Idea Transcript
2018 HEDIS®1 Measures Healthcare Effectiveness Data and Information Set *Measures collected with medicalrecord review.
Prevention and Screening Measure
Pneumococcal Vaccination Coverage for Older Adults
Red= new/addition to measures
Blue= Medicare only
Screening, test or care needed •
Adults 65 years and older
Have received the recommended series of pneumococcalvaccines: − 13-valent pneumococcal conjugate v accine(PCV13) and − 23-valent pneumococcal p olysaccharide v accine ( PPSV23)
*Immunizations for Adolescents
NOTE: This measure includes the Human Papillomavirus Vaccine (HPV) for both males and females.
HPV: 90649-90651
th
1 dose Meningococcal (between the 11 and 13 birthdays) and 1 tetanus, diphtheria toxoids and acelluar pertussis (Tdap) and
•
2-dose or 3-dose HPV vaccination series th th (between the9 and 13 birthdays).
Children who turn 13 years old during the measurement year (2017). CPT Codes: Meningococcal: 90734 Tdap: 90715
th
• •
th
NOTE: All vaccines must be completed by the 13 Birthday Documentation of “immunizations are up-to-date” is not acceptable. Exclusion: Contraindication for a specific vaccine (e.g., anaphylactic reaction to the vaccine or its components)
*Childhood Immunization
Children who turn 2 years old during the measurement year (2017). Vaccines must be completed nd on or before the 2 birthday
• • • • • • • • • •
4 DTaP (do not count any before 42 days of age) 3 IPV (do not count any before 42 days of age) 1 MMR 3 HiB (do not count any before 42 days of age) 3 HepatitisB nd 1 VZV, positive serology, or documented chicken pox disease before 2 birthday 4 pneumococcal conjugate 1 HepatitisA 2 or 3 Rotavirus vaccine ( Dosage depends on the vaccine administered) (do not count any before 42 days of age) 2 Influenza with different dates of service (do not count any vaccine given prior to 6 months after birth)
Documentation of “immunizations are up-to-date” is not acceptable. Documentation of an immunization received “at delivery” or “in the hospital” may be counted. Exclusion: Contraindication for a specific vaccine (e.g., anaphylactic reaction to the vaccine or its components) 1
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Updated 8/2/2017
Measure
*Lead Screening in Children (Medicaid only)
Children who turn 2 years old during the measurement year (2017). CPT Code: 83655
Screening, test or care needed •
nd
At least one capillary or venous lead test by their 2 birthday.
Documentation in the record must include both of the following: • Date the test was performed • The result or finding
*Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Members 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and had evidence of the following documented: • BMI percentile • Counseling for Nutrition • Counseling for Physical Activity
ICD-9 Codes: BMI percentile: Z68.51-Z68.54 Counseling for nutrition : Z71.3 Counseling for physical activity: Z02.5 CPT Codes Counseling for nutrition: 97802-97804
BMI Percentile documentation must include date of the BMI and: • BMI percentile (may be plotted on age-growth chart) Weight and height must be taken during the measurement year (2017). Counseling for Nutrition documentation must include a note indicating the date and evidence of at least one of the following: • Engagement in discussion of current nutrition behaviors • Checklist indicating nutrition was addressed • Counseling or referral for nutrition education • Member received educational materials on nutrition during a face-to-face visit • Anticipatory guidance for nutrition • Weight or obesity counseling Counseling for Physical Activity documentation includes a note indicating the date and evidence of at least one of the following: • Engagement in discussion of current physical activity behaviors • Checklist indicating physical activity was addressed • Counseling or referral for physical activity education • Member received educational materials on physical activity during a face-toface visit • Anticipatory guidance for physical activity • Weight or obesity counseling Documentation of meeting Developmental Milestones only does not meet ® HEDIS criteria for Physical Activity Counseling. Services specific to an acute or chronic condition do not count toward the counseling indicators for either nutrition or physical activity.
Non-recommended PSA-Based Screening in Older Men Men age 70 and older Codes to identify PSA-based Screening CPT: 84152-84154
•
Screened unnecessarily for prostate cancer
Exclusions: • Prostate cancer diagnosis • Dysplasia of the prostate • A PSA test during the year prior to the measurement year (2017)where laboratory data indicate an elevated result. • Dispensed prescription for a 5-alpha reductase inhibitor during the measurement year.
