care excel quality - c.ymcdn.com · 10.06.2014 · use of imaging studies for low back pain 0052...

Health Care Excel

Measures

NQF# HEDIS UDS PQRS Health PlansNCQA Health Plan Accreditation MU (2014)

ORGANIZATIONAL/FUNCTIONAL MEASURES (2011 PCMH Verbiage) 2011 2014 Stage 1

Enhance Access and ContinuityAccess During Office Hours X X XAfter‐Hours Access X X XElectronic Access (ex: Online Access, Clinical Summaries, Secure Messaging) X X XContinuity X XMedical Home Responsibilities (Informing Patients) XCulturally and Linguistically Appropriate Services X XThe Practice Team (Role Definition, Training) XTeam‐Based CareContinuity X XMedical Home Responsibilities (Informing Patients) XCulturally and Linguistically Appropriate Services X XThe Practice Team (Role Definition, Training) XIdentify and Manage Patient Populations

Measurement Set

PCMH*

QUALITY MEASURE CROSSWALK

PCMH and MU Alignment

Patient Information X X X XClinical Data X X X XComprehensive Health Assessment X XUse of Data for Population Management X X X XImplement Evidence‐Based Decision Support X X XPlan and Manage CareImplement Evidence‐Based Guidelines X XIdentify High‐Risk Patients X X XCare Management X XMedication Management X X X XUse Electronic Prescribing X X XSupport Self‐Care and Shared Decision Making X X XProvide Self‐Care Support and Community ResourcesSupport Self‐Care Process X X XProvide Referrals to Community Resources XTrack and Coordinate CareTest Tracking and Follow‐up X X XReferral Tracking and Follow‐up X X XCoordinate with Facilities and Care Transitions X X X XMeasure and Improve PerformanceMeasure Performance X X XMeasure Patient/Family Experience X X XImplement Continuous Quality Improvement (CQI) X X XDemonstrate CQI X X XReport Performance X XReport Data Externally X XUse Certified EHR Technology X X X

June 10, 2014 of 5

Health Care Excel

NQF# HEDIS UDS PQRS Health PlansNCQA Health Plan Accreditation MU (2014)PCMH*

CLINICAL PERFORMANCE MEASURESAsthma: Assessment of Asthma Control‐ Ambulatory Care 0001 #64 PedsAppropriate Testing for Children with Pharyngitis 0002 CWP #66 A X PedsInitiation and Engagement of Alcohol and Other Drug Dependence Treatment 0004 #305 XControlling High Blood Pressure 0018 CBP X #236 X AdultAnnual Monitoring for Patients on Persistent Medications 0021 MPM AUse of High Risk Medications in the Elderly 0022 DAE #238 X AdultWeight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 0024 WCC #239 C X PedsPreventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 0028 MSC X #226 X (advice only) AdultPhysical Activity in Older Adults 0029 POABreast Cancer Screening (40‐69 years of age) 0031 XCervical Cancer Screening 0032 CCS X #309 A X XChlamydia Screening in Women 0033 CHL #310 W X PedsColorectal Cancer Screening 0034 COL X #113 W X XUse of Appropriate Medications for Asthma 0036 ASM X #311 A X PedsOsteoporosis Testing in Older Women 0037 OTO (S)Childhood Immunization Status 0038 CIS X #240 A, C, W X (combo 2) PedsFlu Vaccinations for Adults Ages 65 and Older 0040 FVO (S)Influenza Immunization 0041 #110 XP i i ti t t f ld d lt 0043 PNU (S) #111 X XPneumonia vaccination status for older adults 0043 PNU (S) #111 X XAsthma: Pharmacologic Therapy for Persistent Asthma‐ Ambulatory Care 0047 X #53Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older 0049 #41Osteoarthritis (OA): Function and Pain Assessment 0050 #109

Osteoarthritis (OA): Assessment for Use of Anti‐Inflammatory or Analgesic Over‐the‐Counter Medications 0051 #142Use of Imaging Studies for Low Back Pain 0052 LBP #312 X AdultOsteoporosis Management in Women who had a Fracture 0053 OMW A, W XRheumatoid Arthritis (RA): Disease Modifying Anti‐Rheumatic Drug (DMARD) Therapy 0054 ART #108 A, WComprehensive Diabetes Care: Eye Exam 0055 [CDC] #117 A, C, W X XDiabetes: Foot Exam 0056 #163 XComprehensive Diabetes Care: HbA1c Testing 0057 [CDC] X A, C, W XAvoidance of Antibiotic Treatment in Adults with Acute Bronchitis 0058 AAB #116 XComprehensive Diabetes Care: Hemoglobin A1C Poor Control (HbA1c >9%) 0059 [CDC] X #1 C, W X XHemoglobin A1C Test for Pediatric Patients 0060 #365 XComprehensive Diabetes Care: Blood Pressure Management/ Control 0061 [CDC]Comprehensive Diabetes Care: Medical Attention for Nephropathy 0062 [CDC] #119 A, C, W X XComprehensive Diabetes Care: LDL‐C Screen 0063 [CDC] A, C, W XComprehensive Diabetes Care: LDL‐C Control 0064 [CDC] #2 W XCAD: ACE Inhibitor or ARB Therapy ‐ Diabetes or Left Ventricular Systolic Dysfunction (LVEF <40%) 0066 #118 AChronic Stable CAD: Antiplatelet Therapy 0067 #6Ischemic Vascular Disease (IVD): Aspirin Therapy 0068 X #204 XAppropriate Treatment for Children with Upper Respiratory Infection 0069 URI #65 A X PedsCoronary Artery Disease (CAD): Beta‐Blocker Therapy ‐ Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) 0070 #7 XPersistence of Beta‐Blocker Treatment After a Heart Attack 0071 PBH A XCoronary Artery Disease: Lipid Control 0074 #197Cholesterol Management for Patients with Cardiovascular Conditions 0075 CMC X #241 A, W (screen) X (screen) XOptimal Vascular Care Composite 0076 #349Heart Failure: Left Ventricular Ejection Fraction Assessment (Outpatient Setting) 0079 #198Heart Failure: Angiotensin‐Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction 0081 #5 X

