Introduction to HEDIS 2016 - Gold Coast Health Plan · Reporting HEDIS® Rates • HEDIS® measures...
Transcript of Introduction to HEDIS 2016 - Gold Coast Health Plan · Reporting HEDIS® Rates • HEDIS® measures...
Introduction to HEDIS® 2016
Presented by the Quality Improvement Department at
Gold Coast Health Plan
Ventura County’s Medi-Cal Managed Care Plan
Serving Ventura County since July 1, 2011
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Contents
I. What is HEDIS®?
II. HEDIS® Measures GCHP Reports
III. HEDIS® Measure Definitions
III. Reasons for Low HEDIS® Rates
IV. How to Improve your HEDIS® Rates
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What is HEDIS®?
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What is HEDIS®?
HEDIS® is a standardized set of
performance measures called Healthcare
Effectiveness Data Information Set which
are developed and maintained by the
National Committee for Quality Assurance
(NCQA).
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Who participates in HEDIS®?
• Over 90% of America’s health plans (Medicare,
Medicaid, and commercial) participate in
HEDIS® quality reviews.
• California’s Medi-Cal Managed Care Plans are
mandated by the Department of Health Care
Services (DHCS) to report HEDIS® measures
annually.
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Purpose of HEDIS®
• Health Plans use HEDIS® reviews to:
►Evaluate quality of care and services provided to health plan members
►Evaluate accessibility of care
►Develop performance improvement initiatives
►Perform outreach to providers and members
►Compare performance with other health plans
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Reporting HEDIS® Rates
• HEDIS® measures evaluate the previous year’s clinical
data.
– For example, most HEDIS® rates reported in 2016 are based on
clinical services performed in 2015.
– Some measures, such as Cervical Cancer Screening, look for
services performed up to 5 years prior to the reporting year.
• Results of HEDIS® reviews are reported to DHCS and
NCQA in June each year.
• GCHP distributes HEDIS® Provider Report Cards in
June & July.
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HEDIS® Timeline Month HEDIS® Meetings HEDIS ®
Training Data
Integration Runs
HEDIS ® Audit
Activity
Medical Record
Retrieval
Medical Record Review
HEDIS ® Submissions
Measure Improvement
Projects
September X X X
October X X Q3 Run X X
November X X X X
December X X X X
January X X Q4 Run X Roadmap X
February X X X X X X
March X X X X Convenience Samples
X
April X Q1 Run X X X Preliminary Rates
X
May X X X X Medical Record Review
Validations
X
June X X Final Rates X
July X Q2 Run Audit Results
X
August X X
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What does HEDIS® measure? HEDIS® consists of 88 measures across the following 7 domains of care:
1. Effectiveness of Care
2. Access/Availability of Care
3. Experience of Care
4. Utilization and Risk Adjusted Utilization • NCQA combined “Utilization” with “Risk Adjusted Utilization” in 2015.
5. Relative Resource Use • NCQA removed the “Utilization” measures from this domain in 2015. Previously this domain
was titled “Utilization and Relative Resource Use”.
6. Health Plan Descriptive Information
7. Measures Collected Using Electronic Clinical Data Systems • New domain added by NCQA in 2015.
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Clinical Data Reviewed for HEDIS®
Reporting • Claims data
• Encounter data
• Pharmacy data
• Medical records
• Member data
• Provider data
• Supplemental clinic data such as: • Lab
• Vision
• Immunization
• Electronic medical records
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Two Types of Measures
►Hybrid measures ►Population size reviewed: Sample size of up to 411 eligible members
randomly selected
►Requires reviewing claims, encounter, and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.).
►Requires reviewing medical record documentation to validate if members received the service or care being measured.
►Admin measures ►Population size reviewed: Entire eligible population
►Requires reviewing only claims, encounter and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.).
►No medical record reviews required.
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HEDIS® Measures GCHP Reports
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HEDIS® Measure Type of Measure Domain Sub-Domain
1 Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents
Hybrid Effectiveness of Care Prevention & Screening
2 Childhood Immunization Status Hybrid Effectiveness of Care Prevention & Screening
3 Immunizations for Adolescents Hybrid Effectiveness of Care Prevention & Screening
4 Cervical Cancer Screening Hybrid Effectiveness of Care Prevention & Screening
5 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Admin Effectiveness of Care Overuse/Appropriateness
6 Use of Imaging Studies for Low Back Pain Admin Effectiveness of Care Overuse/Appropriateness
7 Medication Management for People with Asthma Admin Effectiveness of Care Respiratory Conditions
8 Controlling High Blood Pressure Hybrid Effectiveness of Care Cardiovascular
9 Comprehensive Diabetes Care Hybrid Effectiveness of Care Diabetes
10 Annual Monitoring for Patients on Persistent Medications
Admin Effectiveness of Care Medication Management
11 Children & Adolescent Access to PCPs Admin Access & Availability of Care Access & Availability of Care
12 Prenatal & Postpartum Care Hybrid Access & Availability of Care Access & Availability of Care
13 Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life Hybrid Utilization & Risk Adjusted Utilization
Utilization
14 Ambulatory Care Admin Utilization & Risk Adjusted Utilization
Utilization
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HEDIS® Measure Definitions
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Domain: Effectiveness of Care
Sub-Domain: Prevention & Screening
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Weight Assessment & Counseling for Nutrition & Physical Activity in Children & Adolescents (WCC)
• The percentage of 3 to 17 year old children and adolescents who had an outpatient visit with a PCP or OB/GYN and who received ALL of the following three services during the 2015 measurement year:
► BMI percentile assessment
► Counseling for nutrition
► Counseling for physical activity
• Three separate rates are reported for each service
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Medical records
• Hybrid Measure
• NCQA’s Changes to the WCC Measure in 2015
► Documentation of BMI value for adolescents aged 16-17 is no longer accepted – BMI percentile must be documented
► Documentation of anticipatory guidance related to safety (e.g. wears helmet or water safety) without specific mention to physical activity recommendations no longer meets criteria for counseling for physical activity.
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Codes to Identify WCC
Description ICD-9-CM
Diagnosis
ICD-10-CM
Diagnosis
CPT HCPCS UB Revenue
BMI Percentile, Pediatric <5% V85.51 Z68.51
BMI Percentile, Pediatric 5% to
<85%
V85.52 Z68.52
BMI Percentile, Pediatric 85% to
<95%
V85.53 Z68.53
BMI Percentile, Pediatric ≥ 95% V85.54 Z68.54
Counseling for Nutrition V65.3 Z71.3 97802-97804 G0270-G0271,
G0447, S9449,
S9452, S9470,
S9449
Counseling for Physical Activity V65.41 G0447, S9451
Outpatient Visits 99201-99205, 99211- 99215,
99241-99245, 99341-99345,
99347-99350, 99381-99387,
99391-99397, 99401-99404,
99411-99412, 99420, 99429,
99455-99456
G0402, G4038,
G4039, G0463,
T1015
0510-0523,
0526-0529,
0982-0983
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Childhood Immunization Status (CIS) • The percentage of 2-year old children who had the following childhood immunizations
between 42 days after birth and on or before their 2nd birthday: ► 4 DTaP (diphtheria, tetanus, and acellular pertussis)
► 3 IPV (polio)
► 1 MMR (measles, mumps, rubella)
► 3 HiB (H influenza type B)
► 3 Hep B (Hepatitis B) – newborn Hep B vaccine administered during 8-day period after birth is acceptable
► 1 VZV (chicken pox)
► 4 PCV (pneumococcal conjugate)
• Eight rates reported: ► One rate for each of the seven immunizations
► One combo rate reported showing the percentage of children who had all seven immunizations
• Data reviewed to identify compliance with measure: ► Claims and encounter data
► Medical records
► CAIR Immunization Registry
• Hybrid Measure
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Codes to Identify CIS Immunization CPT ICD-9-CM Diagnosis ICD-10-CM Diagnosis
DTaP 90698, 90700, 90721,
90723
IPV 90698, 90713, 90723
MMR 90707, 90710
Measles and rubella 90708
Measles 90705
055.0, 055.1, 055.2, 055.71,
055.79, 055.8, 055.9
B05.0 – B05.4, B05.81, B05.89, B05.9
Mumps 90704
072.0 – 072.3, 072.71, 072.72,
072.79, 072.8, 072.9
B26.0 – B26.3, B26.81 – B26.85, B26.89,
B26.9
Rubella 90706
056.00, 056.01, 056.09, 056.71,
056.79, 056.8, 056.9
B06.00-B06.02, B06.09, B06.81-B06.82,
B06.89, B06.9
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Codes to Identify CIS
Immunization CPT HCPCS ICD-9-CM Diagnosis ICD-10-CM Diagnosis ICD-9-PCS ICD-10-PCS
HiB 90645-
90648,
90698,
90721, 90748
Hepatitis B 90723,
90740,
90744,
90747, 90748
G0010 070.20-070.23, 070.30-
070.33, V02.61
B16.0-B16.2, B16.9, B17.0,
B18.0, B18.1, B19.10,
B19.11, Z22.51
99.55 3E0234Z
VZV 90710,90716 052.0-052.2, 052.7-
052.9, 053.0, 053.10-
053.14, 053.19-053.22,
053.29, 053.71, 053.79,
053.8, 053.9
B01.0, B01.11, B01.12,
B01.2, B01.81, B01.89,
B01.9, B02.0, B02.1, B02.21-
B02.24, B02.29-B02.34,
B02.39, B02.7 – B02.9
Pneumococcal
Conjugate
90669, 90670 G0009
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Immunization for Adolescents (IMA)
• The percentage of 13-year old adolescents who had the following immunizations:
► 1 Meningococcal between the member’s 11th and 13th birthday
► 1 Tdap/Td between the member’s 10th and 13th birthday
• Three rates are reported:
► One rate for each immunization
► One combo rate reported showing the percentage of adolescents who had both immunizations
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Medical records
► CAIR Immunization Registry
• Hybrid Measure
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Codes to Identify IMA
Description CPT
Tetanus vaccine 90703
Td vaccine 90714, 90718
Tdap vaccine 90715
Diphtheria vaccine 90719
Meningococcal vaccine 90733, 90734
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Cervical Cancer Screening (CCS)
• Measures the percentage of women, between the ages of 21 to 64, who had one of the following cervical cancer screenings:
1. Women, aged 21-64, who had a cervical cytology screening within the last 3 years
2. Women, aged 30-64, who had a cervical cytology/HPV co-screening within the last 5 years
• One rate reported
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Medical records
► Labs
• Hybrid Measure
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Codes to Identify CCS
Description CPT HCPCS LOINC UB Revenue
Cervical Cancer
Screening
88141-88143, 88147-
88150, 88152-88154,
88164-88167, 88174-
88175
G0123-G0124, G0141-
G0145, G0147-G0148,
P3000-P3001, Q0091
10524-7, 18500-9,
19762-4, 19764-0,
19765-7, 19766-5,
19774-9, 33717-0,
47527-7, 47528-5
0923
HPV Screening 87620, 87621, 87622 21440-3, 30167-1,
38372-9, 49896-4,
59420-0, 75406-9,
75694-0
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Domain: Effectiveness of Care
Sub-Domain: Respiratory Conditions
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Medication Management for People with Asthma (MMA)
• The percentage of members, 5 to 64 years of age, who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period.
