WHY HEDIS® IS IMPORTANT VALUE OF HEDIS® TO · PDF fileWHY HEDIS® IS IMPORTANT ....

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What is HEDIS®?

HEDIS® (Healthcare Effectiveness Data and Information Set) consists of a set of performance measures utilized by more than 90 percent of American health plans that compare how well a plan performs in these areas:

• Quality of care • Access to care • Member satisfaction with the health plan and doctors

WHY HEDIS® IS IMPORTANT HEDIS® ensures health plans are offering quality preventive care and service to members. It also allows for a true comparison of the performance of health plans by consumers and employers.

VALUE OF HEDIS® TO YOU, OUR PROVIDERS HEDIS® can help save you time while also potentially reducing health care costs. By proactively managing patients’ care, you are able to effectively monitor their health, prevent further complications and identify issues that may arise with their care.

HEDIS® can also help you: • Identify noncompliant members to ensure they receive preventive

screenings • Understand how you compare with other WellCare providers as

well as with the national average

VALUE OF HEDIS® TO YOUR PATIENTS, OUR MEMBERS HEDIS® ensures that members will receive optimal preventive and quality care. It gives members the ability to review and compare plans’ scores, helping them to make informed health care choices.

WHAT YOU CAN DO • Encourage your patients to schedule preventive exams • Remind your patients to follow up with ordered tests • Complete outreach calls to noncompliant members

If you have questions about HEDIS® or need more information, please contact your local Provider Relations representative.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Source: www.ncqa.org

KY019521_PRO_FLY_ENG Internal Approved 06272012 ©WellCare 2012 KY_06_12

http://www.ncqa.org/

HEDIS® Quick Reference Guide for Adults The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in

compliance with the HEDIS® 2012 Volume 2 Technical Specifications. Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: HEDIS® 2012 Volume 2 Technical Specifications Updated: 10/11/2012

NA019250_PRO_GDE_ENG Internal Approved 06202012 ©WellCare 2012 KY_06_12 46077

Prevention and Screening

Immunizations for Adolescents: Percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

CPT Codes

Diphtheria - 90719 Mening – 90733, 90734 Td – 90714, 90718 Tdap – 90715 Tetanus – 90703

Chlamydia Screening in Women: Percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. CPT Codes 87110, 87270, 87320, 87490, 87491, 87492, 87810

Cervical Cancer Screening: Percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer during the measurement year or the two years prior to the measurement year. CPT Codes 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Exclusion Criteria Women who had a total hysterectomy with no residual cervix are excluded.

CPT Codes

51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-58554, 58570-58573, 58951, 58953, 58954, 58956, 59135

ICD-9 CM Diagnosis 618.5, V67.01, V76.47, V88.01, V88.03

Adult BMI Assessment: Percentage of members 18–74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year.

CPT Codes: 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99385-99387,

99395-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456

ICD9-CM Diagnosis:

V85.21 - Body Mass Index 25.0-25.9,adult V85.22- Body Mass Index 26.0-26.9,adult V85.23- Body Mass Index 27.0-27.9,adult V85.24- Body Mass Index 28.0-28.9,adult V85.25- Body Mass Index 29.0-29.9,adult V85.30- Body Mass Index 30.0-30.9,adult V85.31- Body Mass Index 31.0-31.9,adult V85.32- Body Mass Index 32.0-32.9,adult V85.33- Body Mass Index 33.0-33.9,adult V85.34- Body Mass Index 34.0-34.9,adult V85.35- Body Mass Index 35.0-35.9,adult V85.36- Body Mass Index 36.0-36.9,adult





V85.37- Body Mass Index 37.0-37.9,adult V85.38- Body Mass Index 38.0-38.9,adult V85.39- Body Mass Index 39.0-39.9,adult V85.41- Body Mass Index 40.0-44.9,adult V85.42- Body Mass Index 45.0-49.9,adult V85.43- Body Mass Index 50.0-59.9,adult V85.44- Body Mass Index 60.0-69.9,adult V85.45- Body Mass Index 70 and over, adult

HCPCS: G0344, G0402

Breast Cancer Screening: Percentage of women 40–69 years of age who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. CPT Codes: 77055, 75056, 75057 HCPCS: G0202, G0204, G0206

Colorectal Cancer Screening: Percentage of members 50–75 years of age who had appropriate screening for colorectal cancer. ICD9-CM Diagnosis: 45.24, 45.22, 45.23, 45.25, 45.42, 45.43 CPT Codes: FOBT – 82270, 82274

Flexible Sigmoidoscopy – 45330-45335, 45337-45342, 45345 Colonoscopy – 44388-44394, 44397, 45355, 45378-45387, 45391, 45392

HCPCS: FOBT – G0328 Flexible Sigmoidoscopy – G0104 Colonoscopy – G0105, G0121

Exclusion Criteria: Members with a diagnosis of colorectal cancer or total colectomy are excluded. Colorectal Cancer ICD-9-CM Diagnosis: 153, 154.0, 154.1, 197.5, V10.05 Total colectomy CPT Codes: 44150-44153, 44155-44158, 44210-44212

Glaucoma Screening: Percentage of members 65 years of age or older, without a prior diagnosis of glaucoma or suspect, who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions during the measurement year or the year prior to the measurement year. CPT Codes: 92002, 92004, 92012, 92014, 92081-92083, 92100, 92120, 92130, 92135, 92140, 99202-99205,

99213-99215, 99242-99245 HCPCS: G0117, G0118, S0620, S0621

Care for Older Adults: Percentage of adults 66 years and older who had each of the following during the measurement year;

Advance care planning Medication review Functional status assessment Pain screening

CPT Codes: Medication Review – 90862, 99605, 99606 CPT II Codes: Advanced Care Planning – 1157F, 1158F





Medication Review – 1159F, 1160F Medication List – 1159F Functional Status Assessment – 1170F Pain Screening – 0521F, 1125F, 1126F

HCPCS: Advanced Care Planning - S0257

Utilization

Adolescent Well-Care Visits: Percentage of members 12–21 years of age who had at least one comprehensive well care visit with a PCP or OB/GYN during the measurement year. ICD9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT Codes 99383-99385, 99393-99395

Access/Availability of Care

Children & Adolescents Access to Primary Care Practitioners: Percentage of members 12 months–19 years of age who had a visit with a PCP. ICD9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

CPT Codes 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429

HCPCS G0438, G0439

Annual Dental Visits: Percentage of members 2–21 years of age who had at least one dental visit during the measurement year. (This measure applies only if dental care is a covered benefit in the organization's Medicaid contract.) Dental Visit Codes 70300, 70310, 70320, 70350, 70355

Adults’ Access to Preventive/Ambulatory Health Services: Percentage of members 20 years of age and older who had an ambulatory or preventive care visit during the measurement year. ICD9-CM Diagnosis: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

CPT Codes:

Office/other outpatient services - 99201-99205, 99211-99215, 99241-99245 Home services - 99341-99345, 99347-99350 Nursing facility care - 99304-99310, 99315, 99316, 99318 Domiciliary/rest home/custodial care services - 99324-99328, 99334-99337 Preventive medicine - 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429 Ophthalmology and optometry - 92002, 92004, 92012, 92014

HCPCS: G0344, G0402, G0438, G0439

Prenatal Care & Frequency of Ongoing Prenatal Care: Prenatal Care - Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment.