June 10, 2014 of 5

Health Care Excel


Heart Failure: Beta‐Blocker Therapy for Left Ventricular Systolic Dysfunction 0083 #8 XCOPD: Spirometry Evaluation 0091 #51Medication Reconciliation 0097 MRP #46Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 0098 #48Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older 0099 #49Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older 0100 #50Falls: Screening for Future Fall Risk (Assessment) 0101 FRM #154; #318 GPRO XFalls: Screening for Future Fall Risk (Plan of Care) 0101 FRM #155; #318 GPRO XCOPD: Inhaled Bronchodilator Therapy 0102 #52Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation, Diagnosis and Severity 0103 #106Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0104 #107 XAntidepressant Medication Management 0105 AMM #9 A X XADHD: Follow‐up Care for Children Prescribed ADHD Medication 0108 ADD #366 X PedsBipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use 0110 #367 XBack Pain: Advice Against Bed Rest 0313 #151Back Pain: Advice for Normal Activities 0314 #150Back Pain: Physical Exam 0319 #149Back Pain: Initial Visit 0322 #148Ad C Pl 0326 #47Advance Care Plan 0326 #47HIV/AIDS: Medical Visit 0403 #368 XHIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed 0404 #159 XHIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis 0405 #160 XHIV/AIDS: RNA Control for Patients with HIV N/A #381 XHIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis 0409 #205Preventive Care and Screening: Screening for Clinical Depression and Follow‐up Plan 0418 X #134 Adult, PedsDocumentation of Current Medications in the Medical Record 0419 #130 AdultPain Assessment and Follow‐Up 0420 #131Preventive Care and Screening: BMI Screening and Follow‐up (Adult) 0421 ABA X #128 C, W X AdultFunctional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Knee Impairments 0422 #217Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Hip Impairments 0423 #218

Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Lower Leg, Foot, or Ankle Impairments 0424 #219

Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Lumbar Spine Impairments 0425 #220Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Shoulder Impairments 0426 #221

Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Elbow, Wrist, or Hand Impairments 0427 #222Functional Deficit: Change in Risk‐Adjusted Functional Status for Patients with Neck, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments 0428 #223Pharmacotherapy Management of COPD Exacerbation 0549 PCE XCare for Older Adults (Care Plan, Med Review, Func. Status, Pain Assess.) 0553 COA WComprehensive Diabetes Care: HbA1c control (< 8.0%) 0575 [CDC] X C, WComprehensive Diabetes Care: HbA1c control (< 7.0% for a Selected Population) N/A [CDC] C, WFollow‐up After Hospitalization for Mental Illness (7 day rate) 0576 FUH XUse of Spirometry Testing in the Assessment and Diagnosis of COPD 0577 SPR XPregnant Women who had HBsAg Testing 0608 #369 XHeart Failure: Beta‐Blocker Therapy 0615 ACardiac Rehabilitation Patient Referral from an Outpatient Setting 0643 #243

Endoscopy/Polyp Surveillance Appropriate Follow‐up Interval for Normal Colonoscopy in Average Risk Patients 0658 #320

June 10, 2014 of 5

Health Care Excel


Depression Remission at Twelve Months 0710 #370 XDepression Utilization of the PHQ‐9 Tool 0712 #371 XDiabetes Composite: Optimal Diabetes Care 0729 #319Comprehensive Diabetes Care: Composite Measure 0731 CDCChild and Adolescent Major Depressive Disorder: Suicide Risk Assessment 1365 #382 XAnnual Dental Visit 1388 ADVFrequency of Ongoing Prenatal Care 1391 FPCWell‐Child Visits in the First 15 Months of Life 1392 W15 A, CMaternal Depression Screening 1401 #372 XImmunizations for Adolescents (by 13 years of age) 1407 IMAWell‐Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 1516 W34 A, WPrenatal & Postpartum Care 1517 PPC X XAdult Kidney Disease: Laboratory Testing (Lipid Profile) 1668 #121

Adult Kidney Disease: Patients on Erythropoiesis‐Stimulating Agent (ESA) ‐ Hemoglobin Level >12.0 g/dL 1666 #123Medication Management for People with Asthma 1799 MMAAsthma Medication Ratio 1800 AMRAdherence to Antipsychotic Medications for People with Schizophrenia 1879 SAACardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia 1933 SMCDi b t M it i f P l ith Di b t d S hi h i 1934 SMDDiabetes Monitoring for People with Diabetes and Schizophrenia 1934 SMDHuman Papillomavirus Vaccine for Female Adolescents 1959 HPVHIV Viral Load Suppression 2082 #338Prescription of HIV Antiretroviral Therapy 2083 #339HIV Medical Visit Frequency 2079 #340Gap in HIV Medical Visits 2080 #341

Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Prescribed Antipsychotic Medications N/A SSDAdult Kidney Disease: Blood Pressure Management N/A #122Flu Vaccination for Adults 18‐64 N/A FVA (S) XPotentially Harmful Drug‐Disease Interactions in the Elderly N/A DDEManagement of Urinary Incontinence N/A MUI (S)Aspirin Use and Discussion N/A ASP (S)Breast Cancer Screening (50‐74 years of age within past 27 months) N/A BCS #112 A X XLead Screening in Children N/A LSCGlaucoma Screening for Older Adults N/A GSO XWell Child Visits ‐ Adolescents N/A AWC A, C, WNon‐Recommended Cervical Cancer Screening in Adolescent Females N/A NCSMedication Adherence ‐ Diabetes Medications N/A WMedication Adherence ‐ Statins N/A WMedication Adherence ‐ Blood Pressure Medications N/A WNew HIV Cases with Timely Follow‐up N/A XClosing the Referral Loop: Receipt of Specialist Report N/A #374 AdultFunctional Status Assessment for Complex Chronic Conditions N/A #377 AdultPrimary Caries Prevention Intervention as Offered by Primary Care Providers, Including Dentists N/A #379 XChildren who have Dental Decay or Cavities TBD #378 PedsPreventive Care and Screening: Cholesterol ‐ Fasting LDL‐C Test Performed N/A #316 (combo) XPreventive Care and Screening: Cholesterol ‐ Risk‐Stratified Cholesterol ‐ Fasting LDL‐C N/A #316 (combo) XHypertension: Improvement in Blood Pressure N/A #373 XHypertension: Use of Aspirin or Other Antithrombotic Therapy N/A #295Hypertension: Complete Lipid Profile N/A #296Hypertension: Urine Protein Test N/A #297

June 10, 2014 of 5

Health Care Excel


Hypertension: Annual Serum Creatinine Test N/A #298Hypertension: Diabetes Mellitus Screening Test N/A #299Hypertension: Blood Pressure Control N/A #300Hypertension: LDL‐C Control N/A #301Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed N/A #302Functional Status Assessment for Knee Replacement N/A #375 XFunctional Status Assessment for Hip Replacement N/A #376 XADE Prevention and Monitoring: Warfarin Time in Therapeutic Range N/A #380 XPreventive Care and Screening: Screening for High Blood Pressure and Follow‐up Documented N/A #317 XPreventive Care and Screening: Unhealthy Alcohol Use ‐ Screening N/A #173Rheumatoid Arthritis (RA): Tuberculosis Screening N/A #176Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity N/A #177Rheumatoid Arthritis (RA): Functional Status Assessment N/A #178Rheumatoid Arthritis (RA): Assessment and Classification of Disease prognosis N/A #179Rheumatoid Arthritis (RA): Glucocorticoid Management N/A #180Elder Maltreatment Screen and Follow‐up N/A #181Functional Outcome Assessment N/A #182Asthma: Tobacco Use: Screening‐Ambulatory Care Setting N/A #231Asthma: Tobacco Use: Intervention‐Ambulatory Care Setting N/A #232CAD S t M t N/A #242CAD: Symptom Management N/A #242Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence N/A #247

Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence N/A #248

Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions N/A #325Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 weeks N/A #335Maternity Care: Post Partum Follow‐up and Care Coordination N/A #336

Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier N/A #337

*At least annually, the practice measures or receives data on at least 3 preventive care measures, at least 3 different chronic or acute care clinical measures, at least 2 utilization measures affecting health care costs, and performance data stratified for vulnerable populations.