Measure
Non-Recommended Cervical Cancer Screening in Adolescent Females
Screening, test or care needed •
Screened unnecessarily for cervicalcancer Note: A lower rate indicates better performance
Adolescent females ages 16-20
Exclusion: History of cervical cancer, HIV or immunodeficiency *Cervical Cancer Screening Women ages 21-64
•
CPT Codes to identify Cervical Cancer Screening
A PAP test (cervical cytology) during the measurement year (2017) or prior two years (2015, 2016) for women ages 21-64
•
Cervical cytology/human papillomavirus (HPV) co-testing during the measurement year (2017) or prior four years (2013-2016) for women ages 30-64.
Cervical cytology: 88141-88143; 88147-88148; 88150; 88152-88154; 88164- 88167; 8817488175 HPV tests: 87620-87622; 87624-87625
Exclusion: Hysterectomy with no residual cervix. Documentation of “complete”, “total” or “radical” abdominal or vaginal hysterectomy meets the criteria. Documentation of “hysterectomy” alone does not meet the criteria.
Chlamydia Screening Females ages 16-24 and identified as sexually active (by claims or pharmacy data)
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At least one test for Chlamydia during the measurement year (2017).
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A screening mammogram or digital breast tomosynthesis on or between October 1, 2015 -December 31,2017.
CPT Codes to identify Chlamydia Screening: 87110; 87270; 87320; 87490- 87492; 87810 Breast Cancer Screening Women ages 50-74 Codes to identify Breast Cancer Screening
Exclusion: Bilateral Mastectomy
CPT: 77055-77057; 77061-77063; 77065-77067 *Colorectal Cancer Screening Adults ages 50-75 CPT Codes to identify Colorectal Cancer Screening FOBT: 82270; 82274 FIT-DNA: 81528 Flexible Sigmoidoscopy: 45330-45335; 45337-45342; 45345-45347; 45349-45350
One or more of the following screenings: • • • • •
Colonoscopy in past 10 years(2008-2017) Flexible sigmoidoscopy in past 5 years(2013-2017) CT Colonography in the past 5 years(2013-2017) FIT-DNA test in the past 3 years(2015-2017) Fecal occult blood test (FOBT)annually(2017)
CT Colonography: 74261-74263 Colonoscopy: 44388-44394; 44397; 44401-44408; 45355; 45378-45393; 45398
Exclusion: Diagnosis of colorectal cancer or total colectomy.
Measure * Adult BMI Assessment The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year (2017) or the year prior to the measurement year (2016). ICD-10 Codes for BMI
Screening, test or care needed For members ages 20 and older, documentation in the medical record must include: • Date of theBMI • Weight • BMI value For members ages 18-19yo, documentation of BMI percentile is required: th • BMI documented as a percentile(e.g.,75 percentile) • BMI percentile plotted on an age- growth chart. ®
Value: Z68.1; Z68.20Z68.39; Z68.41-Z68.45 Percentile: Z68.51-Z68.54
Documentation of height and weight only does not meet HEDIS criteria. Exclusion: Members with a diagnosis of pregnancy in 2016 or 2017 may be excluded from this measure.
Use of Services *Well-child Exams
Ages 0-15 months (turned 15 months during 2017) Codes to Identify Well-Child Visits CPT: 99381-99385; 99391-99395; 99461 ICD-10: Z00.00-Z00.01; Z00.110-Z00.111;
•
Each visit must show evidence of all of the following: • • •
Health and developmental history (physical and mental) Physical exam Health education/anticipatory guidance
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At least one well-care visit with a PCP during the measurement year (2017).
Z00.121; Z00.129; Z00.8; Z02.0; Z02.5
*Well-child Exams Ages 3-6 years Codes to Identify Well-Child Visits CPT: 99381-99385; 99391-99395; 99461 ICD-10: Z00.00-Z00.01; Z00.110-Z00.111; Z00.121; Z00.129; Z00.8; Z02.0; Z02.5
*Adolescent Well-Care Visit Ages 12-21 years Codes to Identify Adolescent Well-Care Visits CPT: 99381-99385; 99391-99395; 99461 ICD-10: Z00.00-Z00.01; Z00.110-Z00.111; Z00.121; Z00.129; Z00.8; Z02.0; Z02.5
6 well-care visits (at least 2 weeks apart) with aPCP/Pediatrician.
Must show evidence of all the following: • • •
Health and development history (physical and mental) Physical exam Health education/anticipatory guidance
•
At least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year(2017).
Must show evidence of all the following: • • •
Health and development history (physical and mental) Physical exam Health education/anticipatory guidance
• • •
Diagnosis of pharyngitis, Prescribed an antibiotic,and Received a group A streptococcus (strep) test in the 7 day period from 3 days prior to, through 3 days after, theprescription date.