Frequency of Ongoing Prenatal Care - The percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that had <21 percent, 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of expected prenatal visits.





ICD9-CM 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-V23, V28

CPT Codes:

E/M – 99201-99205, 99211-99215, 99241-99245 OB Fetal Monitoring – 76801, 76805, 76811, 76813, 76815-76821, 76825-76828 OB Panel – 80055 TORCH - 86644

HCPCS: H1000-H1004

Postpartum Care The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. ICD-9 CM Diagnosis V24.1, V24.2, V25.1, V72.3, V76.2

CPT Codes 57170, 58300, 59430, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 , 99501

HCPCS G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 CPT II Codes 0503F

Respiratory Conditions

Use of Appropriate Medications for People with Asthma: Percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. ICD-9 CM Diagnosis 493.0, 493.1, 493.8, 493.9

FDA-Approved Asthma Medications Antibody inhibitor • Omalizumab

Inhaled steroid combinations

• Budesonide-formoterol • Fluticasone-salmeterol • Mometasone-formoterol

Inhaled corticosteroids

• Beclomethasone • Budesonide • Flunisolide • Fluticasone CFC free • Mometasone

Leukotriene modifiers • Montelukast • Zafirlukast

Mast cell stabilizers • Cromolyn

Methylxanthines • Aminophylline • Theophylline

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. Two rates are reported:

1. Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. 2. Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.

ICD9-CM Diagnosis 493.0, 493.1, 493.8, 493.9

FDA-Approved Asthma Medications Antibody inhibitor • Omalizumab Inhaled steroid combinations

• Budesonide-formoterol • Fluticasone-salmeterol





• Mometasone-formoterol






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. ICD9-CM Diagnosis: 466.0

Use of Spirometry testing in COPD: Percentage of adults 40 and older newly diagnosed or newly active chronic obstructive pulmonary disease (COPD) who received appropriate spirometry testing to confirm the diagnosis. CPT Codes: 94010, 94014-94016, 94060, 94070, 94375, 94620

Pharmacotherapy Management of COPD Exacerbation: Percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter on or between January 1– November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported:

1. Dispensed a systemic corticosteroid within 14 days of the event 2. Dispensed a bronchodilator within 30 days of the event ICD9-CM Diagnosis: 491, 492, 496 CPT Codes: 99281-99285 Bronchodilators

Anticholinergic agents • Albuterol-ipratropium

• Ipratropium

Beta 2-agonists

• Albuterol • Budesonide-formoterol • Fluticasone-salmeterol • Formoterol • Mometasone-formoterol • Salmeterol


Systemic Corticosteroids • Betamethasone

• Dexamethasone • Hydrocortisone • Methylprednisolone • Prednisolone • Prednisone • Triamcinolone





Behavioral Health

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 health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. ICD9-CM Diagnosis 295-299, 300.3, 300.4, 301, 308, 309, 311-314

Antidepressant Medication Management: Percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported:

1. Effective Acute Phase Treatment - Percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks) 2. Effective Continuation Phase Treatment - Percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months) ICD9-CM Diagnosis: 296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311 Antidepressant Medications

Monoamine oxidase inhibitors

• Phenelzine • Selegiline • Tranylcypromine

Phenylpiperazine antidepressants

• Nefazodone • Trazodone

Psychotherapeutic antidepressants

• Amitriptyline-chlordiazepoxide • Amitriptyline-perphenazine

SSNRI antidepressants • Venlafaxine

SSRI antidepressants

• Citalopram • Fluoxetine • Paroxetine • Sertraline

Tetracyclic antidepressants

• Maprotiline • Mirtazapine

Tricyclic antidepressants

• Amitriptyline • Amoxapine • Clomipramine • Desipramine • Doxepin • Imipramine • Notriptyline • Protriptyline

Miscellaneious antidepressants

• Bupropion

Cardiovascular Conditions

Controlling High Blood Pressure: Percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) on or before June 30 of the measurement year and whose BP was adequately controlled (<140/90) during the measurement year. CPT Codes: 99201-99205, 99211-99215, 99241-99245, 99384-99387, 99394-99397





ICD9-CM Diagnosis: 401

CPT II Codes: Systolic – 3074F (<130 mm Hg), 3075F (130-139 mm Hg), 3077F (≥140 mm Hg) Diastolic – 3078F (<80 mm Hg), 3079F (80-89 mm Hg), 3080F (≥910 mm Hg)

Cholesterol Management for Patients with Cardiovascular Conditions: Percentage of members 18–75 years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1 - November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had each of the following during the measurement year.

LDL-C screening LDL-C control (<100 mg/dl)

CPT Codes: 80061, 83700, 83701, 83704, 83721 CPT II Codes: 3048F, 3049F, 3050F

Persistence of Beta-Blocker Treatment After a Heart Attack: Percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. ICD-CM Diagnosis: 410.x1 Beta Blockers

Cardioselective beta- blockers

• Atenolol • Betaxolol • Bisoprolol • Metoprolol

Noncardioselective beta- blockers

• Carteolol • Carvedilol • Labetalol • Nadolol • Pindolol • Propranolol • Timolol • Sotalol

Antihypertensive combinations

• Atenolol-chlorthalidone • Bisoprolol-hydrochlorothiazide • Hydrochlorothiazide-propranolol





Diabetes

Comprehensive Diabetes Care (CDC): The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had each of the following: • Hemoglobin A1c (HbA1c) testing • HbA1c poor control (>9.0%) • HbA1c control (<8.0%) • HbA1c control (<7.0%) • Eye exam (retinal) performed by an eye care provider • LDL-C screening • LDL-C control (<100 mg/dL) • Medical attention for nephropathy • BP control (<140/80 mm Hg) • BP control (<140/90 mm Hg)

*Additional exclusion criteria are required for this indicator. This indicator is reported only for the commercial and Medicaid product lines. The exclusion criteria are: CABG or PCI, IVD, CHF, Prior MI, CRF, Dementia, Blindness, Amputation of lower extremity.

HbA1C Testing CPT Codes – 83036, 83037

CPT II Codes – 3044F (<7.0%), 3045F (7.0 – 9.0%), 3046F (>9%)

LDL-C Screening CPT Codes – 80061, 83700, 83701, 83704, 83721 CPT II Codes – 3048F (<100 mg/dl), 3049F (100-129 mg/dl), 3050F (≥130 mg/dl)

Nephropathy Screening CPT Codes – 82042, 82043, 82044, 84156 CPT II Codes – 3060F, 3061F

Urine Macroalbumin CPT Codes – 81000-81003, 81005 CPT II Codes – 3062F

Evidence of Treatment for Nephropathy

ICD9-CM Diagnosis - 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0, V45.1 CPT Codes - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512

ACE/ARB Therapy CPT II Codes: 4009F

Angiotensin converting enzyme inhibitors

• Benazepril • Captopril • Enalapril • Lisinopril

Angiotensin II inhibitors • Losartan Antihypertensive combinations

• Benazepril-hydrochlorothiazide • Captopril-hydrochlorothiazide • Enalapril-hydrochlorothiazide • Hydrochlorothiazide-lisinopril • Hydrochlorothiazide-losartan

G:\2012 HEDIS Toolkits\KY\NA019250_PRO_GDE_ENG_KY_06_12.docx


compliance with the HEDIS® 2012 Volume 2 Technical Specifications Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement.



