart deficiencies
bull Height andor weight are documented but there is no calculation of the BMI
bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
16
ADL mdash Adolescent Preventive Care
Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year
Applicable forNew York Quality Assurance Reporting Requirements (QARR)
Documentation needed
bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions
bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)
Common chart deficiencies
bull No documentation in chartbull Not all items addressed during the visit
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
17
AWC mdash Adolescent Well-Care Visits
Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Adolescents being seen for sick visits and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
18
CBP mdash Controlling High Blood Pressure
Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)
Applicable forMedicareMedicaidCommercial
Documentation needed
1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)
2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs
Common chart deficiencies
bull Rechecked elevated pressures during the same visit
not documented
bull Diagnosis date of hypertension is not clearly
documented
Special notes
bull Diagnosis can be from progress note problem list
consult note hospital admission or discharge
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
19
CCS mdash Cervical Cancer Screening
Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test
Applicable forMedicaid Commercial
Documentation needed (one of the following)
bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test
and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix
Common chart deficiencies
bull Lack of documentation related to womenrsquos health in PCP charts
bull Incomplete documentation related to hysterectomy
bull HPVs ordered due to positive Pap tests do not count
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
20
CDC mdash Comprehensive Diabetes Care
Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year
Applicable forMedicareMedicaidCommercial
Documentation needed
bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription
or visits to nephrologists during the measurement year
bull Dilated retinal eye exam (during the measurement year or year prior)
Date and result of last screening in the measurement year
Common chart deficiencies
bull Incomplete information from consultants in the PCP charts
bull Incomplete information related to yearly lab testing and results
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
21
CIS ndash Childhood Immunization Status
Required immunizations
4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)
3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)
2 or 3 RotavirusRV
Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)
2 each Influenza
1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Documentation needed
Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
22
CIS mdash Childhood Immunization Status (cont)
Percentage of children two years of age who had all of the required immunizations
Applicable forMedicaidCommercial
Common chart deficiencies
bull Immunizations received after the second birthday
bull Incomplete number of vaccines administered according to the recommended vaccine series
bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital
at birthbull No documentation of contraindicationsallergies
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
23
COA mdash Care of Older Adults
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Advance care planning bull Includes a discussion about preferences for
resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker
Medication reviewbull Includes at least one medication review
conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
24
COA mdash Care of Older Adults (cont)
Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status
assessmentbull Pain assessment
Applicable forMedicare SNPMMP
Documentation needed
Functional status assessmentbull Includes evidence of at least one functional
status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status
assessment toolo Notation that at least three of the four
following were assessed notation of functional independence sensory ability cognitive status and ambulatory status
Pain assessmentbull Includes evidence of a pain assessment using a
standardized pain assessment tool and the date it was performed
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
25
COL mdash Colorectal Cancer Screening
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Documentation needed
Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in
measurement year) o FOBT tests performed in an office setting or
on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka
Cologuardreg) test (within last 3 years)
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
26
COL mdash Colorectal Cancer Screening (cont)
Members 50-75 years of age who had appropriate screening for colorectal cancer
Applicable forMedicareCommercial
Common chart deficiencies
bull Colorectal screenings are not consistently documented in health histories
bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions
Special notes
bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
27
IMA mdash Immunizations for Adolescents
Adolescent members turning 13 years of age in the measurement year who had these immunizations
Applicable forMedicaid Commercial
Documentation needed
bull Meningococcal one dose on or between 11th and 13th birthdays
bull Tdap one dose on or between 10th and 13th
birthdaysbull HPV 2-dose or 3-dose vaccine series
administered between 9th and 13th birthdaysbull If immunizations are missing please include
o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies
Common chart deficiencies
bull Immunizations not administered during appropriate timeframes
bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
28
LSC mdash Lead Screening in Children
Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday
Applicable forMedicaidNew York QARR
Documentation needed
bull A note indicating the date the test was performed
bull Result or finding
Common chart deficiencies
bull Lead assessment does not constitute a lead screening
bull Testing conducted outside of time framebull Provider assumes that there is no exposure due
to environment
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
29
MRP mdash Medication Reconciliation Post-Discharge
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge
bull Need documentation that it was completed and the date that it was done
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
30
MRP mdash Medication Reconciliation Post-Discharge (cont)
Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge
Applicable forMedicare
Documentation needed
Any of the following evidence meets criteria bull Notation that the medications prescribed upon
discharge were reconciled with the current medications in the outpatient record
bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications
bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for
post-discharge hospital follow-up with evidence of medication reconciliation or review
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
31
PPC mdash Prenatal and Postpartum Care
Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year
Applicable forMedicaid Commercial
Documentation needed
bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester
bull Postpartum care Postpartum visit within 21-56 days of delivery
Common chart deficiencies
bull Incision check for post C-section alone does not constitute a postpartum visit
bull Office visit outside of time frame
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
32
TRC mdash Transitions of Care
Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year
Four rates are reportedbull Notification of Inpatient
Admissionbull Receipt of Discharge
Informationbull Patient Engagement after
Inpatient Dischargebull Medication Reconciliation
Post-Discharge
Applicable forMedicare (new for 2018)
Documentation needed
bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day
