HEDIS/Quality Assurance Reporting Requirements … Assurance Reporting ... (both physical and...

HEDIS/Quality Assurance Reporting

Requirements coding review

Agenda

• What is HEDIS®/Quality Assurance Reporting Review (QARR)?

• Why is coding important for HEDIS/QARR?

• Coding focus topics:

o Adolescent well visits Adult body mass index (BMI)

o Antidepressant medication management

o Breast cancer screening

o Cervical cancer screening

o Childhood and adolescent immunizations: 0 to 2 years of age

o Childhood and adolescent immunizations: 9 to 13 years of age

o Chlamydia screening

o Colorectal screening

o Comprehensive diabetes care: HbA1c testing

o Comprehensive diabetes care: retinal eye exam

o Comprehensive diabetes care: nephropathy screening and urine

microalbumin test

o Comprehensive diabetes care: evidence of treatment for nephropathy

Agenda (cont.)

• Coding focus topics (cont.):

o Controlling high blood pressure

o Diabetes screening for people with schizophrenia or bipolar disorder

o Follow-up after hospitalization for mental illness

o Follow-up care for children prescribed ADHD medication

o Initiation and engagement of alcohol and other drug dependence

treatment

o Medication management for people with asthma

o Prenatal care

o Postpartum care

o Spirometry testing for members with chronic obstructive pulmonary

disease (COPD)

o Viral load suppression

o Weight assessment, counseling for nutrition and counseling for physical

activity

o Well-child visits: 0-15 months

o Well-child visits: 3 to 6 years

What is HEDIS?

Healthcare Effectiveness Data and Information Set:

• HEDIS is a National Committee on Quality Assurance

(NCQA)-developed tool used to measure performance on

important dimensions of care and service.

• More than 90% of America’s health plans use HEDIS.

• HEDIS makes it possible to compare the performance of

health plans on an apples-to-apples basis.

• Measures address a range of health issues and outcomes.

• To ensure the validity of HEDIS results, all of the data is

audited by certified auditors.

• NCQA has a process for evolving the measurement set

each year.

What is QARR?

Quality Assurance Reporting Requirements:

• The New York State Department of Health (NYSDOH)

version of HEDIS

• Set of performance measures that health plans must

report on an annual basis to NYSDOH under

Medicaid Managed Care and Child Health Plus

• Includes performance measures related to many

preventive health services, such as well-care visits,

age-appropriate immunizations, screenings for cancer

and comprehensive diabetes care

• Has many measures in common with HEDIS

Why is coding important for HEDIS and QARR?

• When documented, each measure includes a set of codes that meet the requirements for the measure.

• Codes may be ICD-10, CPT or HCPCS codes.

• Some measures are considered administrative only. This means the data for compliance comes strictly from claim and encounter submission. No medical record review is performed. If services are being performed but the codes are not being submitted on claims or encounters, you will not receive credit.

• In addition, if only some of the services are coded but others are not, you will not have met all the required components of the measure.

Coding focus: Adolescent well visits

Measure description Eligibility for

denominator

Diagnosis coding Procedure

coding

Members ages 12 to 21

years who have had at

least one annual

comprehensive

well-care visit with a

PCP or OB/GYN during

the year

12 to 21 years of

age, must be

enrolled during the

measurement year

Z00.00, Z00.01,

Z00.121, Z00.129

99384, 99385,

99394, 99395,

G0438, G0439

Notes and tips:

• Make sure your medical records reflect all of the following: a health and developmental

history (both physical and mental), a physical exam, health education and anticipatory

guidance.

• Do not include services rendered during an inpatient or emergency department visit, or

that are specific to the assessment or treatment of an acute or chronic condition.

• Sick visits may be missed opportunities for your patient to get health checks; complete

an annual exam during the sick visit.