Created By: Collaborate. Innovate. Improve.

June 10, 2014 of 5

Health Care Excel

UDS PQRSMeasure Identifier

Age/ DemographicsContinuous Enrollment

(CE)Denominator Identification Numerator Requirement

Key Codes ICD‐9, CPT, HCPCS, UBREV

Differences from HEDIS Differences from HEDIS

Appropriate Testing for Children with Pharyngitis

CWP Children 2 years old as of July 1 PY through 18 years old as of July 1 of MY

30d prior through 3d after dx event

Dx of pharyngitis AND antibiotic dispensed ONLY AND no active antibiotics within 30d prior to dx.

Evidence of strep test = compliance. Pharyngitis Dx (Denom): 462, 463, 034.0 Strep Test: 87070, 87071, 87081, 87430, 87650‐87652, 87880

Reporting not available through claims. (Registry, EHR only)

Controlling High Blood Pressure CBP 18 ‐ 85 years old MY Dx of HTN during an outpatient visit in first six months of MY.

Most recent BP (after dx of HTN) in medical record is <140/90

Note: If the member had more than one PCP for the time period, identify the PCP who most recently provided care to the member. Use one medical record to both confirm the dx for the denominator and identify the representative BP level for the numerator.

Hypertension: 401, 401.0, 401.1, 401.9 Requirement:2 or more medical visits in MY

Annual Monitoring for Patients on Persistent MPM

KEY INDICATOR DETAILS

MeasuresHEDIS and NCQA Health Plan

Measurement Set

Annual Monitoring for Patients on Persistent Medications

MPM

‐‐ ACE inhibitor or ARB Members who received at least 180 treatment days of ACE inhibitors or ARBs during the MY.

At least one serum potassium AND either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the MY.

Note: The tests do not need to occur on the same service date, only within the MY.

‐‐ Digoxin Members who received at least 180 treatment days of Digoxin during the MY.

At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the MY.


‐‐ Diuretics Members who received at least 180 treatment days of Diuretics during the MY.

At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the MY.


‐‐ Anticonvulsants Members who received at least 180 treatment days of

At least one drug serum concentration level monitoring test for the prescribed drug during the

Phenobarbital Level: 80184 Carbamazepine Level: 80156

18 and older MY Lab Panel: 80047, 80048, 80050, 80053, 80069ORSerum Potassium Test: 80051, 84132 AND Serum Creatinine: 82565, 82575ORSerum Potassium Test: 80051, 84132 AND Blood Urea Nitrogen test: 84520, 84525

least 180 treatment days of Anticonvulsants during the MY.

monitoring test for the prescribed drug during the MY:• Phenobarbital • Carbamazepine • Phenytoin • Valproic acid or divalproex sodium (must have at least one drug serum concentration for valproic acid).

80156Phenytoin Level: 80185, 80186Valproic acid Level: 80164

June 10, 2014 Page 1 of 14

Health Care Excel





Differences from HEDIS Differences from HEDISMeasuresHEDIS and NCQA Health Plan

Measurement Set

Use of High‐Risk Medications in the Elderly DAE

‐‐ Received at least one high‐risk medication Members who received at least one high‐risk medication during the MY.

‐‐ Received at least two different high‐risk medications

Members who received at least two different high‐risk medications during the MY.

Medicare members who meet age and CE.

High Risk Medications(Any of the following):• Anticholinergics (excludes TCAs), First‐generation antihistamines• Anticholinergics (excludes TCAs), anti‐Parkinson agents• Antithrombotics• Cardiovascular, alpha agonists, central• Cardiovascular, other• Central nervous system, tertiary TCAs • Central nervous system, barbiturates• Central nervous system, vasodilators• Central nervous system, other• Endocrine system, estrogens with or without progestins; include only oral and topical patch products• Endocrine system, sulfonylureas, long‐duration• Endocrine system, other• Gastrointestinal system, other• Pain medications skeletal muscle relaxants

66 and older Reporting not available through claims. (EHR only)

MY

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

WCC

‐‐ BMI Percentile Documented:• BMI Percentile (Patients 15 or younger on the date of service MUST have documented BMI percentile or BMI percentile plotted on an age‐growth chart to count)‐BMI Value will not suffice)• BMI plotted on age‐growth chart (3‐15 yr olds• BMI value (16‐17 yr olds).

BMI or BMI Percentile: V85.0, V85.1, V85.2‐V85.25, V85.3‐V85.39, V85.4‐V85.45, V85.51‐V85.54

‐‐ Nutritional Counseling Documented:• discussion of current nutritional behaviors

Nutrition Counseling: V65.3, 97802‐97804, G0270, G0271, G04477, S9449, S9452, S9470

• Pain medications, skeletal muscle relaxants • Pain medications, other• Anti‐Infectives, other (>90 days supply)• Nonbenzodiazepine hypnotics (>90 days supply)• Reserpine (>0.1 mg/day)• Digoxin (>0.125 mg/day)• Doxepin (>6 mg/day)

MY3 ‐ 17 year olds Reporting not available through claims. (EHR only)

All children meeting age requirements (Stratified into age groups).

* Reporting requires that all 3 criteria are documented* Documentation of diet alone does not meet criteria* Documentation of exercise alone does not meet criteria.

discussion of current nutritional behaviors• counseling/referral for nutrition education• anticipatory guidance for nutrition• weight or obesity counseling.

G0271, G04477, S9449, S9452, S9470

June 10, 2014 Page 2 of 14

Health Care Excel






Measurement Set

‐‐Physical Activity Counseling Documented:* discussion of current physical activity behaviors* counseling/referral for physical activity* anticipatory guidance for physical activity* weight or obesity counseling.

Physical Activity Counseling: V65.41, G0447, S9451

Medical Assistance With Smoking and Tobacco Use Cessation

MSC

‐‐ Querying about Tobacco Use

‐‐ Advising Smokers and Tobacco Users to Quit Members who are current smokers or tobacco users and who received cessation advice during the MY.

‐‐ Discussing Cessation Medications Members who are current smokers or tobacco users and who discussed or were recommended

18 and older All members who meet age.

Same as UDS

Collected through Medicare CAHPS Health Plan Survey

Patients queried about their tobacco use one or more times by any provider during their last visit in MY or within 24 months of their last visit. If using tobacco, requires evidence of one of the following:* receiving tobacco use cessation servicescessation medications during the MY.

‐‐ Discussing Cessation Strategies Members who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the MY.

Physical Activity in Older Adults POA

‐‐ Discussing Physical Activity Members who spoke with a doctor or other health provider about their level of exercise or physical activity.