bull Documentation of receipt of discharge information on the day of discharge or the following day
bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge
bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
33
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Documentation needed
BMI (body mass index) percentile bull BMI percentile and date
o Note BMI values ranges and thresholds do not meet the criteria for this measure
bull Weight and datebull Height and date
Counseling for nutrition bull Discussion on diet and nutrition anticipatory
guidance or counseling on nutrition
Counseling for physical activity bull Discussion of current physical activities
counseling for increased activity or anticipatory guidance on physical activity
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
34
WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)
Members 3-17 years of age who had an outpatient visit with the following components in the measurement year
Applicable forMedicaidCommercial
Common chart deficiencies
bull BMI documented as number not percentile based on height weight age and gender
bull BMI growth chart not included in records submitted
bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations
bull Developmental milestones do not constitute anticipatory guidance or education for physical activity
bull Preprinted forms do not always address nutrition and physical activity
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
35
W15 mdash Well-Child Visits in the First 15 Months of Life
Children who turned 15 months of age during the measurement year who had 0-6 well-child visits
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
36
W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life
Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year
Applicable forMedicaidCommercial
Documentation needed
bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance
Common chart deficiencies
bull Lack of documentation of education and anticipatory guidance
bull Children being seen for sick visits only and no documentation related to well-child visits
Special notes
bull Preventive services may be rendered on visits other than well-child visits
bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
Appendix one section B
HEDIS administrative measures
37
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
38
AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Applicable forMedicaidCommercial
Details
Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the
measurement year) the intake period captures eligible episodes of treatment
bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis
This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
39
AMM mdash Antidepressant Medication Management
Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull Effective Acute Phase Treatment the percentage
of members who remained on an antidepressant medication for at least 84 days (12 weeks)
bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
40
ADD mdash Follow-Up Care for Children Prescribed ADHD Medication
Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)
Applicable forMedicaidCommercial
Details
Two rates are reportedbull Initiation phase received at least one follow-up
visit with a practitioner with prescribing authority within 30 days of prescription
bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
41
ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)
Applicable forCommercial Medicaid Medicare
Details
Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year
There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
42
FUH mdash Follow-Up After Hospitalization for Mental Illness
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner
Applicable forMedicareMedicaidCommercial
Details
Two rates are reportedbull The percentage of discharges for which the
member received follow-up within 30 days of discharge
bull The percentage of discharges for which the member received follow-up within 7 days of discharge
Do not include visits that occur on the date of discharge
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
43
IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
Members 13 years of age and older as of December 31 of the measurement year
Applicable forMedicareMedicaidCommercial
Details
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of
members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis
bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
44
LBP mdash Use of Imaging Studies for Low Back Pain
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis
Applicable forMedicaidCommercial
Details
bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain
bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain
bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
45
MMA mdash Medication Management for People With Asthma
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
Applicable forMedicaidCommercial
Details
Two rates are reportedbull The percentage of members who remained on an
asthma controller medication for at least 50 of their treatment period
bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
46
OMW mdash Osteoporosis Management in Women Who Had a Fracture
The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture
Applicable forMedicare
Details
Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture
Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge
Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture
For direct transfers the first admission date should be used when determining the number of days prior to the IESD
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
47
SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year
Applicable forMedicaid
Details
bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding
bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
Appendix two
HEDIS Physician Documentation Guidelines and Administrative Codes
48
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull This document is located on our provider website (httpsprovidersamerigroupcomTN)
bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements
49
HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
Appendix three
Survey data
50
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
The following are used to collect data
bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations
o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS
bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations
bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
51
Survey data
CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans
bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans
bull Health plans report survey results to NCQA which uses the results to
o Make accreditation decisions
o Rate health plans
o Create national benchmarks for care and service
bull Health plans also use CAHPS survey data for internal quality improvement purposes
52
CAHPS surveys
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
53
CAHPS Health Plan Survey 50 H mdashAdult Version
Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health
care2 Rating of health plan
overall3 Rating of personal
doctor4 Rating of specialist
seen most often
Composite scores also summarize responses for these key areas
1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)
There are two areas that are reported individually
bull Health promotion and educationbull Coordination of care
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
The survey for children with chronic conditions produces the following measures for this population
bull Access to prescription medicines
bull Access to specialized services
bull Family-centered care
bull Having a personal doctor or nurse who knows the child
bull Shared decision making
bull Getting needed information
bull Coordination of care and services
54
CAHPSreg Health Plan Survey for Children with Chronic Conditions Version
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
55
Medicare Health Outcomes Survey
Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected
The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance
56
Thank you
The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance