Performance Measures Performance Measure Requirements Coding Page 1 Blue Cross Community MMAI (Medicare-Medicaid Plan) SM Codes that Correspond to the HEDIS Quality Measures 11/14/2018 The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Measures for Preventive Screening Adult BMI Assessment (ABA) Members age 18-74: An outpatient visit with documentation of the weight and BMI value from the same date of service noted during the measurement year or year prior to the measurement year. • Members 20 years of age or older on the Date of Service: Documentation must include the weight and BMI value entered on the same date of service during the measurement year or the year prior to the measurement year. (The Ht should already be in the record.) • Members younger than 20 years of age on the Date of Service: Documentation must include the height, weight and BMI Percentile entered on the same date of service during the measurement year or the year prior to the measurement year. ▪ A distinct BMI percentile is required for numerator compliance AND - Can be calculated and documented in the notes or on a BMI Percentile Graph. ▪ Documentation of >99% or <1% meet criteria because a distinct BMI percentile is evident (i.e., 100% or 0%). BMI Percentile ranges and thresholds do not meet criteria for this indicator. Office Visits CPT: 99201-99205, 99211-99215, 99241- 99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456 ICD-10: BMI Code for Members (18 to <21yrs of age) Z68.51 BMI <5th percentile for age Z68.52 BMI 5th to <85th percentile for age Z68.53 BMI 85th to <95th percentile for age Z68.54 BMI >95th percentile for age ICD-10: BMI Code for Members (21yrs and older) Z68.1_BMI 19 or less Z68.32_BMI 32.0-32.9 Z68.20_BMI 20.0-20.9 Z68.33_BMI 33.0-33.9 Z68.21_BMI 21.0-21.9 Z68.34_BMI 34.0-34.9 Z68.22_BMI 22.0-22.9 Z68.35_BMI 35.0-35.9 Z68.23_BMI 23.0-23.9 Z68.36_BMI 36.0-36.9 Z68.24_BMI 24.0-24.9 Z68.37_BMI 37.0-37.9 Z68.25_BMI 25.0-25.9 Z68.38_BMI 38.0-38.9 Z68.26_BMI 26.0-26.9 Z68.39_BMI 39.0-39.9 Z68.27_BMI 27.0-27.9 Z68.41_BMI 40.0-44.9 Z68.28_BMI 28.0-28.9 Z68.42_BMI 45.0-49.9 Z68.29_BMI 29.0-29.9 Z68.43_BMI 50-59.9 Z68.30_BMI 30.0-30.9 Z68.44_BMI 60.0-69.9 Z68.31_BMI 31.0-31.9 Z68.45_BMI 70 or greater Breast Cancer Screening (BCS) Women age 50-74: Providers should encourage and educate women on the importance of having a mammogram performed. Providers should obtain a copy of the mammogram results and record the date of the test and the result in the medical record. Exclusions: • Bilateral Mastectomy OR • Right AND Left Unilateral Mastectomies. Document in the member’s medical record that member had a history of a bilateral or a Rt and Lt unilateral mastectomies. Mammogram CPT: 77055-77057, 77061-77063, 77065-77067 HCPCS: G0202, G0204, G0206 (the last 2 are diagnostic mammography) UBREV: 0401, 0403 Mastectomy CPT: 19180, 19200, 19220, 19240, 19303-19307 ICD10CM: Z90.11 - Acquired absence of right breast and nipple Z90.12 - Acquired absence of left breast and nipple Z90.13 - Acquired absence of bilateral breasts and nipples
Transcript
Performance
Measures
Performance Measure
Requirements Coding
Page 1
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final
decision about any service or treatment is between the member and their health care provider.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
Measures for Preventive Screening
Adult BMI Assessment (ABA)
Members age 18-74: An outpatient visit with documentation of the weight and BMI value from the same date of service noted during the measurement year or year prior to the measurement year.
• Members 20 years of age or older on the Date of Service: Documentation must include the weight and BMI value entered on the same date of service during the measurement year or the year prior to the measurement year. (The Ht should already be in the record.)