‐‐ Advising Physical Activity Members who received advice to start, increase or maintain their level exercise or physical activity.

Cervical Cancer Screening CCS 21 ‐ 64 year old women only

Medicaid: MY

Commercial: MY and the two years prior to the MY.

Women who meet age and CE. Women 24‐ 64 with pap within 3 years OR Women 35 ‐ 64 with pap AND HPV co‐testing within 5 years.

PAP: 88141‐88143, 88147, 88148, 88150, 88152‐88154, 88164‐88167, 88174, 88175, G0123, G0124, G0141, G0143‐G0145, G0147, G0148, P3000, P3001, Q0091, 0923HPV: 87620‐87622

Same as HEDIS ‐ updated to reflect Pap and Pap/HPV co‐testing option

Excludes co‐testing option

Reporting not available through claims. (EHR only)

Chlamydia Screening in Women CHL 16 ‐ 24 year old women MY Women identified as sexually active using claims and Rx data ‐ contraceptives, pregnancy, pregnancy test Chlamydia

One Chlamydia test during MY. Chlamydia Test: 87110, 87270, 87320, 87490‐87492, 87810


65 and older All Medicare members 65 and older who had a doctor visit in past 12 mos.

Collected through Medicare HOS

services * receiving an order for cessation medication (Rx or OTC)* currently on cessation medication.

pregnancy test, Chlamydia test, or documentation of sexual activity.

June 10, 2014 Page 3 of 14

Health Care Excel






Measurement Set

Colorectal Cancer Screening COL 51 ‐ 75 year olds MY and PY All members who meet age and CE

Any of the following meet the criteria:*FOBT during MY*Flex sig during MY or 4 PYs*Colonoscopy during MY or 9 PYs

FOBT: 82270, 82274, G0328Flex Sig: 45.24, 45330‐45335, 45337‐45342, 45345, G0104Col: 45.22, 45.23, 45.25, 45.42, 45.43, 44388‐44394, 44397, 45355, 45378‐45387, 45391, 45392, G0105, G0121

50‐75 year olds

Use of Appropriate Medications for People with Asthma

ASM 5 ‐ 64 year olds MY and PY Members with at least one of the following in BOTH MY and PY:*At least 1 ED visit with principal dx of asthma*At least 1 acute inpt encounter with principal dx of asthma *At least 4 outpt or obs visits with dx of asthma AND at least 2 asthma Rx's dispensed*At least 4 asthma Rx's dispensed.

One or more prescriptions for an asthma controller medication during the MY.

Asthma: 493, 493.0, 493.00‐493.02, 493.1, 493.10‐493.12, 493.8, 493.81, 493.82, 493.9, 493.90‐493.92

Age range changes: 5 through 40 year oldsRequirement adjusted to reflect:* dx of persistent asthma* documented prescription of inhaled corticosteroids ORapproved alternative medication prescribed ORmember was on medication.

Visit required during MY only


Osteoporosis Testing in Older Women OTO Women 65 and older All Medicare members who meet demographics.

Members who report ever having received a bone density test to check for osteoporosis.


Childhood Immunization Status CIS 2 year old children 12 mos prior to child's 2nd birthday

Children turning 2 years old in MY.

4 DTaP, 3 IPV, 1 MMR, 3 HiB, 3 HepB, 1 VZV, 4 PCV, 1 HepA, 2/3 RV, and 2 Flu vaccines by the child's 2nd birthday

For MMR, hepatitis B, VZV and hepatitis A, count any of the following:• Evidence of the antigen or combination vaccine, or • Documented history of the illness, or • A seropositive test result for each antigen.

For DTaP, IPV, HiB, pneumococcal conjugate, rotavirus and influenza, count only:• Evidence of the antigen or combination vaccine.

For combination vaccinations that require more than one antigen (i.e., DTaP and MMR), the organization must find evidence of all the antigens.

DTaP:90698, 90700, 90721, 90723IPV: 90698, 90713, 90723MMR:90707, 90710HiB:90645‐90648, 90698, 90721, 90748HepB: 90723, 90740, 90744, 90747, 90748, G0010VZV: 052‐052.2, 052.7‐052.9, 053‐053.14, 053.19, 053.20, 053.2‐053.22, 053.29, 053.7, 053.71, 053.79, 053.8, 053.9, 90710, 90716PCV: 90669, 90670, G0009HepA: 070.0, 070.1, 90633RV: 90680 (3 dose), 90681 (2 dose)Flu: 90655, 90657, 90661, 90662, G0008

HepB dx: 070.2‐070.23, 070.3‐070.33, V02.61 Measles dx: 055‐055.2, 055.7, 055.71, 055.79, 055.8, 055.9, 90705Measles/Rubella dx: 90708Mumps dx: 072‐072.3, 072.7‐072.72, 072.79, 072.8, 072.9, 90704Rubella dx: 056‐056.01, 056.09, 056.7, 056.71, 056,79, 056 8 056 9 90706

Age range expanded to fully immunized by THIRD birthday4 DTaP, 3 IPV, 1 MMR, 3 Hib, 3 Hep B, 1 VZV, 4 PCV (no Hep A, RV, or Flu requirements)


056.8, 056.9, 90706

Flu Vaccination for Adults 65 and Older FVO 65 and older All members who meet age and CE.

Members who received an influenza vaccination between July 1 of MY through Survey Date.


Pneumococcal Vaccination Status for Adults 65 and Older

PNU 65 and older All members who meet age. Members who ever received a pneumococcal vaccination.


June 10, 2014 Page 4 of 14

Health Care Excel






Measurement Set

Use of Imaging Studies for Low Back Pain LBP 18 ‐ 50 year olds 180d prior to identifying event through 28d after

Outpatient or ED visit from Jan 1 through Dec 3 of MY with primary dx of low back pain.

Exclude patients with dx of low back pain within 6 months of current MY's identifying event.

An imaging study with dx of low back pain on or within 28d of identifying event.** NOTE ‐ Intent of measure is to NOT have imaging, measure is reported as inverse [1‐percent of members with imaging studies]

Imaging Study: 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131‐72133, 72141, 72142, 72146‐72149, 72156, 72158, 72200, 72202, 72220, 0320, 0329, 0350, 0352, 0359, 0610, 0612, 0614, 0619, 0972

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, 724.7, 724.70, 724.71, 724.79, 738.5, 739.3, 739.4, 846.0, 846, 846.1‐846.3, 846.8, 846.9, 847.2


Osteoporosis Management in Women Who Had a Fracture

OMW Women, 67 years and older

1 year prior to identifying event through 6 mos after.

Members who had a fracture from July 1 of PY through June 30 of the MY.

If member had more than one fracture, include only the first fracture within the above period

Appropriate testing or treatment including either:• BMD test at dx or within 6 mos.• Osteoporosis therapy at dx or within 6 mos.