• Two rates are reported
► The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period
► The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Pharmacy data
• Administrative measure
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Codes to Identify MMA Description ICD-9-CM ICD-10-CM CPT HCPCS UB Revenue
Asthma 493.00, 493.01, 493.02,
493.10, 493.11, 493.12,
493.81, 493.82, 493.90,
493.91, 493.92
J45.20-J45.22, J45.30-J45.32,
J45.40-J45.42, J45.50-J45.52,
J45.901-J45.902, J45.909,
J45.990, J45.991, J45.998
Outpatient 99201-99205, 99211-99215,
99217-22220, 99241-99245,
99341-99345, 99347-99350,
99381-99387, 99391-99397,
99401-99404, 99411-99412,
99420, 99429, 99455-99456
G0402,
G0438,
G0439,
G0463,
T1015
0510-0517, 0519-
0523, 0526-0529,
0982-0983
ED 99281-99285 0450-0452, 0456,
0459, 0981
Acute
Inpatient
99221-99223, 99231-99233,
99238-99239, 99251-99255,
99291
0100-0101, 0110-
0114, 0119-0124,
0129-0134, 0139-
0144, 0149-0154,
0159-0160, 0164,
0167, 0169, 0200-
0204, 0206-0214,
0219, 0720-0724,
0729, 0987 27
Domain: Effectiveness of Care
Sub-Domain: Cardiovascular
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Controlling High Blood Pressure (CBP)
• The percentage of 18 to 85 year old adults who had a diagnosis of
hypertension and whose blood pressure was adequately controlled
in 2015 based in the following criteria:
► Members 18 to 59 years of age whose BP was < 140/90
► Members 60 to 85 years of age with diabetes whose BP was <140/90
► Members 60 to 85 year of age without diabetes whose BP was <150/90
• One rate reported for all three groups
• Data reviewed to identify compliance with measure:
► Medical records
• Hybrid Measure
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Codes to Identify CBP
Description ICD-9-CM
Diagnosis
ICD-10-CM
Diagnosis
CPT HCPCS
Essential Hypertension I10
Malignant Hypertension 401.0
Benign Hypertension 401.1
Hypertension, NOS 401.9
Outpatient Visits 99201-99205, 99211-99215,
99241-99245, 99341-99345,
99347-99350, 99381-99387,
99391-99397, 99401-99404,
99411-99412, 99420, 99429,
99455-99456
G0402, G0438,
G0439, G0463
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Domain: Effectiveness of Care
Sub-Domain: Diabetes
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Comprehensive Diabetes Care (CDC) • The percentage of 18 to 75 year old adults with diabetes (Type 1 & 2) who had the
following six screenings:
• Six rates reported:
► Hemoglobin A1c (HbA1c) testing
► HbA1c poor control (>9.0%)
► HbA1c control (<8.0%)
► Diabetic retinal eye exam
► Medical attention for nephropathy that includes a nephropathy screening, monitoring test or evidence of nephropathy.
► Blood Pressure control (<140-90 mm Hg)
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Vision claims
► Medical records
► Labs
• Hybrid Measure
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Codes to Identify Members with Diabetes
Description ICD-9-CM ICD-10-CM
Diabetes 250.00. 250.01, 250.02, 250.03,
250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23,
250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43,
250.50, 250.51, 250.52, 250.53,
250.60, 250.61, 250.62, 250.63,
250.70, 250.71, 250.72, 250.73,
250.80, 250.81, 250.82, 250.83,
250.90, 250.91, 250.92, 250.93,
357.2, 362.01, 362.02, 362.03,
362.04, 362.05, 362.06, 362.07,
366.41, 648.00, 648.01, 648.02,
648.03, 648.04
E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321,
E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36,
E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52,
E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630,
E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01,
E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331,
E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40,
E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610,
E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641,
E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11,
E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331,
E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40,
E13.41, E13.42, E413.43, E13.44, E13.49, E13.51, E13.52, E13.59,
E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638,
E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, 024.012,
024.013. 024.019, 024.02, 024.03, 024.111, 024.112, 024.113, 024.119,
024.12, 024.13, 024.311, 024.312, 024.313, 024.319, 024.32, 024.33,
024.811, 024.812, 024.813, 024.819, 024.82, 024.83
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Codes to Place of Diabetic Services
Description CPT CPT Category II LOINC
Outpatient 99201-99205, 99211-99215,
99241-99245, 99341-99345,
99347-99350, 99381-99387,
99391-99397, 99401-99404,
99411-99412, 99420, 99429,
99455-99456
G0402, G0438, G0439,
G0463, T1015
0510-0517, 0519-0523, 0526-0529, 0982-0983
Observation 99217- 99220
ED 99281, 99282, 99823, 99284,
99285
0450, 0451, 0452, 0456, 0459, 0981
Nonacute Inpatient 99304-99310, 99315, 99316,
99318, 99324-99328, 99334-
99337
0118, 0128, 0138, 0148, 0158, 0190-0194, 0199,
0524, 0525, 0550-0552, 0559-0663, 0669
Inpatient 99221, 99222, 99223, 99231,
99232, 99233, 99238, 99239,
99251, 99252, 99253, 99254,
99255, 99291
0100, 0101, 0110-0114, 0116-0124, 0126-0134, 0136-
0144, 0146-0154, 0156-0160, 0164, 0167, 0169-0174,
0179, 0190-0194, 0199-0204, 0206-0214, 0219, 0720-
0724, 0729, 0987, 1000-1002
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Codes to Identify HbA1c