• Members younger than 20 years of age on the Date of Service: Documentation must include the height, weight and BMI Percentile entered on the same date of service during the measurement year or the year prior to the measurement year. ▪ A distinct BMI percentile is required for
numerator compliance AND
- Can be calculated and documented in the notes or on a BMI Percentile Graph.
▪ Documentation of >99% or <1% meet criteria because a distinct BMI percentile is evident (i.e., 100% or 0%).
BMI Percentile ranges and thresholds do not meet criteria for this indicator.
ICD-10: BMI Code for Members (18 to <21yrs of age) Z68.51 BMI <5th percentile for age Z68.52 BMI 5th to <85th percentile for age Z68.53 BMI 85th to <95th percentile for age Z68.54 BMI >95th percentile for age
ICD-10: BMI Code for Members (21yrs and older)
Z68.1_BMI 19 or less Z68.32_BMI 32.0-32.9
Z68.20_BMI 20.0-20.9 Z68.33_BMI 33.0-33.9
Z68.21_BMI 21.0-21.9 Z68.34_BMI 34.0-34.9
Z68.22_BMI 22.0-22.9 Z68.35_BMI 35.0-35.9
Z68.23_BMI 23.0-23.9 Z68.36_BMI 36.0-36.9
Z68.24_BMI 24.0-24.9 Z68.37_BMI 37.0-37.9
Z68.25_BMI 25.0-25.9 Z68.38_BMI 38.0-38.9
Z68.26_BMI 26.0-26.9 Z68.39_BMI 39.0-39.9
Z68.27_BMI 27.0-27.9 Z68.41_BMI 40.0-44.9
Z68.28_BMI 28.0-28.9 Z68.42_BMI 45.0-49.9
Z68.29_BMI 29.0-29.9 Z68.43_BMI 50-59.9
Z68.30_BMI 30.0-30.9 Z68.44_BMI 60.0-69.9
Z68.31_BMI 31.0-31.9 Z68.45_BMI 70 or greater
Breast Cancer Screening (BCS)
Women age 50-74: Providers should encourage and educate women on the importance of having a mammogram performed. Providers should obtain a copy of the mammogram results and record the date of the test and the result in the medical record.
Exclusions: • Bilateral Mastectomy OR
• Right AND Left Unilateral Mastectomies.
Document in the member’s medical record that member had a history of a bilateral or a Rt and Lt unilateral mastectomies.
Mammogram
CPT: 77055-77057, 77061-77063, 77065-77067
HCPCS: G0202, G0204, G0206 (the last 2 are diagnostic mammography)
UBREV: 0401, 0403 Mastectomy
CPT: 19180, 19200, 19220, 19240, 19303-19307 ICD10CM: Z90.11 - Acquired absence of right breast and
nipple Z90.12 - Acquired absence of left breast and
nipple Z90.13 - Acquired absence of bilateral breasts
and nipples
Performance
Measures
Performance Measure
Requirements Coding
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Preventive Screening -- Cont’d
Colorectal Cancer Screening (COL)
Members age 50-75: Documentation in the medical record must include a note indicating the date the colorectal cancer screening was performed. Appropriate screenings are defined by one of the following criteria: • Fecal occult blood test (FOBT Code) during the
measurement year. • Flexible sigmoidoscopy during the measurement
year or the four years prior to the measurement year.
• Colonoscopy during the measurement year or the nine years prior to the measurement year.
• CT colonography during the measurement year or the four years prior to the measurement year.
• FIT-DNA test during the measurement year or the two years prior to the measurement year
Adults 66 years and older who had each of the following during the measurement year: • Advance care planning • Medication review • Functional status assessment • Pain assessment
Advance Care Planning: discussion or documentation about a member’s preferences for resuscitation, life-sustaining treatment and end of life care that includes one of the following:
• The presence of an advance care plan in the medical record.
• Documentation of an advance care planning discussion with the provider and the date when it was discussed during the measurement year.