BMD Test: 88.98, 76977, 77078‐77083, 78350, 78351, G0130

Osteoporosis Meds: J0630, J0897, J1000, J1740, J3110, J3487, J3488

period.Exclude members with documented fracture May 1 through June 30 of the PY OR members with Bone Mineral Density (BMD) Test or osteoporosis therapy within 1 year prior to fracture.

Disease‐Modifying Anti‐Rheumatic Drug Therapy for Rheumatoid Arthritis

ART 18 years and older MY Two of the following on or between Jan 1 and Nov 30 of the MY: • Outpatient visit with any dx of RA• Nonacute inpatient discharge, with any dx of RA.

At least one Rx for a DMARD during MY (claims or pharmacy data).

DMARD: J0129, J0135, J0178, J1438, J1600, J1745, J3262, J7502, J7515‐J7518, J9250, J9260, J9310

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

AAB 18 ‐ 64 year olds 1 year prior through 7d after dx

Dx of Acute Bronchitis ONLY AND no active antibiotics within 30d prior to dx.

Dispensed prescription for antibiotic within three days of dx.Note: this is an inverted measure where NO antibiotic prescription dispensed = compliance .

Acute bronchitis Dx: 466.0 Reporting not available through claims. (Registry only)

A i t T ti f Child ith U URI Child 3 ld f 30d i th h 3d ft D f URI ONLY AND ti Di d i ti f tibi ti ithi th URI D (D ) 460 465 465 0 465 8 465 9 3 th h 18 ldAppropriate Testing for Children with Upper Respiratory Infection

URI Children 3 mos old as of July 1 PY to 20 years old as of July 1 of MY

30d prior through 3d after dx event

Dx of URI ONLY AND no active antibiotics within 30d prior to dx.

Dispensed prescription for antibiotic within three days of dx.Note: this is an inverted measure where NO antibiotic prescription dispensed = compliance .

URI Dx (Denom): 460, 465, 465.0, 465.8, 465.9 3 mos through 18 year olds

Reporting not available through claims. (Registry , EHR only)

June 10, 2014 Page 5 of 14

Health Care Excel






Measurement Set

Persistence of Beta‐Blocker Treatment After a Heart Attack

PBH 18 years and older Discharge through 180 days after (6 months)

Members discharged alive from an acute inpt setting with an AMI from Jul 1 of PY through Jun 30 of MY.

180‐day course of treatment with beta‐blockers.

(Persistence of treatment for this measure is defined as at least 75% of the days supply filled [i.e. members whose dispensed days supply is ≥135 days in the 180 days following discharge.]

AMI: 410.x1

Cholesterol Management for Patients with Cardiovascular Conditions

CMC 18 ‐ 75 year olds MY and PY Members discharged alive for AMI, CABG or PCI in PY ORMembers with dx of IVD in PY and MY.

LDL‐C test during the MY (calculated or direct LDL) AND LDL‐C level during the MY is <100 mg/dL. (most recent level)

LDL‐C Screen: 80061, 83700, 83701, 83704, 83721, 3049F, 3050F AND/ORLevel l<100 mg/dL: 3048F

Requirement ‐ 2 or more medical visits ever (with at least one in MY) prescribed a lipid‐lowering therapy

18 years and older

Medication Reconciliation Post‐Discharge MRP 66 and older Date of discharge through 30d after discharge

An acute or nonacute inpatient discharge on or between Jan 1 and Dec 1 of the MY.

Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or RN on or within 30 days of discharge.

Medication Reconciliation: 99495, 99496, 1111F 65 years and older

the MY.

Fall Risk Management FRM‐‐ Discussing Fall Risk Members who discussed falls or problems with

balance or walking with their provider.Risk assessment for patients with history of falls (2 or more falls in past year or any fall with injury in past year).

‐‐ Managing Fall Risk Members who received fall risk intervention from their provider.

Plan of care of all patients with risk assessment indicating 2 or more falls in past year or any fall with injury in past year.

Antidepressant Medication Management AMM

‐‐ Acute Phase 18 years and older 105d prior to Rx through 231d after

New dx of depression between May 1 of PY through Apr 30 of MY.

12 weeks/84 days continuous treatment with antidepressant during 114 days following initial prescription date.

‐‐ Continuation Phase 6 months/180 days continuous treatment with antidepressant during 231 days following initial prescription date.

Treatment with Rx antidepressants:• Misc antidepressants• Monoamine oxidase inhibitors• Phenylpiperazine antidepressants• Psychotherapeutic combinations• SSNRI antidepressants• SSRI antidepressants• Tetracyclic antidepressants• Tricyclic antidepressants.

65 and older All Medicare members 75 and older and members 65‐74 years of age with balance or walking problems or fall in past 12 mos.


Reporting not available through claims. (Registry, EHR only)

June 10, 2014 Page 6 of 14

Health Care Excel






Measurement Set

Follow Up for Children Prescribed ADHD Medication

ADD

‐‐ Initiation Phase 120d prior to though 30d after earliest Rx dispensing date

All children of age newly prescribed (no other ADHD meds within 4 mos) ADHD medication from Mar 1 of PY through Feb 28 of MY.

One follow up visit with practitioner with prescribing authority within 30d of Rx dispensing date.

ADD Stand Alone Visit (within 30 days of initial Rx): 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, G0155, G0176, G0177, G0409‐G0411, H0002, H0004, H0031, H0034‐H0037, H0039, H0040, H2000, H2001, H2010‐H2020, M0064, S0201, S9480, S9484, S9485 UBREV 0510, 0513, 0515‐0517, 0519, 0520‐0523, 0526‐0529, 0900, 0902‐0905, 0907, 0911‐0917, 0919, 0982, 0983

Additional Group Codes available for alternative POS.

‐‐ Continuation & Maintenance Phase All children of age newly prescribed (no other ADHD meds within 4 mos) ADHD medication from Mar 1 of PY

Two additional follow‐up visits within 9m after initiation phase. (1 of the 2 visits may be a telephone visit)

Same coding criteria as above for two visitsORCoding as above for one visit, plus:Telephone Visit: 98966‐98968 99441‐99443

Six years as of March 1 of PY to 12 years as of February 28 of MY


medication from Mar 1 of PY through Feb 28 of MY AND who filled a sufficient number of Rx to provide continuous treatment for at least 210 days out of the 300‐day period after the initial Rx.

Telephone Visit: 98966 98968, 99441 99443

Adult BMI Assessment ABA 18 ‐ 74 year olds MY and PY All members who meet age and CE with outpatient visit in MY or PY.

BMI documented during MY or PY. (BMI should be documented as a value for patients 19 yrs and older. BMI percentile is acceptable for patients 18 yrs and younger at time of screening.)

BMI or BMI Percentile: V85.0, V85.1, V85.2‐V85.25, V85.3‐V85.39, V85.4‐V85.45, V85.51‐V85.54

BMI recorded at their last visit or within 6 months of that visit AND–had a follow‐up plan documented if they were under age 65 and BMI was ≥ 25 OR < 18.5 or age 65 or older and BMI was ≥ 30 OR < 22.