Musculoskeletal Conditions

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 within 28 days of the diagnosis.

ICD9-CM Diagnosis: 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5, 724.6, 724.7, 738.5, 739.3, 739.4, 846, 847.2

Osteoporosis Management in Women who had a fracture: The percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. CPT Codes: 76977, 77078-77083, 78350, 78351 HCPCS G0130 FDA-Approved Osteoporosis Therapies Description Biphosphonates • Alendronate

Estrogens

• Conjugated estrogens • Conjugated estrogens synthetic • Esterified estrogens • Estradiol • Estropipate

Sex Hormones Combinations

• Conjugated estrogens-medroxy-progesterone • Ethinyl estradiol-norethindrone

Other agents

• Calcitonin • Raloxifene • Teriparatide

Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis: 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 a disease modifying anti-rheumatic drug (DMARD). ICD9-CM Diagnosis: 714.0, 714.1, 714.2, 714.81 DMARDs 5-Aminosalicylates • Sulfasalazine Alkylating agents • Cyclophosphamide Aminoquinolines • Hydroxychloroquine Anti-rheumatics • Auranofin

• Leflunomide • Methotrexate

Immunomodulators • Adalimumab • Golimumab

Immunosuppressive agents

• Azathioprine • Cyclosporine • Mycophenolate

Tetracyclines • Minocycline






Medication Management

Medication Reconciliation Post-Discharge: Percentage of discharges from January 1 to December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge. CPT II Codes: 1111F

Annual Monitoring for Patients on Persistent Medications: Percentage of members 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 at least one therapeutic monitoring event for the therapeutic agent in the measurement year. CPT Codes: Physiologic Monitoring Tests – 80047, 80048, 80050, 80051, 80053, 80069, 82565, 82575, 84132, 84520,

84525 Drug Serum Concentration Monitoring Tests – 80156, 80157, 80164, 80184, 80185, 80186

Diuretics Inotropic agents • Digoxin Antihypertensive combinations

• Amiloride-hydrochlorothiazide • Atenolol-chlorthalidone • Benazepril-hydrochlorothiazide • Bisoprolol-hydrochlorothiazide • Captopril-hydrochlorothiazide • Enalapril-hydrochlorothiazide • Hydrochlorothiazide-lisinopril • Hydrochlorothiazide-losartan • Hydrochlorothiazide-methyldopa • Hydrochlorothiazide-propranolol • Hydrochlorothiazide-spironolactone • Hydrochlorothiazide-triamterene

Loop diuretics • Bumetanide • Furosemide

Potassium-sparing diuretics

• Spironolactone

Thiazide Diuretics • Chlorothiazide • Chlorthalidone • Hydrochlorothiazide • Indapamide • Metolazone

Anticonvulsants Barbiturates • Phenobarbital Dibenzazepine • Carbamazepine Hydantoin • Phenytoin Miscellaneous • Divalproex sodium

• Valproic acid






Potentially Harmful Drug-Disease Interactions in the Elderly: Percentage of members 65 years of age and older who have evidence of an underlying disease, condition of health concern and who were dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis.

ICD9-CM Diagnosis:

Falls - E880, E884, E885.9, E887, E888 Psychosis - 290.11, 290.12, 290.20, 290.3, 290.41, 290.42, 290.8, 290.9, 293, 294.11, 295, 296.x4, 297, 298 Dementia - 290, 291.2, 292.82, 294.0, 294.1, 294.8, 331.0, 331.1, 331.82

CPT Codes:

Hip Fractures - 27230, 27232, 27235, 27236, 27238, 27240, 27244-27246, 27248, 27254, 27267-27269, 27767-27769 Chronic Renal Failure - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90921, 90925, 90935, 90937, 90940, 90945, 90947, 90960- 90962, 90966, 90970, 90989, 90993, 90997, 90999, 99512

Tricyclic Antidepressants Psychotherapeutic combinations

• Amitriptyline-chlordiazepoxide • Amitriptyline-perphenazine

Tricyclic antidepressants

• Amitriptyline • Amoxapine • Clomipramine • Doxepin • Imipramine

Antipsychotics and Sleep Agents Miscellaneous antipsychotic agents

• Clozapine • Haloperidol • Loxapine • Pimozide • Quetiapine • Risperidone

Miscellaneous anxiolytics, sedatives and hypnotics

• Zolpidem

Phenothiazine antipsychotics

• Prochlorperazine • Chlorpromazine • Fluphenazine • Perphenazine • Thioridazine • Trifluoperazine

Thioxanthenes • Thiothixene Medications for Dementia Cholinesterase inhibitors

• Donepezil • Rivastigmine

Miscellaneous central nervous system agents

• Memantine

Anticholinergic Agents Anticholinergic agents • Meclizine Anticholinergic anti- Parkinson agents

• Benztropine • Trihexyphenidyl

Anticholinergics/ • Dicyclomine




Use of High Risk Medications in the Elderly:



antispasmodics • Hyoscyamine

• Propantheline Antihistamines • Chlorpheniramine

• Cyproheptadine • Diphenhydramine • Hydroxyzine hydrochloride • Hydroxyzine pamoate

Skeletal muscle relaxants

• Carisoprodol • Chlorzoxazone • Cyclobenzaprine • Methocarbamol

Upper respiratory combinations

• Brompheniramine/dextromethorphan • Chlorpheniramine/codeine/pseudoephedrine • Chlorpheniramine/dextromethorp/phenylephrine • Chlorpheniramine/dextromethorphan/PSE • Chlorpheniramine/hydrocodone/PSE • Codeine/phenylephrine/promethazine • Codeine-promethazine • Phenylephrine-promethazine

Urinary antispasmodics

• Oxybutynin

NSAIDs and Cox-2 Selective NSAIDs Cox-2 inhibitors • Celecoxib Nonsteroidal anti- inflammatory agents

• Diclofenac potassium • Diclofenac sodium • Etodolac • Fenoprofen • Flurbiprofen • Ibuprofen • Indomethacin • Ketoprofen • Ketorolac • Meloxicam • Nabumetone • Naproxen • Naproxen sodium • Oxaprozin • Piroxicam • Sulindac • Tolmetin






Percentage of members 65 years of age and older who received at least one high-risk medication.