Screening for Diabetic Members
Description CPT CPT Category II LOINC
HbA1c Tests 83036, 83037 3044F, 3045F, 3046F 17856-6, 4548-4, 4549-2
HbA1c Levels < 7.0 % 3044F
HbA1c Levels 7.0 – 9.0 % 3045F
HbA1c Levels > 9.0 % 3046F
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Codes to Identify
Retinal Eye Exams for Diabetic Members
Description CPT CPT Category II HCPCS
Diabetic Retinal
Screening
67028, 67030, 67031, 67036, 67039, 67040,
67041, 67042, 67043, 67101, 67105, 67107,
67108, 67110, 67112, 67113, 67121, 67141,
67145, 67208, 67210, 67218, 67220, 67221,
67227, 67228, 92002, 92004, 92012, 92014,
92018, 92019, 92134, 92225, 92226, 92227,
92228, 92230, 92235, 92240, 92250, 92260,
99203, 99204, 99205, 99213, 99214, 99215,
99242, 99243, 99244, 99245
2022F, 2024F,
2026F,
S0620, S0621, S0625,
S3000
Negative Diabetic
Retinal Screening
3072F
36
Codes to Identify
Screening/Monitoring for Nephropathy
Description CPT CPT Category II LOINC
Nephropathy
Screening Test
81000, 81001,
81002, 81003,
81005, 82042,
82043, 82044,
84156
3060F, 3061F,
3062F
11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1,
1753-3, 1754-1, 1755-8, 1757-4, 18373-1, 20454-5, 20621-9, 21059-1, 21482-5, 26801-
1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 30000-4, 30001-2, 30003-8, 32209-9,
32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3,
43607-1, 44292-1, 47558-2, 49023-5, 50561-0, 50949-7, 53121-0, 53525-2, 53530-2,
53531-0, 53532-8, 56553-1, 57369-1, 57735-3, 5804-0, 58448-2, 58992-9, 59159-4,
60678-0, 63474-1, 9318-7
Description ICD-9-CM ICD-10-CM CPT Category II
Evidence of
Nephropathy
Treatment
250.40-250.43, 403.00, 403.01, 403.10, 403.11,
403.90, 403.91, 404.00-404.03, 404.10-404.13,
404.90-404.93, 405.01, 405.11, 405.91, 580.0,
580.4, 580.81, 580.89, 580.9, 581.0-581.3, 581.81,
581.89, 581.9, 582.0, 582.1, 582.2, 582.4, 582.81,
582.89, 582.9, 583.0-583.2, 583.4, 583.6, 583.7,
583.81, 583.89, 583.9, 584.5-584.9, 586, 587,
588.0, 588.1, 588.81, 588.89, 588.9, 753.0,
753.10-753.17, 753.19, 791.0
E08.21, E08.22, E08.29, E09.21, E09.22 E09.29, E10.21,
E10.22, E10.29, E11.21, E11.22, E11.29, E13.21,
E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2,
I15.0, I15.1, N00.0-N00.9, N01.0-N01.9, N02.0-N02.9,
N03.0-N03.9, N04.0-N04.9, N05.0-N05.9, N06.0-N06.9,
N07.0-N07.9, N08, N14.0-N14.4, N17.0, N17.1, N17.2,
N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1,
N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0-
Q60.6, Q61.00-Q61.02, Q61.11, Q61.19, Q61.2-Q61.5,
Q61.8, Q61.9, R80.0-R80.3, R80.8, R80.9
3066F, 4010F
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Codes to Identify
Evidence of Nephropathy
Description ICD-9-CM ICD-9-PCS ICD-10-CM ICD-10-PCS CPT HCPCS Revenue Codes
CKD Stage 4 585.4 N18.4
ESRD 585.5, 585.6,
V45.11,
V45.12
38.95, 39.27,
39.42, 39.43,
39.53, 39.93,
39.94, 39.95,
54.98
N18.5, N18.6,
Z91.15, Z99.2
3E1M39Z,
5A1D00Z,
5A1D60Z
36147, 36800, 36810,
36815, 36818-36821,
36831-36833, 90935,
90937, 90940, 90945,
90947, 90957-90962,
90965, 90966, 90969,
90970, 90989, 90993,
90997, 90999, 99512
G0257,
S9339
0800-0804, 0809,
0820-0825, 0829-0835,
0839-0845, 0849-0855,
0859, 0880-0882, 0889
Kidney
Transplant
V42.0 55.61, 55.69 Z94.0 0TY00Z0,
0TY00Z1,
0TY00Z2,
0TY10Z0,
0TY10Z1,
0TY1072
50300, 50320, 50340,
50360, 50365, 50370,
50380
S2065 0367
38
Domain: Effectiveness of Care
Sub-Domain: Medication Management
39
Annual Monitoring for Patients on Persistent Medications (MPM)
• The percentage of adults, 18 years of age and older, who received at least
180 treatment days of ambulatory medication therapy for a select
therapeutic agent during the measurement year and had at least one
therapeutic monitoring event for the therapeutic agent during the
measurement year.
• Four rates are reported for the following therapeutic agents: ► Angiotensin Converting Enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
► Digoxin
► Diuretics
► Total rate
• Data reviewed to identify compliance with measure: ► Claims and encounter data
► Pharmacy Data
► Labs
• Administrative measure 40
Codes to Identify MPM Description CPT LOINC
Lab Panel 80047, 80048, 80050,
88053, 80069
Digoxin Level 80162 3563-4, 10535-3
Serum Potassium (K+) 80051, 84132 12812-4, 12813-2, 22760-3, 2823-3, 2824-1, 29349-8, 32713-0, 39789-3, 39790-1,
41656-0, 51618-7, 6298-4
Serum Creatinine (SCr) 82565, 82575 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0, 13447-8,
13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 2160-0, 2163-4, 2164-2,
26752-6, 31045-8, 33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1,
38483-4, 39955-0, 39956-8, 39957-6, 39958-4, 39959-2, 39960-0, 39961-8,
39962-6, 39963-4, 39964-2, 39965-9, 39966-7, 39967-5, 39968-3, 39969-1,
39970-9, 39971-7, 39972-5, 39973-3, 39974-1, 39975-8, 39976-6, 40112-5,
40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2, 40119-0, 40120-8,
40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3, 40128-1,
40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2,
40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5,
40269-3, 40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3,
51619-5, 51620-3, 59826-8, 59834-2, 62425-4
41
Domain: Effectiveness of Care
Sub-Domain: Overuse/Appropriateness
NCQA Added New Sub-Domain in 2015
42
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
• The percentage of 18 to 64 year old adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.