Coding focus: Adult body mass index (BMI)

Measure

description

Eligibility for

denominator

Diagnosis coding

The percentage of

members 18 to 74

years of age who had

an outpatient visit and

whose BMI was

documented during the

measurement year or

the year prior to the

measurement year

Members younger than

21 must have a height,

weight and BMI

percentile documented

and/or plotted on a BMI

chart

The measurement

year and the year

prior to the

measurement year;

anchor date

December 31 of

measurement year

For members 21 and older:

• Z68.1 (BMI of 19 or less)

• Z68.2 (BMI of 20-29)

• Z68.20 (20.0–20.9)

• Z68.21 (21.0–21.9)

• Z68.22 (22.0–22.9)

• Z68.23 (23.0-23.9)

• Z68.24 (24.0-24.9)

• Z68.25 (25.0-25.9)

• Z68.26 (26.0-26.9)

• Z68.27 (27.0-27.9)

• Z68.28 (28.0-28.9)

• Z68.29 (29.0-29.9)

• Z68.3 (BMI of 30-39)

• Z68.30 (30.0-30.9)

• Z68.31 (31.0-31.9)

• Z68.32 (32.0-32.9)

• Z68.33 (33.0-33.9)

• Z68.34 (34.0-34.9)

• Z68.35 (35.0-35.9)

• Z68.36 (36.0-36.9)

• Z68.37 (37.0-37.9)

• Z68.38 (38.0-38.9)

• Z68.39 (39.0-39.9)

• Z68.4 (BMI of 40 or greater)

• Z68.41 (40.0-44.9)

• Z68.42 (45.0-49.9)

• Z68.43 (50.0-59.9)

• Z68.44 (60.0-69.9)

• Z68.45 (BMI of 70 or greater)

For 19- and 20-year-old members

(in percentiles):

• Z68.51 (less than 5th)

• Z68.52 (5th to less than 85th)

• Z68.53 (85th to less than 95th)

• Z68.54 (greater than or equal to

95th)

Notes and tips:

• Document all discussions about BMI in the medical record, including

documentation of any patient nutritional counseling sessions.

Coding focus: Antidepressant medication management


denominator

Diagnosis coding Procedure coding

Members ages 18

years or older with a

diagnosis of major

depression who were

newly treated with an

antidepressant

medication and

remained on

antidepressant

medication treatment

The measurement year

and the year prior to the

measurement year;

anchor date

December 31 of

measurement year

F32.0-F32.4, F32.9,

F33.0-F33.3, F33.41,

F33.9

Not applicable

Notes and tips:

• Two timelines are required for this measure:

o Effective acute phase treatment — patients newly diagnosed and treated who remained on an

antidepressant medication for at least 84 days (12 weeks)

o Effective continuation phase treatment — members newly diagnosed and treated who remained

on an antidepressant medication for at least 180 days (six months)

• Educate your patients and their caregivers about the importance of complying with long-term medications,

not abruptly stopping medications, contacting you immediately if they experience any unwanted/adverse

reactions.

Coding focus: Breast cancer screening


denominator


The percentage of

women 50 to 74

years of age who

had a mammogram

to screen for breast

cancer

October 1 two years

prior to the

measurement year

through December

31 of the

measurement year

Not applicable 77065, 77066,

77067,

87.36, 87.37,

G0202,

G0204, G0206

Notes and tips:

• The procedure codes for mammography are most often billed by a radiology center or

outpatient hospital location.

• MRIs do not count as primary breast cancer screening.

• Be sure to follow-up with patients after giving a referral for a mammogram to ensure

they follow through with your plan of care.

• Tell your patients to make sure the radiology center or outpatient hospital location sends

a copy of the screening to your office for your records.