Percentage of members 65 years of age and older who received at least two different high-risk medications. High-Risk Medications Antianxiety • Meprobamate Analgesics • Ketorolac Antihistamines • Cyproheptadine

• Diphenhydramine • Hydroxyzine hydrochloride • Hydroxyzine pamoate • Phenylephrine-promethazine • Promethazine

Antipsychotic, typical • Thioridazine Amphetamines • Amphetamine-dextroamphetamine

• Dexmethylphenidate • Dextroamphetamine • Methylphenidate

Barbiturates • Phenobarbital Long-acting benzodiazepines

• Amitriptyline-chlordiazepoxide • Chlordiazepoxide • Diazepam

Calcium channel blockers

• Nifedipine—short-acting only

Gastrointestinal antispasmodics

• Dicyclomine • Propantheline

Belladonna alkaloids • Atropine • Atropine-diphenoxylate • Hyoscyamine • Hyoscyamine/methenam/m-blue/phenyl salicyl

Skeletal muscle relaxants

• Carisoprodol • Chlorzoxazone • Cyclobenzaprine • Methocarbamol

Oral estrogens • Conjugated estrogen • Conjugated estrogen-medroxyprogesterone • Esterified estrogen • Estropipate

Oral hypoglycemic • Chlorpropamide Narcotics • Naloxone-pentazocine Vasodilators • Dipyridamole—short-acting only

• Ergot mesyloid Others (including androgens and anabolic steroids, thyroid drugs, urinary anti-infectives)

• Methyltestosterone • Nitrofurantoin macrocrystals • Nitrofurantoin macrocrystals-monohydrate • Thyroid desiccated

HEDIS® Quick Reference Guide for Pediatrics The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in


HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: HEDIS® 2012 Volume 2 Technical Specifications NA019251_PRO_GDE_ENG Internal Approval 06202012 ©WellCare 2012 KY_06_12

Updated: 10/11/2012

46079

Prevention and Screening

Lead Screening in Children: Percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday. CPT Codes 83655

Childhood Immunizations by their 2nd Birthday: Percentage of children two years of age who had four DTaP, three IPV, one MMR, two H influenza type B, three hepatitis B, one chickenpox vaccine (VZV), four pneumococcal conjugate, two hepatitis A, two or three rotavirus, and two influenza vaccines on or before their second birthday.

CPT Codes

DTap – 90698, 90700 90721, 90723 HepA - 90633 HepB – 90723, 90740, 90744, 90747, 90748 HIB – 90645, 90646, 90647, 90648, 90698, 90721, 90748 Influenza – 90655, 90657, 90661, 90662 IPV – 90698, 90713, 90723 MMR – 90707, 90710 MR – 90708 Measles – 90705 Mumps – 90704 Rubella – 90706 Pneumo – 90669, 90670 Rotavirus (2 dose) – 90681 / (3 dose) - 90680 VZV – 90710, 90716

Immunizations for Adolescents: Percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

CPT Codes

Diphtheria - 90719 Mening – 90733, 90734 Td – 90714, 90718 Tdap – 90715 Tetanus – 90703

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of members 3 –17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

*Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.

ICD9-CM Diagnosis

V85.51 - Body Mass Index, pediatric, less than 5th percentile for age V85.52- Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age V85.53- Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age V85.54- Body Mass Index, pediatric, greater than or equal to 95th percentile for age

CPT Codes

Outpatient Visits – 99201-99205, 99211-99215, 99217-99220, 99411, 99412, 99241-99245, 99341-99345, 99347-99350 Evaluations – 99420, 99455, 99456 Counseling – 99381-99387, 99391-99397, 99401-99404, 99429, 97802-97804

HCPCS Nutritional Counseling - G0270, G0271, S9449, S9452, S9470




Updated: 10/11/2012

46079

Physical Activity Counseling – S9451

Chlamydia Screening in Women: Percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. CPT Codes 87110, 87270, 87320, 87490, 87491, 87492, 87810

Cervical Cancer Screening: Percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer during the measurement year or the two years prior to the measurement year. CPT Codes 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Exclusion Criteria Women who had a total hysterectomy with no residual cervix are excluded.

CPT Codes

51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-58554, 58570-58573, 58951, 58953, 58954, 58956, 59135

ICD-9 CM Diagnosis 618.5, V67.01, V76.47, V88.01, V88.03

Utilization

Well-Child Visits in the First 15 months of Life: Percentage of members who turned 15 months old during the measurement year and who had 6 or more well-child visits with a primary care provider during their first 15 months of life. ICD9-CM Diagnosis V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT Codes 99381, 99382, 99391, 99392, 99432, 99461

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life: Percentage of members who were three, four, five, or six years of age who received one or more well-child visits with a primary care provider during the measurement year. ICD9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT Codes 99382, 99383, 99392, 99393

Adolescent Well-Care Visits: Percentage of members 12 –21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year. ICD9-CM Diagnosis

V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

CPT Codes 99383-99385, 99393-99395

Access/Availability of Care

Children & Adolescents Access to Primary Care Practitioners: Percentage of members 12 months – 19 years of age who had a visit with a PCP. ICD9-CM Diagnosis

V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

CPT Codes 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401- 99404, 99411-99412, 99420, 99429




Updated: 10/11/2012

46079

HCPCS G0438, G0439

Annual Dental Visits: Percentage of members 2–21 years of age who had at least one dental visit during the measurement year. (This measure applies only if dental care is a covered benefit in the organization's Medicaid contract.) Dental Visit Codes 70300, 70310, 70320, 70350, 70355

Prenatal Care & Frequency of Ongoing Prenatal Care: Prenatal Care - Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment.

Frequency of Ongoing Prenatal Care - The percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that had <21 percent, 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of expected prenatal visits. ICD9-CM 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-V23, V28

CPT Codes:

E/M – 99201-99205, 99211-99215, 99241-99245 OB Fetal Monitoring – 76801, 76805, 76811, 76813, 76815-76821, 76825-76828 OB Panel – 80055 TORCH - 86644

HCPCS: H1000-H1004

Postpartum Care The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. ICD-9 CM Diagnosis V24.1, V24.2, V25.1, V72.3, V76.2

CPT Codes 57170, 58300, 59430, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175, 99501

HCPCS G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 CPT II Codes 0503F

Respiratory Conditions

Appropriate Testing for Children With Pharyngitis: Percentage of children 2 –18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test; 3 days before diagnosis, the day of diagnosis, or 3 days after diagnosis. Strep Test Codes 87070, 87071, 87081, 87430, 87650-87652, 87880

Appropriate Treatment for Children with Upper Respiratory Infection: Percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. ICD9-CM Diagnosis 460, 465

Use of Appropriate Medications for People with Asthma: Percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. ICD9-CM Diagnosis 493.0, 493.1, 493.8, 493.9

FDA-Approved Asthma Medications Antibody inhibitor • Omalizumab Inhaled steroid • Budesonide-formoterol




Updated: 10/11/2012

46079

combinations • Fluticasone-salmeterol • Mometasone-formoterol






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. Two rates are reported: 1. Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. 2. Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. ICD9-CM Diagnosis 493.0, 493.1, 493.8, 493.9

FDA-Approved Asthma Medications Antibody inhibitor • Omalizumab

Inhaled steroid combinations

• Budesonide-formoterol • Fluticasone-salmeterol • Mometasone-formoterol







Updated: 10/11/2012

46079



Diabetes

Comprehensive Diabetes Care (CDC): The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had each of the following: • Hemoglobin A1c (HbA1c) testing • HbA1c poor control (>9.0%) • HbA1c control (<8.0%) • HbA1c control (<7.0%) • Eye exam (retinal) performed by an eye care provider • LDL-C screening • LDL-C control (<100 mg/dL) • Medical attention for nephropathy • BP control (<140/80 mm Hg) • BP control (<140/90 mm Hg)

*Additional exclusion criteria are required for this indicator. This indicator is reported only for the commercial and Medicaid product lines. The exclusion criteria are: CABG or PCI, IVD, CHF, Prior MI, CRF, Dementia, Blindness, Amputation of lower extremity.