• One rate reported
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Rx data
• Administrative measure
• NCQA’s Changes to the AAB Measure in 2015 ► AAB measure moved from Respiratory Conditions sub-domain to
Overuse/Appropriateness sub-domain
43
Codes to Identify AAB
Description ICD-9-CM
Diagnosis*
ICD-10-CM
Diagnosis
CPT HCPCS UB Revenue
Acute
Bronchitis
466.0 J20.3-J20.9
Outpatient
Visits
99201-99205, 99211-99215, 99217-
99220, 99241-99245, 99341-99345,
99347-99350, 99381-99387, 99391-
99397, 99401-99404, 99411-99412,
99420, 99429, 99455-99456
G0402
G0438
G0439
G0463
T1015
0510-0517,
0519-0523,
0526-0529,
0982-0983
Emergency
Department
Visits
99281 - 99285 0450-0452,
0456, 0459,
0981
44
Use of Imaging Studies for Low Back Pain (LBP)
• The percentage of members (any age) with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis.
• One rate reported
• Data reviewed to identify compliance with measure:
► Claims and encounter data
• Administrative measure
• NCQA’s Changes to the LBP Measure in 2015 ► LBP measure moved from Musculoskeletal Conditions sub-domain to
Overuse/Appropriateness sub-domain
45
Codes to Identify LBP
Description ICD-9-CM Diagnosis ICD-10-CM Diagnosis
Low Back Pain 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03,
724.2, 724.3, 724.5, 724.6, 724.70, 724.71, 724.79,
738.5, 739.3, 739.4, 846.0, 846.1, 846.2, 846.3, 846.8,
846.9, 847.2
M46.46-M46.48, M47.26-M47.28, M47.816-M47.818,
M47.896-M47.898, M48.06-M48.08, M51.16, M51.17,
M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M51.86,
M51.87, M53.2X6 - M53.2X8. M53.3, M53.86 - M53.88,
M54.30 - M54.32, M54.40- M54.42, M54.5, M54.89, M54.9,
M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A,
S33.110D, S33.110S, S33.120A, S33.120D, S33.120S,
S33..130A, S33.130D, S33.130S, S33.140A, S33.140D,
S33.140S, S33.5XXA, S33.6XXA, S33.8XXA, S33.9XXA,
S39.002A, S39.002D, S39.002S, S39.0012A, S39.012D,
S39.012S, S39.029A, S39.029D, S39.029S, S39.82XA, S39.82XD,
S39.82XS, S39.92XA, S39.92XD, S39.92XS
46
Codes to Identify LBP Description CPT HCPCS UB Revenue
Osteopathic Manipulative Study 98925 - 98929, 98940 - 98942
Imaging Study 72010, 72020, 72052, 72100, 72110,
72114, 72120, 72131, 72132, 72133,
72141, 72142, 72146, 72147, 72148,
72149, 72156, 72158, 72200, 72202,
72220
0320, 0329, 0350, 0352 ,
0359, 0610, 0612, 0614, 0619,
0972
Outpatient Visits/Observation 99201 - 99205, 99211 - 99215, 99217 -
9220, 99241 - 99245, 99341 - 99345,
99347 - 99350, 99381 - 99387, 99391 -
99397, 99401 - 99404, 99411 - 99412,
99420, 99429, 99455 - 99456
G0402, G0438, G0439. G0463,
T1015
0510 - 0517, 0519 - 0523,
0526 - 0529, 0982 - 0983
Emergency Department Visits 99281 - 99285 0450, 0451, 0452, 0456, 0459,
0981
47
Domain: Access and Availability of Care
48
Children & Adolescents’ Access to PCPs (CAP)
• The percentage of members: ► 12 months to 6 years old who had a visit with a PCP during the measurement
year (2015)
► 7 to 19 years old who had a visit with a PCP during the measurement year (2015) or the year prior to the measurement year (2014)
• Four rates are reported for the following age groups: ► 12 to 24 months
► 25 months to 6 years
► 7 to 11 years
► 12 to 19 years
• Data reviewed to identify compliance with measure:
► Claims and encounter data
• Administrative measure
49
Codes to Identify CAP
Description ICD-9-CM
Diagnosis
ICD-10-CM
Diagnosis
CPT HCPCS UB REV
Wellness Exams
V20.2
V70.0
V70.3
V70.5
V70.6
V70.8
V70.9
Z00.00 – Z00.01,
Z00.121, Z00.129,
Z00.5, Z00.8,
Z02.0-Z02.6,
Z02.71, Z02.81-
Z02.83, Z02.89,
Z02.9
Ambulatory Visit 99201-99205, 99211-
99215, 99241-99245,
99341-99345, 99347-
99350, 99381-99387,
99391-99397, 99401-
99404, 99411-99412,
99420, 99429
0510-0517,
0519-0523,
0526-0529,
0982-0983
Wellness Visits G0402, G4038,
G4039, G0463,
T1015
50
Prenatal & Postpartum Care (PPC) • The percentage of women with live birth deliveries, between
November 6, 2014 and November 5, 2015, who had prenatal and postpartum care visits.