Coding focus: Cervical cancer screening


denominator

Diagnosis

coding

Procedure coding

Ages 21 to 64 years:

• At least one cervical

cytology (Pap) test

every three years

Ages 30 to 64:

• Pap test/human

papillomavirus (HPV)

cotesting every five

years

Ages 21 to 64

years and

enrolled during

measurement

year

Z12.4 Pap codes:

88141-88143, 88147, 88148,

88150, 88152-88154,

88164-88167, 88174, 88175,

G0123, G0124, G0141,

G0143-G0145, G0147, G0148

HPV codes:

87623-87625, G0476

Notes and tips:

• Remember to document any history of hysterectomy in your patient’s chart; include details

(complete, total, radical abdominal or vaginal hysterectomy). Also document history of

cervical agenesis or acquired absence of cervix.

• Be sure to keep a copy of the lab results on file.

Coding focus: Childhood and adolescent immunizations: 0 to 2 years of age

DescriptionEligibility for

denominatorImmunization Doses Procedure coding CVX

Members ages

2 years and

younger who

received these

specific

vaccinations by

their 2nd

birthday

Ages 2 years

and younger

and enrolled on

the date of their

2nd birthday

Diphtheria, tetanus and

acellular pertussis (Dtap)4 90698, 90700, 90723

20, 50, 106,

110, 120

Polio (IPV) 3 90698, 90713, 90723 10, 110, 112

Measles, mumps and

rubella (MMR)1 90707, 90710 03, 94

Haemophilus influenza

type B (Hib)3 90647, 90648, 90698, 90748

46-51, 120,

148

Hepatitis B (Hep B) 390723, 90740, 90744, 90747,

9074808, 44, 51, 110

Varicella Zoster (VZV) 1 90710, 90716 21, 94

Pneumococcal Conjugate

(PCV)4 90670 100, 133

Hepatitis A (Hep A) 1 90633 83

Rotavirus 3Two dose = 90681

Three dose = 90680119, 116

Influenza 290655, 90657, 90661, 90662,

90673, 90685, 90687

135, 140, 141,

153, 155, 161,

166

Notes and tips:

• Document any parental refusal, history of anaphylactic reaction or seropositive test

result.

Coding focus: Childhood and adolescent immunizations: 9 to 13 years of age

DescriptionEligibility for

denominatorImmunization Doses Specific age

Procedure

codingCVX

Members ages

9 to 13 who

received these

specific

immunizations

by their 13th

birthday

Ages 9 to 13,

males and

females

Meningococcal 1 11 to 13 90644, 90734 136, 138

Tdap 1 10 to 13 90715 115

HPV 3 9 to 1390649,90650,

9065162, 118, 165

Notes and tips:

• Be sure to document:

o A note indicating the name of the specific antigen and the date of the immunization.

o The certificate of immunization prepared by an authorized health care provider or agency.

o Any parental refusal, history of anaphylactic reaction or seropositive test result.

o The date of the first hepatitis B vaccine given at the hospital and name of the hospital if

available.

Coding focus: Chlamydia screening


denominator


Members who as of

December 31, 2017, are

16 to 24 years of age,

identified as sexually

active and who had at

least one test for

chlamydia in 2015

Must be eligible during

the measurement year

Not applicable 87110, 87270, 87320,

87490, 87491, 87492,

87810

Notes and tips:

• Remember to document any history of hysterectomy in your patient’s chart; include details

(complete, total, radical abdominal or vaginal hysterectomy). Also document history of cervical

agenesis or acquired absence of cervix.


Coding focus: Colorectal screening


denominator

Diagnosis

coding

Procedure coding

The percentage of members 51 to 75

years of age who had one of the

appropriate screenings for colorectal

cancer:

• Fecal occult blood test (FOBT) during


• Flexible sigmoidoscopy during the

measurement year or during the prior

four years

• Colonoscopy during the measurement

year or during the prior nine years

51 to 75 years of age

by

December 31, 2017,

and enrolled in the

measurement year

Not

applicable

Colonoscopy:

44388-44392, 44401-

44408,

45378-45393, 45398,

45399, G0105, G0121

Flex sigmoidoscopy:

45330-45347,45349,

45350, G0104

FOBT:

82270, 82274, G0328

Notes and tips:

• Be sure to follow up with patients after giving a referral for colonoscopy to ensure they follow through

with your plan of care.