HbA1C Testing CPT Codes – 83036, 83037

CPT II Codes – 3044F (<7.0%), 3045F (7.0 – 9.0%), 3046F (>9%)

LDL-C Screening CPT Codes – 80061, 83700, 83701, 83704, 83721 CPT II Codes – 3048F (<100 mg/dl), 3049F (100-129 mg/dl), 3050F (≥130 mg/dl)

Nephropathy Screening

CPT Codes – 82042, 82043, 82044, 84156 CPT II Codes – 3060F, 3061F

Urine Macroalbumin

CPT Codes – 81000-81003, 81005 CPT II Codes – 3062F

Evidence of Treatment for Nephropathy

ICD9-CM Diagnosis - 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0, V45.1 CPT Codes - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512

ACE/ARB Therapy CPT II Codes: 4009F

Angiotensin converting enzyme inhibitors

• Benazepril • Captopril • Enalapril • Lisinopril

Angiotensin II inhibitors • Losartan Antihypertensive combinations • Benazepril-hydrochlorothiazide

• Captopril-hydrochlorothiazide • Enalapril-hydrochlorothiazide • Hydrochlorothiazide-lisinopril • Hydrochlorothiazide-losartan

HEDIS® Quick Reference Billing Guide The following diagnosis and/or procedure codes are in compliance with

the HEDIS® 2012 Volume 2 Technical Specifications Reimbursements of these codes may be different based on your contractual fee schedule.

Behavioral Health

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 health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. ICD9-CM Diagnosis 295-299, 300.3, 300.4, 301, 308, 309, 311-314

Follow-Up Care for Children Prescribed ADHD Medications: Percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported.

Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.

Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who 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 with a practitioner within 270 days (9 months) after the Initiation Phase ended.

CPT Codes 90804-90815, 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383, 99384, 99393, 99394, 99401-99404, 99411, 99412, 99510

HCPCS G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485

ADHD Medications

CNS Stimulants

• Amphetamine- dextroamphetamin • Dexmethylphenidate • Dextroamphetamine • Methylphenidate


NA019251_PRO_GDE_ENG Internal Approval 06202012 ©WellCare 2012 KY_06_12 46079

CLINICAL PRACTICE GUIDELINE FOR PROVIDERS: ADULT PREVENTIVE HEALTH

HS-1018

Clinical Practice Guideline Original Effective Date: 2/2008 Revised: 2/2010, 5/19/2011

page 1


Clinical Practice Guideline for Providers: Adult Preventive Health

The best practice recommendations detailed below represent services that are considered medically necessary by WellCare for the prevention of certain diseases and medical conditions in adults. WellCare strongly recommends that all members receive the necessary preventive services, leading to improved healthcare quality and outcomes.

Frequency of Physical Examination

All members should visit their physician on a regular basis. A baseline physical exam visit should occur for all new non- pregnant adult members regardless of age, within the first 90 days of enrollment. Pregnant members should be seen within the first 14 days of enrollment. Recommendations for periodic health exam visits for asymptomatic adults are as follows:

• Ages: 18 to 39 years: Exam frequency: every 1 to 3 years (annual Pap smears are indicated for females

unless 3 consecutive normal smears, allowing pap smears every 3 years) • Ages 40 to 64 years: Exam Frequency: every 1 to 2 years based on risk factors • Ages 65 and Over: Exam frequency: every year

Age Screening Frequency

• 18 and older Blood Pressure, Height, Body Mass Index (BMI), Alcohol Use

Annually, 18-21 years. After 21, every 1-2 years or per PCP recommendations

• Male > 35 years or female > 45 years of

age or any adults age 20 or older at high risk

Cholesterol

Every 5 years (More frequent if elevated)

• Male 35 – 65 years • Female 45 - 65 years

Cholesterol

Every 5 years (More frequent if elevated)

• Female 18 years of age and older who are sexually active or pregnant (consider at age 12 if sexually active)

Pap Smear and Chlamydia Every 1-3 Years or per PCP’s recommendations

• Female 40 years and older Mammography Every 1-2 years • 50 years and older • 50 years and older

Colorectal Hearing Screening

Periodically depending upon test Periodically

• Female > 65 years old, or > 60 years at risk

• 65 years and older, or younger for those

that have diabetes or other risk factors

Osteoporosis (Bone Mass Measurement)

Vision including a Glaucoma or Diabetic Retinal exam as needed

Every two years or per PCP’s recommendations

Every two years for routine exams or Annual if Diabetic or other risk factors


HS-1018


page 2


Immunization* (see attached schedule) • Tetanus-Diphtheria and acellular

pertussis (Td/Tdap) 18 years and older, Tdap: Substitute 1-time dose of Tdap for Td then boost with Td every 10 years

• Varicella (VZV) All adults without evidence of immunity to varicella should receive 2 doses of single- antigen varicella vaccine if not previously vaccinated or the second dose if they have received only 1 dose,.

• Measles, Mumps, Rubella (MMR)

Adults born during or after 1957 should receive 1-2 doses

• Pneumococcal polysaccharide (PPSV)

65 years of age and older, all adults who smoke or have certain chronic medical conditions – 1 dose may, need a 2nd dose if identified at risk.

• Seasonal Influenza All adults annually • Hepatitis A Vaccine (HepA) All unvaccinated individual who anticipate close contact with an international adoptee

or those with certain high-risk behaviors. • Hepatitis B vaccine (HepB) Adults at risk, 18 years of age and older – 3 doses • Meningococcal conjugate

vaccine (MCV) College freshmen living in dormitories not previously vaccinated with MCV and others at risk, 18 years of age and older – 1 dose. Meningococcal polysaccharide vaccine) is preferred for adults aged > 56 years.

• Human Papillomavirus (HPV)** * For eligible members through 26 years of age (three dose series) • Zoster Age 60 and older 1 dose • Haemophilus Influenza type b

(Hib) For eligible members who are at high-risk and who have not previously received Hib vaccine (1 dose)

Prevention

• Discuss aspirin to prevent cardiovascular events. Men – 40 years and older periodically Women – 50 years and older periodically

• Discuss the importance of preventive exams (Mammograms and Breast self-examination for women at high risk and who have family history.)