18 years and older with BMI recorded at their last visit or within 6 months of that visit AND–had a follow‐up plan documented if they were under age 65 and BMI was <18.5 OR >25 or age 65 or older and BMI was <18.5 OR >30.

Pharmacotherapy Management of COPD Exacerbation

PCE 40 years and older Within 30d after discharge with principal dx of COPD

Members with acute inpatient discharge or ED visit with principal dx of COPD, emphysema, or chronic bronchitis.

Systemic Corticosteroids ‐ Dispensed Rx on or by 14d after identifying eventBronchodilators ‐ Dispensed Rx on or by 30d after identifying event.

COPD: 493.2, 493.20‐493.22, 496Emphysema: 492, 492.0, 492.8Chronic Bronchitis: 491, 491.0‐491.2, 491.20‐491.22, 491.8, 491.9

Care for Older Adults COA 66 years and older MY Only members of Medicare Special Needs Plans (SNP) who meet age and CE

• Evidence of advance care planning during the MY.• One medication review by a prescribing practitioner or clinical pharmacist AND a med list in

Advance Care Planning: 1157F, 1158F, S0257,1170FMedication Review: 90862, 90863, 99605, 99606, 1160Fmeet age and CE. practitioner or clinical pharmacist AND a med list in

the medical record on the same date of service during the MY.• One functional status assessment during the MY• One pain screening or pain management plan during the MY.

1160FMedication List: 1159F, G8427Func. Status Assess: 1170FPain Assess: 1125F, 1126F

June 10, 2014 Page 7 of 14

Health Care Excel






Measurement Set

Follow Up After Hospitalization for Mental Illness (7 day rate)

FUH

‐‐30‐Day Follow‐up An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30d after discharge.

‐‐7‐day Follow‐up An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7d after discharge.

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

SPR 42 years and older 730d (2 years) prior to dx through 180d (6 mos) after

Members with new dx or newly active COPD, emphysema, or chronic b hi i h 1 i i

Evidence of one spirometry testing event during the 730d (2 yrs) prior through 180d (6 mos.) after identifying event.

COPD: 493.2, 493.20‐493.22, 496Emphysema: 492, 492.0, 492.8Chronic Bronchitis: 491, 491.0‐491.2, 491.20‐491.22, 491 8 491 9

6 years and older Date of discharge through 30d after discharge

Members discharged alive from an acute inpt setting with a principal dx of mental illness Jan1 ‐ Dec 1 of MY.

FUH stand Alone Visit: 90804‐90815, 98960‐98962, 99078, 99201‐99205, 99211‐99215, 99217‐99220, 99241‐99245, 99341‐99345, 99347‐99350, 99383‐99387, 99393‐99397, 99401‐99404, 99411‐99412, 99510, G0155, G0176, G0177, G0409, G0410, G0411, H0002, H0004, H0031, H0034‐H0037, H0039, H0040, H2000, H2001, H2010‐H2020, M0064, S0201S9480, S9484, S9485

Additional Group Codes available for alternative POS.

bronchitis whose 1st visit occurs between Jul 1 of PY through Jun 30 of MY.

491.8, 491.9Spirometry: CPT: 94010, 94014‐94016, 94060, 94070, 94375, 94620

Comprehensive Diabetes Care CDC

‐‐ HbA1c Testing One HbA1c test during the MY HbA1C Test: 83036, 86037, 3044F, 3045F, 3046F

‐‐ Poor Control (HbA1c >9.0%) Most recent HbA1c test result of >9.0 % during the MY **NOTE: the measure reports A1c's in poor control, so a lower rate is better.

HbA1c >9.0%: 3046F

‐‐ HbA1c Control (<8.0%) Most recent HbA1c test result of <8.0 % during the MY.

HbA1c <8.0%: 3044F(note: Use of CPT 3045F indicates HcA1c between 7.0 and 9.0 and is not specific enough alone to demonstrate compliance. When using this code, organizations must use other sources for actual value)

‐‐ Eye Exam Diabetic retinal disease screen performed by an eye care professional: * A retinal or dilated eye exam in MY* A negative retinal or dilated exam in PY.

Diabetic Retinal Screening by Eye Professional: 2022F, 2024FDiabetic Retinal Screening by Eye Professional, negative: 3072F

(Any other CPTs for Diabetic Retinal Screening must be

18 ‐ 75 year olds MY Members identified as having diabetes during the MY or the PY through one of the following criteria:• 2 outpatient, obs or nonacute visits with dx of diabetes• An inpatient acute stay with dx of diabetes• An ED visit with dx of diabetes• Prescribed insulin or hypoglycemics/ antihyperglycemics in MY or PY.

Same as HEDIS, but reported in the following categories:‐ <8%‐ 8% ‐ 9%,‐ >9% or no test (Failure)

billed by Eye Professional)

‐‐ LDL‐C Screen One LDL‐C screening test during the MY. LDL‐C Screen: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F

‐‐LDL‐C Control (<100 mg/dL) Most recent LDL‐C screen result of <100 mg/dL during the MY.

LDL‐C Screen: 80061, 83700, 83701, 83704, 83721, 3049F, 3050F AND/ORLevel l<100 mg/dL: 3048F

June 10, 2014 Page 8 of 14

Health Care Excel






Measurement Set

‐‐ Medical Attention for Nephropathy Nephropathy screening testOREvidence of nephropathy:*Evidence of treatment*Evidence of CKD stage 4, ESRD, or kidney transplant*Visit with nephrologist (evidenced through specialty codes)* Positive urine macroalbumin test* Evidence of ACE inhibitor/ARB therapy.

Nephropathy Screening: 82042‐82044, 84156, 3060F, 3061FPositive Urine Macroalbumin Test: 3062FUrine Macroalbumin Test (with lab data indicating positive): 81000‐81003, 81005

‐‐ BP Control (<140/80 mm Hg) Most recent BP reading is <140/80 mm HG during the MY.

Systolic Less than 140: 3074F, 3075FANDDiastolic Less than 80: 3078F

‐‐ BP Control (<140/90 mm Hg) Most recent BP reading is <140/90 mm HG during the MY.

Systolic Less than 140: 3074F, 3075F ANDDiastolic Less than 80: 3078F ORDiastolic 80‐89: 3079FDiastolic 80 89: 3079F

‐‐HbA1c Control (<7.0%) for a selected population

As above, but excludes ages 65 and older, and those with dx in PY or MY of CABG, PCI, IVD, or Thoracic Aortic Aneurysm. OR any of the following any time in patient history: CHF, MI, ESRD, CKD, Dementia, blindness, or amputation.

Most recent HbA1c test result of <7.0 % during the MY.

HbA1c <7.0%: 3045F

Frequency of ongoing Prenatal care FPC Pregnant women 43d prior to delivery through 56d after

Delivery between Nov 6th of PY and Nov 5th of MY (Medicaid Only).