• Two rates are reported: ► Prenatal Care: The percentage of women who had a prenatal care visit
during the first trimester or within 42 days of enrollment with their health plan
► Postpartum Care: The percentage of women who had a postpartum care visit between 21 and 56 days after delivery
• Data reviewed to identify compliance with measure: ► Claims and encounter data
► Medical records
• Hybrid measure
51
Codes to Identify Members for
the Prenatal and Postpartum Care Measure
Description ICD-9-CM ICD-10 –CM
Pregnancy
Diagnosis
640.x3, 641.x3,
642.x3, 643.x3,
644.x3, 645.x3,
646.x3, 647.x3,
648.x3, 649.x3,
651.x3, 652.x3,
653.x3, 654.x3,
655.x3, 656.x3,
657.x3, 658.x3,
659.x3, 678.x3,
679.x3, V22.0-
V22.2, V23.0-
V23.3, V23.41,
V23.42, V23.49,
V23.5, V23.7,
V23.81-V23.87,
V23.89, V23.9,
V28.0-V28.6,
V28.81, V28.82,
V28.89, V28.9
O09.0x, O09.1x, O09.21x, O09.29x, O09.3x, O09.4x, O09.51x, O09.52x, O09.61x, O09.62x, O09.7x, O09.81x, O09.82x, O09.89x, O09.9x,
O10.1x, O10.21x, O10.31x, O10.41x, O10.91x, O11.x, O12.0x, O12.1x, O12.2x, O13.x, O14.0x, O14.1x, O14.2x, O14.9x, O15.0x, O15.1,
O15.9, O16.x, O20.x, O21.x, O22.0x, O22.1x, O22.2x, O22.3x, O22.4x, O22.5x, O22.8Xx, O22.9x, O23.0x, O23.1x, O23.2x, O23.3x,
O23.4x, O23.51x, O23.52x, O23.59x, O23.9x, O24.01x, O24.11x, O24.31x, O24.41x, O24.81x, O24.91x, O25.1x, O26.0x, O26.1x,
O26.2x, O26.3x, O26.4x, O26.5x, O26.61x, O26.71x, O26.81x, O26.82x, O26.83x, O26.84x, O26.85x, O26.86, O26.87x, O26.89x,
O26.9x, O28.x, O29.01x, O29.02x, O29.09x, O29.11x, O29.12x, O29.19x, O29.21x, O29.29x, O29.3Xx, O29.4x, O29.5Xx, O29.6x,
O29.8Xx, O29.9x, O30.00x, O30.01x, O30.02x, O30.03x, O30.04x, O30.09x, O30.10x, O30.11x, O30.12x, O30.19x, O30.20x, O30.21x,
O30.22x, O30.29x, O30.80x, O30.81x, O30.82x, O30.89x, O30.9x, O31.00Xx, O31.01Xx, O31.02Xx, O31.03Xx, O31.10Xx, O31.11Xx,
O31.12Xx, O31.13Xx, O31.20Xx, 031.21Xx, O31.22Xx, O31.23Xx, O31.30Xx, O31.31Xx, O31.32Xx, O31.33Xx, O31.8X1x, O31.8X2x,
O31.8X3x, O31.8X9x, O32.0XXx, O32.1XXx, O32.2XXx, O32.3XXx, O32.4XXx, O32.6XXx, O32.8XXx, O32.9XXx, O33.0 - O33.2,
O33.3XXx, O33.4XXx, O33.5XXx, O33.6XXx, O33.7-O33.9, O34.0x, O34.1x, O34.2x, O34.3x, O34.4x, O34.51x, O34.52x, O34.53x,
O34.59x, O34.6x, O34.7x, O34.8x, O34.9x, O35.0XXx, O35.1XXx, O35.2XXx, O35.3XXx, O35.4XXx, O35.5XXx, O35.6XXx, O35.7XXx,
O35.8XXx, O35.9XXx, O36.011x, O36. 012x, O36.013x, O36.019x, O36.091x, O36.092x, O36.093x, O36.099x, O36.111x, O36.112x,
O36.113x, O36.119x, O36.191x, O36.192x, O36.193x, O36.20Xx, O36.21Xx, O36.22Xx, O36.23Xx, O36.4XXx, O36.511x, O36.512x,
O36.513x, O36.519x, O36.591x, O36.592x, O36.593x, O36.599x, O36.60Xx, O36.61Xx, O36.62Xx, O36.63Xx, O36.70Xx, O36.71Xx,
O36.72Xx, O36.73Xx, O36.80Xx, O36.812x, O36.813x, O36.819x, O36.821x, O36.822x, O36.823X, O36.829x, O36.891x, O36.892x,
O36.893x, O36.899x, O36.90Xx, O36.91Xx, O36.92Xx, O36.93Xx, O40.1XXx, O40.2XXx, O40.3XXx, O40.9XXx, O41.00Xx, O41.01Xx,
O41.02Xx, O41.03Xx, O41.101x, O41.102x, O41.103x, O41.109x, O41.121x, O41.122x, O41.123x, O41.129x, O41.141x, O41.142x,
O41.143x, O41.149x, O41.8X1x, O41.8X2x, O41.8X3x, O41.8X9x, O41.90Xx, O41.91Xx, O41.92Xx, O41.93Xx, O42.00, O42.01x, O42.02,
O42.10, O42.11x, O42.12, O42.90, O42.91x, O42.92, O43.01x, O43.02x, O43.10x, O43.11x, O43.12x, O43.19x, O43.21x, O43.22x,
O43.23x, O43.81x, O43.89x, O43.9x, O44.0x, O44.1x, O45.00x, O45.01x, O45.02x, O45.09x, O45.8Xx, O45.9x, O46.00x, O46.01x,
O46.02x, O46.09x, O46.8Xx, O46.9x, O47.0x, O47.1, O47.9, O48.x, O60.0x, O71.0x, O71.1-O71.7, O71.8x, O71.9, O88.01x, O88.11x,
O88.21x, O88.31x, O88.81x, O91.01x, O91.03, O91.11x, O91.03, O91.21x, O91.23, O92.01x, O92.03, O92.11x, O92.13, O92.3-O92.6,
O92.7x, O98.01x, O98.11x, O98.21x, O98.31x, O98.41x, O98.51x, O98.61x, O98.71x, O98.81x, O98.91x, O99.01x, O99.11x, O99.21-
O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.41x,
O99.51x, O99.61x, O99.71x, O99.810, O99.820, O99.840-O99.843, O9A.11x, O9A.21x, O9A.31x, O9A.41x, O9A.51x, Z03.7x, Z33.x,
Z34.0x, Z34.8x, Z34.9x, Z36
52
Codes to Identify Members for
the Prenatal and Postpartum Care Measure
Description ICD-9-CM ICD-9-PCS ICD-10-PCS CPT