• Discuss prostate-specific antigen (PSA) test and rectal exam for men after 40 years old per PCP discretion.

Counseling

• Calcium intake: 1,000mg/day (women age 18-50 years old), 1200-1500 mg/day (women >50 years). • Folic Acid: 0.4 mg/day (women of childbearing age) ; women who have had children with Neural Tube Defects

(NTD) should take 4 mg/day. • Breastfeeding: Women after childbirth. • Tobacco cessation, drug and alcohol use, STD’s and HIV, nutrition, physical activity, sun exposure, oral health,

and injury prevention. • Medication list. • Advance directives.

* Unless there is a medical reason not to get a specific vaccine **Subject to individual state coverage.


HS-1018


page 3


Recommended adult immunization schedule, by vaccine and age group United States 2011

Vaccines that might be indicated for adults, based on medical and other indications - United States, 2011


HS-1018


page 4


References

Centers for Disease Control and Prevention. Recommended adult immunization schedule---United States, 2011. MMWR 2011;60(4). The recommended adult immunization schedule has been approved by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians.

Guide to Clinical Preventive Services, 2007: Recommendations of the U.S. Preventive Services Task Force, 2007. Press Release CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination June 29, 2006 Recommended Adult Immunization Schedule – United States, 2010

Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) May 2001 Bone Health and Osteoporosis: A Report of the Surgeon General (2004)

Cleveland Clinic www.cchs.net/health/health-info Periodic Health Exams and Cancer Screening

ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice, April 2008.

http://www.cchs.net/health/health-info


HS-1018


page 5


Legal Disclaimer: Clinical practice guidelines made available by WellCare are informational in nature and are not a substitute for the professional medical judgment of treating physicians or other health care practitioners. These guidelines are based on information available at the time and may not be updated with the most current information available at subsequent times. Individuals should consult with their physician(s) regarding the appropriateness of care or treatment options to meet their specific needs or medical condition. Disclosure of clinical practice guidelines is not a guarantee of coverage. Members of WellCare health plans should consult their individual coverage documents for information regarding covered benefits. WellCare does not offer medical advice or provide medical care, and therefore cannot guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for any deficiencies in the information contained herein or for any inaccuracies or recommendations made by independent third parties from whom any of the information contained herein was obtained.

The WellCare Group of Companies

Harmony Behavioral Health, Inc. ~ Harmony Behavioral Health of Florida, Inc. ~ Harmony Health Plan of Illinois, Inc. HealthEase of Florida, Inc. ~ ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.

WellCare Health Insurance of Illinois, Inc. ~ WellCare Health Insurance of New York, Inc. WellCare Health Plans of New Jersey, Inc. ~ WellCare of Florida, Inc. ~ WellCare of Connecticut, Inc.

WellCare of Georgia, Inc. ~ WellCare of Kentucky, Inc. ~ WellCare of Louisiana, Inc. ~ WellCare of New York, Inc. WellCare of Ohio, Inc. ~ WellCare of Texas, Inc. ~ WellCare Prescription Insurance, Inc.

Date History and Revisions 12/1/2011 • New template design approved by MPC. 5/19/2011 • Approved by MPC.

PEDIATRIC PREVENTIVE HEALTH CARE GUIDELINES FOR PROVIDERS HS-1019

Clinical Practice Guideline Original Effective Date: 2/2010 Revised: 10/2010, 5/2011

page 1


2011 Pediatric Preventive Health Care Guidelines for Providers

Copyright © 2008 by the American Academy of Pediatrics. Please see the following link for additional information concerning the AAP recommendations. http://brightfutures.aap.org/ Reference: American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008.

http://brightfutures.aap.org/

http://brightfutures.aap.org/



page 2


Recommended immunization schedule for persons aged 0 through 6 years --- United States, 2011

(for those who fall behind or start late, see the catch-up schedule)

Reference: The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

Recommended immunization schedule for persons aged 7 through 18 years --- United States, 2011

(for those who fall behind or start late, see the schedule below and the catch-up schedule)

Reference: The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).



page 3


Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are

more than 1 month behind --- United States, 2011

PERSONS AGED 4 MONTHS THROUGH 6 YEARS

Vaccine Minimum Age for Dose 1

Minimum Interval Between Doses

Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to

Dose 5

Hepatitis B1 Birth 4 weeks 8 weeks

(and at least 16 weeks after first dose)

Rotavirus2 6 wks 4 weeks 4 weeks2

Diphtheria, Tetanus, Pertussis3 6 wks 4 weeks 4 weeks 6 months 6 months3

Haemophilus influenzae type b4 6 wks 4 weeks

if first dose administered at younger than age 12 months

8 weeks (as final dose)

if first dose administered at age 12-- 14 months

No further doses needed

if first dose administered at age 15 months or older

4 weeks4

if current age is younger than 12 months 8 weeks (as final dose)4

if current age is 12 months or older and first dose administered at younger than age 12 months and second dose administered at younger than 15 months No further doses needed if previous dose administered at age 15 months or older

8 weeks (as final dose) This dose only necessary for children aged 12 months through 59 months who received 3 doses before age 12 months



page 4


Pneumococcal5 6 wks 4 weeks


8 weeks (as final dose for healthy children)

if first dose administered at age 12 months or older or current age 24 through 59 months


for healthy children if first dose administered at age 24 months or older

4 weeks if current age is younger than 12 months

8 weeks

(as final dose for healthy children)

if current age is 12 months or older


for healthy children if previous dose administered at age 24 months or older

8 weeks (as final dose) This dose only necessary for children aged 12 months through 59 months who received 3 doses before age 12 months or for high-risk children who received 3 doses at any age

Inactivated Poliovirus6 6 wks 4 weeks 4 weeks 6 months

Measles,Mumps, Rubella7 12 mos 4 weeks

Varicella8 12 mos 3 months

Hepatitis A9 12 mos 6 months

PERSONS AGED 7 THROUGH 18 YEARS

Tetanus,Diphtheria/ Tetanus,Diphtheria,Pertussis10

7 yrs10 4 weeks 4 weeks


6 months

if first dose administered at 12 months or older

6 months if first dose administered at younger than age 12 months



page 5


Human Papillomavirus11

9 yrs Routine dosing intervals are recommended11

Hepatitis A9 12 mos 6 months

Hepatitis B1 Birth 4 weeks 8 weeks

(and at least 16 weeks after first dose)

Inactivated Poliovirus6 6 wks 4 weeks 4 weeks 6 months

Measles,Mumps, Rubella7 12 mos 4 weeks

Varicella8 12 mos 3 months

if person is younger than age 13 years

4 weeks

if person is aged 13 years or older

For more information on Pediatric Immunization schedules, please click here: http://www.cdc.gov/vaccines/recs/schedules/default.htm

References

Centers for Disease Control and Prevention. Recommended childhood immunization schedule---United States, 2011. MMWR 2011;60(4).