Women who had an unduplicated count of <21%, 21%–40%, 41%–60%, 61%–80% or ≥81% of the number of expected visits, adjusted for the month of pregnancy at time of enrollment and gestational age. (Using ACOG Guidelines to calculate each woman’s expected prenatal care visits.)

Well Child Visits in First 15 Months W15 Children turning 15m in MY

31d (after birth) through 15months of age

All children meeting age requirements.

6 or more well child visits with a primary care practitioner with documented ‐* health and developmental history* physical exam* health education/ anticipatory guidance.

Well Care: V20.2, V20.3, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9, 99381‐99385, 99391‐99395, 99461, G0438, G0439

Immunization of Adolescents IMA 13 year old adolescents 12 mos prior to child's 13th birthday

Adolescents turning 13 years old in MY.

1 meningococcal vaccine (between 11th and 13th birthdays) AND 1 tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or 1 tetanus, diphtheria toxoids vaccine (Td) (between the 10th and 13th birthdays)

Meningococccal: 90733, 90734 Td: 90714, 90718Tdap: 90715

June 10, 2014 Page 9 of 14

Health Care Excel






Measurement Set

Well Child Visits ‐ 3‐6 year olds W34 3 ‐ 6 year olds MY All children meeting age requirements.

At least 1 well child visit with a primary care practitioner with documented ‐* health and developmental history* physical exam* health education/ anticipatory guidance.


Prenatal and Postpartum Care PPC

‐‐ Timeliness of Prenatal Care Prenatal visit within first trimester or 42d of enrollment.

n/a Report on all of the following within first trimester:* Referral for prenatal care* some prenatal care provided and then transferred due to risk status* some prenatal care provided and then referred for late PNC and delivery* some or all prenatal care and referral for delivery* full perinatal services including delivery

43d prior to delivery through 56d after

Delivery between Nov 6th of PY and Nov 5th of MY (Commercial and Medicaid only).

Pregnant women

‐‐ Postpartum Care Visit on or between 21d and 56d after deliveryVisits should be with prenatal care practitioner and meet visit criteria

n/a

Medication Management for People with Asthma

MMA 5 ‐ 64 year olds MY and PY Members with at least one of the following in BOTH MY and PY:• At least 1 ED visit with principal dx of asthma• At least 1 acute inpt encounter with principal dx of asthma • At least 4 outpt or obs visits with dx of asthma AND at least 2 asthma Rx's dispensed• At least 4 asthma Rx's dispensed.

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

Asthma: 493, 493.0, 493.00‐493.02, 493.1, 493.10‐493.12, 493.8, 493.81, 493.82, 493.9, 493.90‐493.92

Asthma Medication Ratio AMR 5 ‐ 64 year olds MY and PY Members with at least one of the following in BOTH MY and PY:• At least 1 ED visit with

The number of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the MY.

Asthma: 493, 493.0, 493.00‐493.02, 493.1, 493.10‐493.12, 493.8, 493.81, 493.82, 493.9, 493.90‐493.92

• At least 1 ED visit with principal dx of asthma• At least 1 acute inpt encounter with principal dx of asthma • At least 4 outpt or obs visits with dx of asthma AND at least 2 asthma Rx's dispensed• At least 4 asthma Rx's dispensed.

June 10, 2014 Page 10 of 14

Health Care Excel






Measurement Set

Adherence to Antipsychotic medications for People with Schizophrenia

SAA 19 ‐ 64 year olds MY Members with schizophrenia who had at least one inpt or two outpatient/ED visits during the MY AND who had at least 60 days supply of medication, with at least one Rx on or between Jan 1 and Sep 30 of MY.

Patients who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period (Treatment period = date of earliest Rx through end of MY).

Proportion of days covered = days member covered by at least one Rx, divided by the number of days in the treatment period.

Allowable Rx includes Miscellaneous antipsychotic agents, Phenothiazine antipsychotics, Psychotherapeutic combinations, Thioxanthenes, andLong‐acting injections.

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia

SMC 18 ‐ 64 year olds MY and PY Members with schizophrenia and cardiovascular disease (includes AMI, CABG, or PCI in PY or IVD in PY and MY) who had at least one inpt or two outpatient/ED visits during the MY.

An LDL‐C test performed during the MY (May use a calculated or direct LDL.)

LDL‐C Screen: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F

Diabetes Monitoring for People with Diabetes and Schizophrenia

SMD 18 ‐ 64 year olds MY Members with schizophrenia and diabetes who had at least one inpt or two outpatient/ED visits during the MY.

An HbA1c test AND an LDL‐C test performed during the MY (May use a calculated or direct LDL.)

HbA1C Test: 83036, 86037, 3044F, 3045F, 3046FANDLDL‐C Screen: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F

Human Papillomavirus Vaccine for Female Adolescents

HPV 13 year old female adolescents

12 mos prior to the child's 13th birthday

Female adolescents turning 13 years old in MY.

At least 3 HPV vaccinations, with different dates of service, on or between the adolescent’s 9th and 13th birthdays.

HPV: 90649, 90650

Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Prescribed Antipsychotic Medications

SSD 18 ‐ 64 year olds MY Members with schizophrenia or bipolar disorder who had at least one inpt or two outpatient/ED visits during the MY (Excluding members with current dx of diabetes).

A glucose test or an HbA1c test performed during the MY.

Glucose Test: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951HbA1C Test: 83036, 86037, 3044F, 3045F, 3046F

June 10, 2014 Page 11 of 14

Health Care Excel






Measurement Set

Flu Vaccinations for Adults 18‐64 FVA 18 ‐ 64 year olds All Commercial and Medicaid members who meet age and CE.

Members who received an influenza vaccination between July 1 of MY through Survey Date.


Potentially Harmful Drug‐Disease Interactions in the Elderly

DDE

‐‐A history of falls and Rx for anticonvulsants, nonbenzodiazepine hypnotics, SSRIs, antiemetics, antipsychotics, benzodiazepines or tricyclic antidepressants.

An accidental fall or hip fracture on or between Jan 1 of the PY and Dec 1 of the MY.Note: Hip fractures are used as a proxy for accidental falls.Excludes members with psychosis, schizophrenia, bipolar disorder, or seizure disorder.

Dispensed Rx for anticonvulsant, nonbenzodiazepine hypnotic, SSRI or antiemetic, antipsychotic, benzodiazepine or tricyclic antidepressant on or between the identification of fracture and Dec 31 of the MYNote:A lower rate represents better performance.

N/A

Dementia and Rx for antiemetics Members with dementia on or Dispensed Rx for an antiemetic antipsychotic N/A

MY and PY65 and older

‐‐ Dementia and Rx for antiemetics, antipsychotics, benzodiazepines, tricyclic antidepressants, H2 Receptor Antagonists, nonbenzodiazepine hypnotics or anticholinergic agents.

Members with dementia on or between Jan 1 of the PY and Dec 1 of the MY.Excludes members with psychosis, schizophrenia, or bipolar disorder.