Respiratory Conditions
Appropriate Testing of Children with Pharyngitis Children ages 3-18 years ICD-10 Codes to Identify Pharyngitis:
J02.0; J02.8-J02.9; J03.00-J03.01; J03.80-J03.81; J03.90-J03.91
Measure
Screening, test or care needed
Appropriate Treatment of Children with Upper Respiratory Infections Children ages 3 mos-18 yrs ICD-10 Codes to identify URI:
• •
Diagnosis of Upper Respiratory Infection (URI),and Not prescribed an antibiotic within 3 days of URI diagnosis.
• •
Diagnosis of acute bronchitis, and Not dispensed an antibiotic prescription within 3 days of diagnosis.
J00; J06.0; J06.9
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Adults ages 18-64 ICD-10 Codes to identify Acute Bronchitis
Exclusion: members with a diagnosis of any of the following comorbid conditions:
J20.3-J20.9; J40
Emphysema; COPD; Cystic Fibrosis; HIV; Malignant neoplasm
Use of Spirometry Testing in the Assessment and Diagnosis of COPD Adults age 40 and older Codes for Spirometry Testing:
• •
New diagnosis of, (in 2017) or newly active, COPD and Spirometry testing to confirm diagnosis.
CPT: 94010; 94014-94016; 94060; 94070; 94375; 94620
Pharmacotherapy Management of COPD Exacerbation Adults age 40 and older ICD-10 Codes to identify COPD: J44.0-J44.1; J44.9
Members discharged from an acute inpatient admission or an ED encounter with a primary diagnosis of COPD who were dispensed both: • •
A systemic corticosteroid within 14 days of theevent A bronchodilator within 30 days of theevent
• •
Identified as having persistent asthma and Dispensed appropriate medication that they remained on during the treatmentperiod.
Medication Management for People with Asthma Members ages 5-64 ICD-10 Codes to identify Persistent Asthma: 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
Two rates are reported: 1. Members remaining on asthma controller medication for at least 50% of their treatmentperiod. 2.
Members remaining on asthma controller medication for at least 75% of their treatmentperiod.
Cardiovascular Measure
Screening, test or care needed
Statin Therapy for Patients with Cardiovascular Disease Males ages 21-75 and Females ages 40-75
•
Identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria:
Codes to identify ASCVD: CABG: CPT: 33510-33514; 33516-33519; 33521-33523; 33533-33536 MI:
ICD-10: I21.01-I21.02;I21.09; I21.11;
PCI:
CPT: 92920; 92924; 92928; 92933; 92937; 92941; 92943; 92980; 92982; 92995
Two rates are reported: 1.
Received Statin Therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year(2017).
2.
Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period (from prescription date through end of year).
I21.19; I21.21; I21.29;I21.3-I21.4; I22.0-I22.2; I22.8-I22.9; I23.0-I23.8; I25.2
*Controlling High Blood Pressure Adults ages 18-85
• •
Diagnosis of hypertension prior to June 30,2017. Most recent blood pressure reading in the medical record for 2017. Adequate control is defined as: − Ages 18-59: 120mg)
NOTE: Reported as the rate per 1,000. A lower rate indicates better performance. Use of Opioids From Multiple Providers Adults ages 18 and older
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Receiving prescription opioids for ≥15 days during 2017 who received opioids from: − Multiple Prescribers (four or more prescribersduring2017) − Multiple Pharmacies (four or more pharmacies during2017) − Multiple Prescribers and Multiple Pharmacies(both four or more prescribers and four or more pharmacies in2017)
Measure
Screening, test or care needed
Potentially Harmful Drug- Disease Interactions in the Elderly Adults age 65 and older
Three rates are reported: 1.
A history of falls and a prescription for anticonvulsants, SSRI’s, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, ortricyclicantidepressants
2.
Dementia and a prescription for antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants, H2 receptor antagonists, oranticholinergicagents.
3.
Chronic kidney disease and a prescription for Cox-2 Selective NSAIDs or nonaspirin NSAIDs
Use of High-Risk Medications in the Elderly Adults age 66 and older
Two rates are reported: 1.
Members who received at least one dispensing event for a high-risk medication
2.
Members who received at least two dispensing events for the same high-risk medication For both rates, a lower rate represents better performance.