• Tell your patients to make sure the service location sends a copy of the screening to your office for your

records.

• Exclusions for this measure include: Evidence of a diagnosis of colorectal cancer on or before

December 31, 2017, or documentation of a total colectomy on or before December 31, 2017.

Coding focus: Comprehensive diabetes care:HbA1c testing

Measure

description

Eligibility for

denominator


Members ages

18 to 75 years with

type 1 or type 2

diabetes with a

HbA1c test once per

year

Must be eligible

during the

measurement year

Not applicable 83036, 83037,

3044F, 3045F, 3046F

Notes and tips:

• For the recommended frequency of testing and screening, refer to the Clinical Practice Guidelines for

diabetes mellitus.

• Educate your patients about the multiple tests needed to properly manage their diabetes.


• Try scheduling your patients to come in for all diabetes care services on the same day.

Coding focus: Comprehensive diabetes care:retinal eye exam

Measure

description

Eligibility for

denominator

Procedure coding

Members ages 18 to

75 years with type 1

or type 2 diabetes

with a dilated eye

exam in current year

or negative exam in

previous year

Must be eligible

during the

measurement year

67028, 67030, 67031, 67036, 67039-67043,

67101, 67105, 67107, 67108, 67110, 67113,

67121, 67141, 67145, 67208, 67210, 67218,

67220, 67221, 67227, 67228, 92002, 92004,

92012, 92014, 92018, 92019, 92134, 92225-

92228, 92230, 92235, 92240, 92250, 92260,

99203-99205, 92213-99215, 99242-99245

Notes and tips:

• Tell your patients to make sure the service location sends a copy of the screening to

your office for your records.

Coding focus: Comprehensive diabetes care:nephropathy screening and urine microalbumin test

Measure

description

Eligibility for

denominator

Diagnosis

coding

Procedure coding

Members ages 18 to

75 years with type 1

or type 2 diabetes

with a nephropathy

screening at least

once per year

Must be eligible

during the

measurement year

Not applicable 82042, 82043, 82044,

84156

Urine microalbumin

codes:

81000-81003, 81005,

3060F-3062F

Notes and tips:

• Be sure to follow up with patients after giving referral for a nephrologist visit to ensure


• Tell your patient to ask the nephrologist to send a visit summary to your office and be

sure to keep a copy on file.

Coding focus: Comprehensive diabetes care: evidence of treatment for nephropathy

Notes and tips:

• Be sure to follow up with patients after giving referral for a nephrologist visit to ensure


• Tell your patient to ask the nephrologist to send a visit summary to your office and be

sure to keep a copy on file.

Measure

description

Eligibility for

denominator

Procedure coding

Members ages

18 to 75 years with

type 1 or type 2

diabetes with

evidence of

treatment for

nephropathy

Must be eligible

during the

measurement year

36800, 36810, 36815, 36818-36821,

36831-36833, 36901-36906, 50300, 50320,

50340, 50360, 50365, 50370, 50380, 90935,

90937, 90940, 90945, 90947,90957-90962,

90965, 90966, 90969, 90970, 90989, 90993,

90997, 90999, 99512

Coding focus: Controlling high blood pressure

Notes and tips:

• Both systolic and diastolic must be below stated value to be considered controlled.

• Most recent BP measurement during the year counts towards compliance.