The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

http://www.cdc.gov/vaccines/recs/schedules/default.htm



page 6


Legal Disclaimer: Clinical practice guidelines made available by WellCare are informational in nature and are not a substitute for the professional medical judgment of treating physicians or other health care practitioners. These guidelines are based on information available at the time and may not be updated with the most current information available at subsequent times. Individuals should consult with their physician(s) regarding the appropriateness of care or treatment options to meet their specific needs or medical condition. Disclosure of clinical practice guidelines is not a guarantee of coverage. Members of WellCare health plans should consult their individual coverage documents for information regarding covered benefits. WellCare does not offer medical advice or provide medical care, and therefore cannot guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for any deficiencies in the information contained herein or for any inaccuracies or recommendations made by independent third parties from whom any of the information contained herein was obtained.

The WellCare Group of Companies

Harmony Behavioral Health, Inc. ~ Harmony Behavioral Health of Florida, Inc. ~ Harmony Health Plan of Illinois, Inc. HealthEase of Florida, Inc. ~ ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.

WellCare Health Insurance of Illinois, Inc. ~ WellCare Health Insurance of New York, Inc. WellCare Health Plans of New Jersey, Inc. ~ WellCare of Florida, Inc. ~ WellCare of Connecticut, Inc.

WellCare of Georgia, Inc. ~ WellCare of Kentucky, Inc. ~ WellCare of Louisiana, Inc. ~ WellCare of New York, Inc. WellCare of Ohio, Inc. ~ WellCare of Texas, Inc. ~ WellCare Prescription Insurance, Inc.

Date History and Revisions 12/1/2011 •New template design approved by MPC. 5/2011 •Approved by MPC.

Source: HEDIS® 2012 Volume 2 Technical Specifications. The guidelines above are HEDIS measures and should not take the

place of clinical practice guidelines.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Reimbursement for these services will be in

accordance with the terms and conditions of your agreement.

GA019209_PRO_GDE_ENG State Approved MMDDYYYY © WellCare 2012 GA_05_12 45930

HEDIS Guide ADULT QUICK TIPS ADULT QUICK TIPS

Submit consistent, detailed claims to help reduce medical record review in your offices. Include all existing conditions on the claim at the time of each visit. Schedule regular checkups and/or blood work for members who are on long term medications. Assess member compliance/adherence to long-term medication therapy. Document in your medical record all the procedures done by other physicians, including the date performed and the result of the test. Include physician’s name and specialty type (i.e. GYN). Men and Women’s Preventive Health Visit: One annual preventive health visit. CPT Codes: Ages 18–39: 99385, Ages 40–64: 99386, Ages 65+: 99387 • Cervical Cancer Screening: Women ages 21–64 years

should have an exam every 1-3 years (annual Pap smears are indicated for females unless 3 consecutive normal Pap smears, then may decrease to every 3 years). Sample must be sent to lab vendor for analysis. Exam can be done by PCP.

• Chlamydia Screening: Sexually active women ages 16–24 years should be tested with either a urine analysis or Pap smear. Sample must be sent to lab vendor for analysis.

• Breast Cancer Screening: Women ages 40–69 years should be referred for a Screening Mammogram at least every 2 years.

• Osteoporosis Management: Women ages 67+ years, who have had a fracture need a Bone Mineral Density Test or a prescription for appropriate osteoporosis treatment within 6 months of the fracture.

Referrals for Adult Men and Women: Colorectal Cancer Screening: Ages 50–75 years should have an annual FOBT. Samples sent to lab vendor for analysis, or refer for a Sigmoidoscopy or Colonoscopy. Glaucoma Screening: Ages 65+ years, or younger for those that have diabetes, or other risk factors by an optometrist or ophthalmologist, at least every other year. Body Mass Index (BMI): To be calculated and documented at every visit. Please add the following Dx codes to your claim: Adult BMI values:

o Less than 19: V85.0 o 19 to 24: V85.1 o 25.0 to 29.9: V85.21 - V85.25 o 30.0 to 39.9: V85.30 – V85.39 o 40.0 to 49.9: V85.41 – V85.42 o 50.0 to 59.9: V85.43 o 60.0 to 69.9: V85.44 o 70+: V85.45

If dispensing an antibiotic please submit an appropriate diagnosis to substantiate reason for prescription (i.e. Secondary infection such as sinusitis or otitis media).

Tobacco Cessation: For active tobacco users, counsel regarding Tobacco Cessation Strategies and Medications.

CPT Codes: 99406, 99407

Care of Older Adults: Ages 66+ years, an annual assessment of the following: • Advance Care Planning: Advanced directives, living

wills. CPT II Code: 1157F • Medication Review and List of Medications: Must

review medications and have a list of medications in the medical record with the same date of service as the review of the medications. o Med. Review CPT Code: 90862 AND o Medication List CPT II Code: 1159F

• Functional Status Assessment: Documentation of IADLs, cognitive status, ambulation status, sensory ability. CPT II Code: 1170F

• Pain Screening: Notation of a comprehensive pain assessment and treatment plan or notation of no pain and documentation of any interventions to alleviate the pain. CPT II Code: 0521F

Medication Reconciliation Post-Discharge: Ages 66+ years, who have had an inpatient admission should be seen within 30 days of discharge and their medications should be reviewed, including a list of the current medications. CPT II Code: 1111F High Risk Medication Management: Please review members’ medication list for “high risk” medications according to CMS requirements and adjust accordingly. Appropriate Testing for Persistent Medications: Members on ACE/ARBs, digoxin or diuretics should have a serum K+ AND a serum creatinine or a BUN annually. Members on anticonvulsant therapy should have a serum drug level annually. Comprehensive Diabetes Care: Annual screenings for diabetic members. Samples should be sent to lab vendor for analysis. If labs done in the office, please use the following codes on claims for results: • HbA1c Results: HbA1c is <7%: 3044F; HbA1c is 7%-

9%: 3045F; HbA1c is >9%: 3046F • LDL-C Results: LDL-C <100: 3048F; LDL-C 100–129:

3049F; LDL-C >130: 3050F • Nephropathy Screening: CPT II Codes: 3060F, 3061F • Annual Dilated Retinal Eye Exam: By optometrist or

ophthalmologist • Blood Pressure: o Systolic BP <130: 3074F; Systolic BP 130–139: 3075F;

Systolic BP >140: 3077F o Diastolic BP <80: 3078F; Diastolic BP 80–89: 3079F;

Diastolic BP >90: 3080F Use of Appropriate Medications for People with Asthma: Ages 5–64 years diagnosed with persistent asthma should be on appropriate medications for control. Ensure members are filling prescriptions regularly. • Appropriate Medications: Anti-asthmatic combinations,

antibody inhibitors, inhaled steroid combinations, inhaled corticosteroids, leukotriene modifiers, mast cell stabilizers, methylxanthines.

• Continued medication use: Please ensure members refill medications for long-term control of asthma.

HEDIS Guide PEDIATRIC QUICK TIPS PEDIATRIC QUICK TIPS

Submit consistent, detailed claims to help to reduce medical record review in your offices. Include all existing conditions on the claim, at the time of each visit. Every time you see a member is an opportunity for preventive care as well as sick care. Schedule regular check-ups and/or blood work for members who are on long term medications.