Annual Monitoring for Patients on Persistent Medications Adults age 18 and older
• •
At least 180 days of ambulatory medication therapy during the measurement year (2017)who Received the following lab test monitoring during 2017:
Medications
Annual monitoring lab tests
CPT Codes to identify
ACE / ARBs
A serum potassium test and a serum creatinine test (or a panel containing them)
80051, 84132 82565, 82575
A Digoxin level test and a lab panel test O R A Digoxin level test and both a serum potassium test and a serum creatinine
80162
Diuretics
Dioxin
80047, 80048, 80050, 80053, 80069
80047, 80048, 80050, 80053, 80069
80162 80051, 84132 82565, 82575
Access/Availability of Care Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics Ages 1-17 years Codes to identify psychosocial care: CPT: 90832-90834; 90836-90840; 90845-90847; 90849; 90853; 90875-90876; 90880
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A new prescription (4 month negative medication history) for an antipsychotic medication Documentation of psychosocial care as a first-line treatment
• Exclusions: −
At least one acute inpatient encounter, or at least 2 visits in an outpatient, intensive outpatient or partial hospitalization setting with A diagnosis of schizophrenia, bipolar disorder or other psychotic disorder during the measurement year (2017)
− Adult Access to Preventive/Ambulatory Care Adults age 20 and over
•
An ambulatory or preventive carevisit
− in the measurement year (2017) for Medicaid and M edicare members − in the measurement year or the two years p rior (2015-2017) for Commercialmembers Children and Adolescents’ Access to PCPs Age 12 months to 19 years
*Prenatal/Postpartum Care Pregnant Women who delivered a live infant between November 6, 2016 and November 5, 2017 Initiation and Engagement of Alcohol and Other Drug Dependence (AOD) Treatment Age 13 and older Codes to identify AOD visits: 98960-
98962; 99078; 99201-99205; 99211-99215; 99217-99220; 99241-99245; 99341-99345; 99347-99350; 99384-99387; 99394-99397; 99401-99404; 99408-99409; 99411-99412; 99510
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An ambulatory or preventive carevisit with a PCP −
in the measurement year (2017) for ages 12 months to6years
−
in the measurement year or the year prior(2016-2017) for ages 7 to 19 years
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Prenatal visit within first trimester (or within 42 days of enrollment)
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Postpartum visit between 21 and 56 days after delivery
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A new episode (60 days negative diagnosis history) of alcohol or other drug (AOD) abuse ordependence
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Initiate treatment within 14 days of the diagnosis through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, ormedication-assisted treatment (MAT)
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Receive at least 2 additional AOD services or MAT within 30 days of treatment initiation
Measures Collected through CAHPS Health Plan Survey Medical Assistance with Smoking Cessation Current Smoker/Tobacco user age 18 and older
• • •
Received advice to quit during the measurement year(2017). Discussed or were recommended cessation medications during the measurement year. Discussed or were provided cessation methods or strategies during the measurement year.
Flu Vaccinations for Adults (ages 18-65)
Received an influenza vaccination after July 1, 2017.
Flu Vaccinations for Older Adults (ages 65+)
Pneumococcal Vaccination Status for Older Adults
•
Have ever received a pneumococcal vaccine.
Adults ages 65 and older
Measures Collected through Medicare Health Outcomes Survey (HOS) Fall Risk Management Adults ages 65 and older
Management of Urinary Incontinence in Older Adults
1.
Discussing Fall Risk • Seen by a practitioner in the past 12months • Discussed falls or problems with balance or walking with current practitioner
2.
Managing Fall Risk • Had a fall or problems with balance or walking in the past 12months • Seen by a practitioner in the past 12months • Received a recommendation for how to prevent falls or treat problems with balance or walking from their current practitioner
1.
Discussing Urinary Incontinence • Reported having urine leakage in the past6months • Discussed their urinary leakage problem with a health care provider
2.
Discussing Treatment of Urinary Incontinence • Reported having urine leakage in the past6months • Discussed treatment options for their current urine leakage problem
3.
Impact ofUrinary Incontinence • Reported having urine leakage in the past6months • Reported that urine leakage made them change their daily activities or interfered with their sleep a lot.
Adults ages 65 and older
Osteoporosis Testing in Older Women
•
Women ages 65-85
Physical Activity in Older Adults
Reported ever having received a bone density test to check for osteoporosis
1.
Discussing Physical Activity • Had a doctor’s visit in the past 12 months • Spoke with a doctor or other health provider about their level of exercise or physical activity
2.
Advising Physical Activity • Had a doctor’s visit in the past 12 months • Received advice to start, increase or maintain their level of exercise or physical activity
Adults ages 65 and older
For more information regarding HEDIS® 2018, please contact Quality Improvement Dept. at 757-252-8400 or toll-free at 1-866-425-5257.