Dispensed Rx for an antiemetic, antipsychotic, benzodiazepine or tricyclic antidepressant or H2 receptor antagonist, nonbenzodiazepine hypnotic or anticholinergic agent on or between the identification of dementia and Dec 31 of the MY.Note:A lower rate represents better performance.

N/A

‐‐ CKD and Rx for Cox‐2 Selective NSAIDs or non‐aspirin NSAIDs.

Members with CKD as identified by a dx of ESRD, stage 4 CKD, or kidney transplant on or between Jan 1 of the PY and Dec1 of the MY.

Dispensed Rx for an NSAID or Cox‐2 selective NSAID on or between the identification of CKD and Dec 31 of the MY.Note:A lower rate represents better performance.

N/A

Management of Urinary Incontinence MUI

‐‐ Discussing Urinary Incontinence Members who discussed their urinary leakage problem with a health care provider.

‐‐ Discussing Treatment of Urinary Incontinence Members who discussed treatment options for their current urine leakage problem.

‐‐ Impact of Urinary Incontinence Members who reported that urine leakage made them change their daily activities or interfered with

65 and older All Medicare members 65 and older who reported having urine leakage in the past 6 mos.


g ytheir sleep a lot.

June 10, 2014 Page 12 of 14

Health Care Excel






Measurement Set

Aspirin Use and Discussion ASP

‐‐ Aspirin Use • Women 56–79 years of age with at least two risk factors for cardiovascular disease.• Men 46–65 years of age with at least one risk factor for cardiovascular disease.• Men 66–79 years of age, regardless of risk factors.

Members who are currently taking aspirin.

‐‐ Discussing Aspirin Risks and Benefits • Women 56–79 years of age.• Men 46–79 years of age.

Members who discussed the risks and benefits of using aspirin with a doctor or other health provider.

Breast Cancer Screening BCS 50 ‐ 74 year old Oct 1 two years prior to Women who meet age and CE. One or more mammograms any time on or Mammography: 87.36, 87.37, 77055‐77057, G0202, Screening within 27 mos.

ages 46‐79 Collected through Medicare CAHPS Health Plan Survey

women MY through Dec 31 of MY between Oct 1 two years prior to the MY and Dec 31 of the MY (27 months).

G0204, G0206, 0401, 0403

Lead Screening in Children LSC 2 year old children 12 mos prior to the child's 2nd birthday

Children turning 2 years old in MY.

At least one lead capillary or venous blood test on or before the child’s second birthday.

Lead Tests: 83655

Glaucoma Screening for Older Adults GSO 67 years and older MY and PY All members who meet age and CE.

One or more eye exams for glaucoma by an eye care professional (i.e., ophthalmologist, optometrist) during the MY or PY.

Glaucoma Screening: 92002, 92004, 92012, 92014, 92081‐92083, 92100, 92120, 92130, 92140, 99202‐99205, 99213‐99215, 99242‐99245, G0117,G0118, S0620, S0621

Well Child Visits ‐ Adolescents AWC 12 ‐ 21 year olds MY All children meeting age requirements.

At least 1 well child visit with a primary care practitioner with documented ‐• health and developmental history• physical exam• health education/ anticipatory guidance.


Non‐Recommended Cervical Cancer Screening in Adolescent Females

NCS 16‐20 year old female adolescents

MY Women who meet age and CE. Pap or an HPV test performed during the MY.

Note: A lower rate indicates better performance

PAP: 88141‐88143, 88147, 88148, 88150, 88152‐88154, 88164‐88167, 88174, 88175, G0123, G0124, G0141, G0143‐G0145, G0147, G0148, P3000, P3001, Q0091, 0923HPV: 87620‐87622

Asthma: Pharmacologic Therapy for Persistent Asthma‐ Ambulatory Care

Patients aged 5 through 40 with persistent asthma seen at least once in h ( d h d b f l

5 ‐ 64 year olds

the MY (and had been seen for at least 2 visits ever) with evidence of any of the following:• received or had Rx for inhaled corticosteroids• received or had Rx for approved alternative medication• was on medication

June 10, 2014 Page 13 of 14

Health Care Excel






Measurement Set

IVD: Aspirin Therapy Patients 18 and older with dx of IVD in MY or PY (or had AMI, CABG, PTCA in PY) receiving aspirin or another anti‐thrombotic medication.

Screening for Clinical Depression and Follow‐up Plan

Patients ages 12 and over who were screened for depression with a standardized tool and had follow‐up plan documented if depressed.


June 10, 2014 Page 14 of 14

Health Care Excel

A Anthem CommercialADHD Attention Deficit Hyperactivity DisorderADD Attention Deficit DisorderAdult Adult Recommended CoreAMI Acute Myocardial InfarctionC Coventry CaresCABG Coronary Artery Bypass GraftCE Continuous EnrollmentCHF Congestive Heart FailureCKD Chronic Kidney DiseaseCOPD Chronic Obstructive Pulmonary Disease d Daysdx DiagnosisED Emergency DepartmentESRD End Stage Renal DiseaseFOBT Fecal Occult Blood TestHEDIS Healthcare Effectiveness Data and Information Set HTN HypertensionInpt InpatientIVD Ischemic Vascular DiseaseMCO Managed Care OrganizationMI Myocardial Infarctionmos MonthsMU Meaningful UseMY Measurement Year

ABBREVIATIONS

June 10, 2014 Page 1 of 2

MY Measurement YearNCQA National Committee for Quality Assurance NQF National Quality ForumPCI Percutaneous Coronary InterventionPCMH Patient Centered Medical HomePCP Primary Care ProviderPeds Pediatric Recommended CorePQRS Physician Quality Reporting SystemPY Year Prior to the Measurement YearRx Prescription(S) Data collection through member surveyUDS Uniform Data SystemW WellCareX Indicates "Must Pass" and/or Critical Factor Inclusion


Health Care Excel

HEDIS 2014 Techinical Specifications, NCQAUpdated FY 2013 Clinical and Financial Performance Measures, HRSAIntroduction to UDS Clinical Measures Slides, Bureau of Primary Health Care2014 PQRS Measures List, CMS2014 PQRS Measure Specifications Manual, CMSMeasurement Period Handbook For Enhanced Personal Health Care (2014), AnthemCoventryCares HEDIS Quality Gain Share Measurement Criteria (CY 2014 and 2015)2014 Quality Incentive Program Measure Fact Sheets (Medicare, Mediciad), WellCare2014 NCQA Health Plan Accreditation Requirements, NCQAPCMH 2014 Standards and Guidelines, NCQAPCMH 2014 and CMS Stage 2 Meaningful Use Requirements, NCQA2014 Clinical Quality Measures (CQMs) Adult Recommended Core Measures, CMS2014 Clinical Quality Measures (CQMs) Pediatric Recommended Core Measures, CMS2014 Eligible Professional Clinical Quality Measures for EHR Incentive Programs, CMS

RESOURCES




care excel quality - c.ymcdn.com · 10.06.2014 · use of imaging studies for low back pain 0052...

Documents