Live Deliveries 640.x1, 641.x1, 642.x1, 642.x2,
643.x1, 644.21, 645.x1, 646.x1,
646.x2, 647.x1, 647.x2, 648.x1,
648.x2, 649.x1, 649.x2, 650,
651.x1, 652.x1, 653.x1, 654.x1,
654.x2, 655.x1, 656.01, 656.11,
656.21, 656.31, 656.51, 656.61,
656.71, 656.81, 656.91, 657.01,
658.x1, 659.x1, 660.x1, 661.x1,
662.x1, 663.x1, 664.x1, 665.x1,
665.x2, 666.x2, 667.x2, 668.x1,
668.x2, 669.x1, 669.x2, 670.02,
671.x1, 671.x2, 672.02, 673.x1,
673.x2, 674.x1, 674.x2, 675.x1,
675.x2, 676.x1, 676.x2, 678.x1,
679.x1, 679.x2, V27.0, V27.2,
V27.3, V27.5, V27.6
72.0, 72.1, 72.21, 72.29,
72.31, 72.39, 72.4, 72.51-
72.54, 72.6, 72.71, 72.79,
72.8, 72.9, 73.01, 73.09,
73.1, 73.21, 73.22, 73.3,
73.4, 73.51, 73.59, 73.6,
73.8, 73.91-73.94, 73.99,
74.0-74.2, 74.4, 74.99
10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4,
10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10D17ZZ,
10D18ZZ, 10D27ZZ, 10D28ZZ, 10E0XZZ
59400, 59409,
59410, 59510,
59514, 59515,
59610, 59612,
59614, 59618,
59620, 59622
53
Codes to Identify Prenatal Office Visits
Description CPT CPT Category II HCPCS UB
Revenue
Prenatal
Bundles Visits
Billed on date of
delivery
59400, 59425, 59426, 59510,
59610, 59618
H1005
Prenatal Visits 80055, 99201- 99205, 99211-
99215, 99241-99245, 99500
0500F, 0501F, 0502F G0463, H1000, H1001,
H1002, H1003, H1004,
T1015
0514
54
Codes to Identify Prenatal Screenings
Description ICD-9-PCS ICD-10-PCS CPT LOINC
Prenatal Ultrasound 88.78 BY49ZZZ,
BY4BZZZ,
BY4CZZZ,
BY4DZZZ,
BY4FZZZ,
BY4GZZZ
76801,
76805,
76811,
76813,
76815-
76821,
76825-
76828
Antibody
Screenings:
Taxoplasmy,
Rubella, Herpes
Simplex, or
Cytomegalovirus
86644,
86694,
86695,
86696,
86762,
86777,
86778
10350-7, 11598-0, 12261-4, 12262-2, 13225-8, 13279-5, 13280-3, 13286-0, 13323-1, 13324-9, 13501-2, 13505-3,
13949-3, 14213-3, 15377-5, 16714-8, 16715-5, 16716-3, 16944-1, 16949-0, 16950-8, 16954-0, 16955-7, 16957-3,
16958-1, 17550-5, 17717-0, 17850-9, 17851-7, 19106-4, 21326-4, 21327-2, 21570-7, 22239-8, 22241-4, 22244-8,
22246-3, 22247-1, 22249-7, 22339-6, 22341-2, 22343-8, 22496-4, 22497-2, 22577-1, 22580-5, 22582-1, 22584-7,
23485-6, 23486-4, 23784-2, 24014-3, 24116-6, 24119-0, 24242-0, 25298-1, 25300-5, 25420-1, 25435-9, 25514-1,
25542-2, 25837-6, 25839-2, 26927-4, 27948-9, 30325-5, 30355-2, 31411-2, 31616-6, 32170-3, 32687-6, 32688-4,
32790-8, 32791-6, 32831-0, 32834-4, 32835-1, 32846-8, 33291-6, 33336-9, 34152-9, 34403-6, 34421-8, 34422-6,
34613-0, 35281-5, 35282-3, 36921-5, 40466-5, 40667-8, 40677-7, 40678-5, 40697-5, 40728-8, 40729-6, 40785-8,
40786-6, 41123-1, 41124-9, 41149-6, 41399-7, 41763-4, 42337-6, 42338-4, 42949-8, 43028-0, 43030-6, 43031-4,
43111-4, 43180-9, 43810-1, 44008-1, 44480-2, 44494-3, 44507-2, 45210-2, 45326-6, 47230-8, 47307-4, 47363-7,
47389-2, 47390-0, 47430-4, 48784-3, 49107-6, 49539-0, 49848-5, 50694-9, 50758-2, 5121-9, 5122-7, 5124-3,
5125-0, 5126-8, 5127-6, 51915-7, 51916-5, 51931-4, 5202-7, 5203-5, 5204-3, 5205-0, 5206-8, 5207-6, 5208-4,
5209-2, 5210-0, 52976-8, 52977-6, 52981-8, 52984-2, 52986-7, 5330-6, 5331-4, 5332-2, 5333-0, 5334-8, 5335-5,
53377-8, 53560-9, 5387-6, 5388-4, 5389-2, 5390-0, 5391-8, 56990-5, 56991-3, 57321-2, 59838-3, 63462-6, 7851-
9, 7852-7, 7853-5, 7907-9, 7908-7, 7909-5, 7910-3, 7911-1, 7912-9, 7913-7, 8013-5, 8014-3, 8015-0, 8039-0,
8040-8, 9422-7, 9513-3
ABO Screening 86900 883-9, 57743-7
Rh Screening 86901 10331-7, 1305-2, 34961-3, 972-0, 978-7
ABO and Rh
Screening
882-1, 884-7
55
Codes to Identify Postpartum Visits
Description ICD-9-CM ICD-10-CM CPT CPT
Category
II
HCPCS LOINC UB
Revenue
ICD-9-PCS
Postpartum
Visits
V24.1, V24.2, V25.11,
V25.12, V25.13, V72.31,
V72.32, V76.2
Z01.411, Z01.419,
Z01.42, Z30.430,
Z39.1, Z39.2
57170, 58300,
59430, 99501
0503F G0101 89.26
Postpartum
Bundled
Visits
59400, 59410,
59510, 59515,
59610, 59614,
59618, 59622
Cervical
Cytology
88141, 88142,
88143, 88147,
88148, 88150,
88152, 88153,
88154, 88164,
88165, 88166,
88167, 88174,
88175
G0123, G0124,
G0141, G0143,
G0144, G0145,
G0147, G0148,
P3000, P3001,
Q0091
10524-7, 18500-9,
19762-4, 19764-0,
19765-7, 19766-5,
19774-9, 33717-0,
47527-7, 47528-5