• Retake BPs over 140/90 during the same visit and document the second reading.


denominator

Diagnosis

coding

Procedure coding

Members ages

18 to 75 years who

have had a diagnosis of

hypertension and whose

blood pressure (BP) is

regularly monitored and

controlled

18 to 85 years and

eligible during the

measurement year

I10 3074F: systolic BP <130

3075F: systolic BP 130-139

3077F: systolic BP > 140

3078F: diastolic BP <80

3079F: diastolic BP 80-89

3080F: > 90

Member age range Blood pressure

18 to 59 years <140/90 mm Hg

60 to 85 years with diabetes <140/90 mm Hg

60 to 85 years without diabetes <150/90 mm Hg

Members whose BP is adequately controlled include:

Coding focus: Diabetes screening for people with schizophrenia or bipolar disorder

Notes and tips:

• Be sure to follow up with patients after giving referral for a psychologist visit to ensure they follow

through with your plan of care.

• Tell your patient to ask the psychiatrist to send a visit summary to your office and be sure to keep a

copy on file.


denominator


The percentage of

members 18 to 64

years of age with

schizophrenia or

bipolar disorder, who

were dispensed an

antipsychotic

medication and had a

diabetes screening

test during the

measurement year

Must be eligible during


Not applicable 80047, 80048, 80050

80053, 80069, 82947

82950, 82951, 83036

83037

3044F, 3045F, 3046F

Coding focus: Follow-up after hospitalization for mental illness

Notes and tips:

• Two timelines are required:

o An outpatient visit, intensive outpatient encounter or partial hospitalization within seven days

of discharge

o An outpatient visit, intensive outpatient encounter or partial hospitalization within 30 days of

discharge

• The date of service on the claim is the date of the face-to-face visit


denominator


Members ages 6 years and

older who were hospitalized

for treatment of select

mental health disorders and

who had an outpatient visit,

intensive outpatient

encounter or partial

hospitalization with a mental

health practitioner

6 years and older and

enrolled for the

measurement year

F03.90, F03.91,

F20.0 – F99

Not applicable

Coding focus: Initiation and engagement of alcohol and other drug dependence treatment

Notes and tips:

• Initiation of treatment refers to the percentage of members diagnosed with alcohol

or other drug dependence and who have initiated treatment within 14 days of being

diagnosed.

• Engagement of treatment refers to the percentage of members who had two

additional alcohol or other drug dependence treatment sessions within 30 days

after initiating treatment.

Measure

description

Eligibility for

denominator

CPT and HCPCS coding

Members ages

13 years and

older for two

indicators

related to

alcohol and

other drug

dependence

treatment

13 years and

older and

enrolled in the

measurement

year

IET visits group 1:

90791, 90792, 90832-90840,

90845, 90847, 90849, 90853,

90875, 90876

IET stand-alone outpatient

visits:

98960-98962, 99078,

99201-99205, 99211-99215,

99217-99220, 99241-99245,

99341-99345, 99344-99350,

99384-99837, 99394-99397,

99401-99404, 99408, 99409,

99411, 99412, 99510

IET visits group 2:

99221-99223, 99231-99233,

99238, 99239, 99251-99255,

G0155, G0176, G0177, G0396,

G0397, G0409, G0443, G0463

H0001, H0002, H0004, H0005,

H0007, H0016, H0020, H0022,

H0031, H0034, H0037, H0039,

H0040, H2000, H2010, H2020,

H2035, H2036, S9475, T1006,

T1012, T1015

Coding focus: Medication management for people with asthma


denominator

Asthma controller medications

Members ages 5 to 64

years old who were

identified as having

persistent asthma, were

dispensed appropriate

medications and

remained on asthma

controller medication

during the treatment

period

5 to 64 years and enrolled

during the measurement

year

Anti-asthmatic

combinations

Dyphylline-guaifenesin

Antibody inhibitors Omalizumab

Inhaled steroid

combinations

Budesonide-formoterol

Fluticasone-formoterol

Mometasone-formterol

Inhaled corticosteroids Beclomethasone

Budesonide

Ciclesonide

Flunisolide

Fluticasone CFC-free

Mometasone

Triamcinolone

Leukotriene modifiers Montelukast

Zafirlukast

Zileuton

Mast cell stabilizers Cromolyn

Methylxanthines Aminophylline

Dyphylline

Theophylline

Coding focus: Medication management for people with asthma (cont.)