Immunizations for Adolescents: Members 13 years of age o One dose of Meningococcal vaccine:

CPT Code: 90733 o One Tdap, or Td: CPT Code: 90715

th

Assess member compliance/adherence to long term medication therapy (i.e. Asthma medications.)

o Females only: Three doses of HPV by 13 CPT Code: 90649

birthday:

Document all procedures done by other physicians with a date and result. All Well-Child / Well Care Visits must include: • A comprehensive health and developmental history:

physical health, mental health (including social, emotional and behavioral issues), development and nutrition.

• A comprehensive unclothed physical exam: measurements, height/weight, head circumference, general appearance, head/neck/eyes/ears, cardiovascular, respiratory, gastrointestinal, neurological evaluation, reproductive systems and breast, musculoskeletal, lymphatic system, integument, speech patterns, orientation and mental alertness, parent and child interaction/behavior.

• Health education/anticipatory guidance, oral health, infant care, parent interaction, injury/illness prevention and community resources.

Well-Child Visits (0–15 months): Children should be seen 6+ times on or before their 15 month birthday. CPT Codes: Ages 0–12 months: 99391, Ages 1–4: 99392 Childhood Immunizations: Should be given to members according to AAP guidelines and completed by the 2nd birthday. Combination vaccine CPT codes should be used when applicable.

o DTP: 90700 o IPV: 90713 o HIB: 90645 o HEP B: 90744 o VZV: 90716 o MMR: 90707 o HEP A: 90633 o Pneumococcal conjugate: 90669 (7 valent), 90607

(13 valent) o Influenza: 90655 o Rotovirus: Two doses: 90681; Three doses: 90680

Lead Screening: One completed by 2nd birthday. Sample sent to lab vendor for analysis. CPT: 83655

Well-Child Visits (3–6 years): Annual visit for children.

CPT Codes: Ages 1–4: 99392, Ages 5–11: 99393

Adolescent Well-Care Visits (12–21 years): Annual visit for members. Remember to notate discussions around tobacco use, drugs and alcohol, sexual activity, physical activity, tobacco cessation and depression in the medical record. Consider Pelvic exam, Pap Smear and Chlamydia testing at age 12 years, if sexually active

CPT Codes: Ages 12–17: 99394, Ages 18–39: 99395

Weight Assessment & Counseling for Nutrition and Physical Activity for Children/Adolescents (for all children 3–21 years): • Measure BMI Percentile or Value depending on age: Adult BMI Value (Ages 20+ years):

o Less than 19: V85.0 o 19 to 24: V85.1 o 25.0 to 29.9: V85.21 - V85.25 o 30.0 to 39.9: V85.30 – V85.39 o 40.0 to 49.9: V85.41 – V85.42 o 50.0 to 59.9: V85.43 o 60.0 to 69.9: V85.44 o 70+: V85.45

Pediatric BMI (Ages 2–20 years):

o Less than 5th percentile for age: V85.51 o 5th percentile to less than 85th percentile for age:

V85.52 o 85th percentile to less than 95th percentile for age:

V85.53 o greater than or equal to 95th percentile for age:

V85.54 • Nutritional Counseling: Dx Code: V65.3 • Physical Activity: Dx Code: V65.41 Chlamydia Screening: Sexually active females aged 16– 24 years should be tested with either a urine analysis or Pap. Samples sent to lab vendor for analysis. Strep Test: Rapid Strep Test-throat culture samples sent to lab vendor for analysis. • If dispensing an antibiotic please submit a diagnosis to

substantiate reason for prescription. CPT Code: 87880 Use of Appropriate Medications for People with Asthma: Ages 5–64 years diagnosed with asthma should be on appropriate medications for control. Ensure members are filling prescriptions regularly. • Appropriate Medications: Anti-asthmatic combinations,

antibody inhibitors, inhaled steroid combinations, inhaled corticosteroids, leukotriene modifiers, mast cell stabilizers, methylxanthines.

• Continued medication use: Please ensure members refill medications for long-term control of asthma.

Dental Visit: Ages 2–21 years, Annual dental visit.

Source: HEDIS® 2012 Volume 2 Technical Specifications. The guidelines above are HEDIS measures and should not take the place

of clinical practice guidelines.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Reimbursement for these services will be in

accordance with the terms and conditions of your agreement.

GA019209_PRO_GDE_ENG State Approved MMDDYYYY © WellCare 2012 GA_05_12 45930

Documentation Standards for Medical Record Requirements This document outlines the required medical record documentation needed to demonstrate compliance with State required medical record documentation standards.

Kentucky Medical Record Requirements

The medical record organization and documentation shall, at a minimum, require the following: • Member identification information on each page; • Personal/biographical data, including:

o Date of birth o Age o Gender o Marital status for adults o Race or ethnicity o Mailing address o Home and work addresses as applicable o Home and work telephone numbers as applicable o Employer, if applicable o School name for children o Name and telephone information for emergency contact(s) o Consent forms o Language spoken o Guardianship/parent information for children

• Date of data entry and date of encounter; • Provider identification by name; • Allergies, adverse reactions and any known allergies are noted in a prominent location in the

record; • Past medical history, including serious accidents, operations, illnesses. For children, past medical

history includes prenatal care and birth information, operations, and childhood illnesses (i.e. documentation of chickenpox);

• Identification of current problems; • The consultation, laboratory, and radiology reports filed in the medical record shall contain the

ordering provider’s initials or other documentation indicating review; • Behavioral health summary reports as applicable, initial evaluation and routine follow up

consultations; • Documentation of immunizations pursuant to 902 KAR 2:060; • Identification and history of nicotine, alcohol use or substance abuse; • Documentation of reportable diseases and conditions to the local health department serving the

jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR 2:020 as applicable;

• Follow-up visits provided secondary to reports of emergency room care as applicable; • Hospital discharge summaries as applicable; • Advanced medical directives for adults. PCPs have the responsibility to discuss advance medical

directives with adult members at the first medical appointment and chart that discussion in the medical record of the member;

• All written denials of service and the reason for the denial as applicable; • Signature of the provider conducting the encounter; and • Record legibility to at least a peer of the writer. Records judged illegible by one reviewer are

evaluated by another reviewer. NA019853_PRO_GDE_ENG Internal Approved 09042012 © WellCare 2012 KY_07_12 47807

In addition, a member’s medical record shall include the following minimal detail for individual clinical encounters:

• History and physical examination for presenting complaints containing relevant psychological and social conditions affecting the member’s medical/behavioral health, including mental health, and substance abuse status;

• Unresolved problems, referrals and results from diagnostic tests including results and/or status of preventive screening services (i.e. EPSDT) are addressed from previous visits; and

• Plan of treatment that includes: o Medication history, medications prescribed, including the strength, amount, directions for

use and refills; o Therapies and other prescribed regimen; and o Follow-up plans including consultation and referrals and directions, including time to

return.

NA019853_PRO_GDE_ENG Internal Approved 09042012 © WellCare 2012 KY_07_12 47807

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