0923
56
Domain: Utilization and Risk Adjusted
Utilization
NCQA revised domain in 2015 from “Utilization and
Relative Resource Use” to “Utilization and Risk Adjusted Utilization”
57
Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34)
• The percentage of 3 to 6 year old children who had one or more well-child visit(s) with a
PCP in 2015 and the provider of care assessed and documented ALL of the following:
► Health history
► Physical developmental history
► Mental developmental history
► Physical Exam
► Health education/anticipatory guidance
• One rate reported
• Data reviewed to identify compliance with measure:
► Claims and encounter data
► Medical records
• Hybrid measure
58
Codes to Identify W34
Description ICD-9-CM Diagnosis ICD-10-CM Diagnosis CPT HCPCS
Well care exam V20.2, V70.0, V70.3, V70.5,
V70.6, V70.8, V70.9
Z00.00, Z00.01, Z00.121,
Z00.129, Z00.5, Z00.8,
Z02.0-Z02-6, Z02.71,
Z02.79, Z02.81-Z02.83,
Z02.89, Z02.9
Annual Wellness Visit G0438, G0439
Office Visit 99381-99385,
99391-99395,
99461
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Ambulatory Care (AMB)
• This measures summarizes utilization of ambulatory care in 2015 in
the outpatient and emergency department.
• Two rates reported:
►Outpatient utilization
►Emergency Department utilization
• Data audited to identify compliance with measure:
►Claims and encounter data
• Administrative measure
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Codes to Identify AMB Description CPT HCPCS UB Revenue POS
Ambulatory
Outpatient Visits
92002, 92004, 92012, 92014, 99201-
99205, 99211-99215, 99241-99245,
99304-99310, 99315-99316, 99318,
99324-99328, 99334-99337, 99341-
99345, 99347-99350, 99381-99387,
99391-99397, 99401-99404, 99411-
99412, 99420, 99429, 99461
G0463, T1015 0510-0517,
0519-0529,
0982-0983
Emergency
Department
99281-99285
0450-0452,
0456, 0459,
0981
23
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Codes to Identify AMB
Description CPT UB Revenue POS
Emergency
Department Visit
99281-99285 0450-0452, 0456,
0459, 0981
23
ED Procedure Code 10030, 10040, 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, 10180. 11000,
11001, 11004-11006, 11008, 11010-10012, 10042-10047, 10055-10057, 11100, 11101,
11200, 11201, 11300 -11208, 11310-11313, 11400-11406, 11420-11424, 11426, 11440-
11446, 11450, 11451,
23
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Reasons for Low HEDIS® Rates
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Reason for Low HEDIS® Rates
• Clinics did not submit claims or encounter data
– No data = No history of services performed
• Coding on claims and encounter data is incomplete or inaccurate
– Incomplete or inaccurate coding = No history of services performed
• Delayed claims & encounter submissions
• Medical record documentation is incomplete
• Patients did not receive annual screenings
• Patients with chronic conditions are not monitored
• Patients on persistent medications are not monitored
• Clinics are not familiar with HEDIS® measure criteria
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How to Improve your HEDIS® Rates
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How to Improve your HEDIS® Rates
• Timely submission of all claims and encounter data
• Complete and accurate coding of all services performed
• Document all services and care provided in the medical record
– Include child and adolescent counseling for nutrition and physical activity
• Schedule patients for their annual screenings and check-ups
– Children are expected to have annual check-ups
• Continually monitor patients with chronic conditions
• Continually monitor patients on persistent medications
• Understand the HEDIS® measure criteria and the standard practice
guidelines
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2016 Medical Codes for HEDIS® Reporting
To obtain a complete list of the medical codes used by NCQA to
identify compliance with HEDIS® measures click on the following
link, NCQA’s Quality Rating System HEDIS® Value Set Directory or
visit www.NCQA.org.
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