Notes and Tips:

For patients with asthma, you should:

• Prescribe controller medication.

• Educate patients in identifying asthma triggers and proper use of controller medications.

• Create an asthma action plan.

• Be aware of what medications are on formulary as well as require prior authorization and/or step

therapy prior to prescribing. Advise your patients to use mail order whenever possible; this will assist

with compliance.

• Remind your patients to get their controller medications filled regularly and to continue taking them

even if they are feeling better and are symptom-free.

Measure description Eligibility for denominator Asthma reliever Medications

Members ages 5 to 64 years

old who were identified as

having persistent asthma,

were dispensed appropriate

medications and remained on

asthma controller medication

during the treatment period

5 to 64 years and enrolled

during the measurement year

Short-acting

inhaled beta-2

agonists

Albuterol,

Levalbuterol,

Pirbuterol,

Coding focus: Prenatal care

Notes and tips:

• The patient must have at least 14 visits for a 40-week pregnancy.

• Make sure your records accurately reflect all prenatal visit dates

• When seeing a PCP for monitoring of a pregnancy, the diagnosis of pregnancy

must be present and a basic physical obstetrical examination or a standard prenatal

care visit must be documented.

Measure

description

Eligibility for

denominator


The percentage of

pregnant members

who received at

least one prenatal

care visit on the

enrollment start

date or within 42

days of enrollment

or within the first

trimester of

pregnancy

Enrolled

during the

measurement

year

• O00-O08 pregnancy with

abortive outcome

• O09 supervision of a

high-risk pregnancy

• O10-O16 edema, proteinuria

and hypertensive disorders

in pregnancy, childbirth and

the puerperium

• O20-O29 other maternal

disorders

• O30-O48 maternal care

related to the fetus

• O94-O9A other obstetric

conditions

Prenatal visits:

59400, 59425, 59426, 59510,

59610, 59618, 99201-99205,

99211-99215 or 99241-99245

with one of the following CPT

II codes: 0500F, 0501F,

0502F, G0463, H1002-H1004,

H1005, T1015

Prenatal ultrasound:

76801, 76805, 76811, 76813,

76815-76821, 76825-76828

Coding focus: Postpartum care

Notes and tips:

• Be sure to document the exact date of the postpartum visit.

• A visit for post cesarean staple removal or incision check does not satisfy the postpartum

requirement. At the time of the visit, remind your patient to return for a postpartum visit within

21-56 days post delivery; if possible, schedule the appointment before the patient leaves your office.

• If you use a global billing code, make sure the postpartum visit date is on the claim.

Measure

description

Eligibility for

denominator


The percentage of

members who had a

postpartum visit on or

between 21 and 56

days after delivery

Enrolled during the

measurement year

Z01.411, Z01.419,

Z01.42, Z30.430,

Z39.1, Z39.2

57170, 58300,

59400, 59410,

59430, 59510,

59515, 59610,

59614, 59618, 59622

99201 with CPT II

code 0503F

G0101

Coding focus: Spirometry testing for members with COPD

Notes and tips:

• Perform a spirometry test for patients who present with dyspnea, chronic cough, increased sputum

production or wheezing.

• To support a COPD diagnosis, perform and document a spirometry test prior to initiating

pharmacotherapy treatment.

• Educate patients about the use of and compliance with both long-term and quick-relief medications,

the proper use of metered inhalers and avoiding elements that trigger attacks.


denominator


Members ages 40

years and older with a

new diagnosis of

COPD or newly active

COPD who received

appropriate spirometry

testing to confirm the

diagnosis

Enrolled during the

measurement year

Chronic bronchitis:

J41.0, J41.1, J41.8,

J42

Emphysema:

J43.0, J43.1, J43.2,

J43.8, J43.9

COPD:

J44.0, J44.1, J44.9

94010,

94014-94016,

94070, 94375, 94620

Coding focus: Viral load suppression

Notes and tips:

• Preschedule the next follow-up appointment while the patient is still in your office and make a

reminder call prior to the appointment.


This measure is unique in that health plans do not report the data; instead the AIDS

Institute and the Office of Quality and Patient Safety will calculate the performance in

this measure using the laboratory testing data captured in the NYSDOH HIV

Surveillance System.

• It is important to make sure patients with HIV keep their follow-up appointments and

complete a viral load screening at least every six months or twice in one calendar

year.

• Regular testing helps identify any needs for changes in a patient’s medication

regimen or helps determine if he or she is complying with treatment plans.

• Reaching viral load suppression can help your patients to live healthier, longer lives

and reduce the risk of transmitting the virus to others.

• For more information on viral load suppression and HIV treatment guidelines, please

visit the NYSDOH AIDS Institute website at https://www.hivtrainingny.org

Coding focus: Weight assessment, counseling for nutrition and counseling for physical activity

Notes and tips:

• Remember a nutritional evaluation and anticipatory guidance are required as

part of the routine health check visit.

• Document any advice you give the patient and/or their caregivers.


denominator

Diagnosis coding Procedure

coding

Nutrition The percentage of members 3 to 17

years of age who had an outpatient

visit with a PCP or OB/GYN and who

had counseling for nutrition during the

measurement year

Must be eligible

during the

measurement

year

Z71.3 97802,

97803,

97804

BMI The percentage of members 3 to 17



had a BMI percentile documented


Must be eligible

during the

measurement

year

Z68.51, Z68.52, Z68.53,

Z68.54

Not

applicable

Physical

activity

The percentage of members 3 to 17



had counseling for physical activity


Must be eligible

during the

measurement

year

Z71.9

This is a miscellaneous

code; therefore, you must

document counseling

specific to physical

activity. Do not document

solely for sports activity

Not

applicable

Coding focus: Well-child visits: 0 to 15 months

Notes and tips:

• The PCP of record will be the PCP as of the date the child turns 15 months old.

• If the dates of service are less than 14 days apart, only one will count for this measure.

• Confirm that your medical record reflects all of the following: five or more visits with a PCP completed

at least two weeks apart, a medical history, physical and mental developmental histories, a physical

exam, health education, and anticipatory guidance.

• Sick visits may be missed opportunities for your patient to get health checks; complete an annual

exam during the sick visit and code with appropriate ICD-10 codes.


denominator

Diagnosis

coding

Procedure

coding

Children turning 15 months

old in 2017 who have five

visits with one of the listed

CPT codes or one of the

listed ICD-10 codes during

their first 15 months of life

with a PCP

31 days to 15

months of age;

enrolled at 15

months

Z00.110,

Z00.111, Z00.121, Z00.129

99381, 99382,

99391, 99392,

99461

G0438, G0439

Coding focus: Well-child visits 3 to 6 years

Notes and tips:

• Make sure your medical records reflect all of the following: a note indicating a visit to a

PCP, the date the well-child visit occurred, physical and mental developmental histories,

a physical exam, health education, and anticipatory guidance.

• Sick visits may be missed opportunities for your patient to get health checks; complete

an annual exam during the sick visit.

Measure

description

Eligibility for

denominator


Members ages 3 to 6

years who had one

or more

comprehensive

well-child visits with a

PCP during the year

3 to 6 years of age,

enrolled during the

measurement year

Z00.121, Z00.129,

Z00.8, Z02.0

99382, 99383, 99384,

99392, 99393, 99394,

G0438, G0439

Legal notice

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 state/provider 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 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 2017 technical specifications and

is subject to change based on guidance given by the National Committee for

Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services

(CMS) and state recommendations. Please refer to the appropriate agency for

additional guidance.

Thank you

www.empireblue.com/nymedicaiddocEmpire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue

Cross and Blue Shield Association.

NYEPEC-1125-17 September 2017

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