• Notation that the member previously executed an advance care plan
Examples of an Advance Care Plan • Advance directive: treatment preferences and
who can make medical decisions if the patient is unable to make them (e.g., living will, power of attorney, health care proxy).
• Actionable medical orders: Written instructions regarding initiating, continuing, withholding or withdrawing life-sustaining treatment (e.g., Physician Orders for Life Sustaining Treatment, Five Wishes).
• Living will: Legal document denoting preferences for life-sustaining treatment and end-of-life care.
• Surrogate decision maker: designee other than the member who can make future medical treatment choices.
Examples of an Advance Care Planning Discussion • Notation in the medical record of a discussion
with a provider or initiation of a discussion by a provider during the measurement year.
• Oral statements. Conversations with relatives or friends about life-sustaining treatment and end-of-life care, documented in the medical record. Patient designation of an individual who can make decisions on behalf of the patient.
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Preventive Screening -- Cont’d
Care for Older Adults (COA) ---- Cont’d
Functional Status Assessment: Documentation in the member’s record of at least one complete functional status assessment during the year, which include one of the following: • Notation that Activities of Daily Living (ADL) were
assessed for at least 5 areas (i.e., bathing, dressing, eating, toileting, etc.)
• Notation that Instrumental Activities of Daily Living (IADL) were assessed in 4 areas (i.e., meal preparation, transportation, telephone use, etc.)
• Result of a standardized functional assessment • Notation that at least 3 of the 4 areas were
Functional Status Assessment CPT-CAT-II: 1170F HCPCS: G0438, G0439
Functional Status Assessment Tools • SF-36®. • Assessment of Living Skills and Resources
(ALSAR). • Barthel ADL Index Physical Self-Maintenance
(ADLS) Scale. • Bayer ADL (B-ADL) Scale. • Barthel Index. • Extended ADL (EADL) Scale. • Independent Living Scale (ILS). • Katz Index of Independence in ADL. • Kenny Self-Care Evaluation. • Klein-Bell ADL Scale. • Kohlman Evaluation of Living Skills (KELS). • Lawton & Brody’s IADL scales. • Patient Reported Outcome Measurement
Information System (PROMIS) Global or Physical
Medication Review: At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the year AND the presence of a medication list in the medical record, which includes the following
• A medication list that is reviewed by the a prescribing practitioner or clinical pharmacist and is dated and signed on the day the review was performed
OR
• Notation that the member is not taking any medication and the date when it was noted
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Respiratory Conditions
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
Members age 40 and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. • Providers should educate and encourage
members to fill and take inhalers for COPD exacerbation.
with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease
with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease,
unspecified
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Respiratory Conditions -- Cont’d
Pharmacotherapy Management of COPD Exacerbation (PCE)
Members 40 years of age and older with COPD Exacerbation. Members admitted to an acute inpatient setting or seen in the ED with a COPD Exacerbation who were dispensed a: • Systemic Corticosteroid (Long Acting Inhaler)
within 14 days of discharge or ED visit AND
• Bronchodilator (Short Acting Inhaler) within 30 days of discharge or ED visit.
Providers should educate and encourage members to fill and take inhalers for COPD exacerbation.
Systemic Corticosteroids/ Long Acting Inhalers: Glucocorticoids: Dexamethasone,
Members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: • Ages 18–85
▪ BP <140/90 mm Hg.
Blood Pressure CPT-CAT-II Systolic 3078F - Diastolic Less Than 80 mm Hg 3079F - Diastolic 80-89 mm Hg 3080F - Diastolic Greater or Equal to 90 mm Hg
Diastolic 3074F - Systolic less than 130 mm Hg 3075F - Systolic of 130-139 mm Hg 3077F - Systolic greater or equal to 140 mm Hg
Telehealth Modifier CPT Modifier: 95, GT
Telephone Visits CPT: 98966-98968, 99441-99443
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
Members age 18 and older who were hospitalized and discharged with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Cardiovascular Conditions -- Cont’d
Statin Therapy for Patients with Cardiovascular Disease (SPC)
Males 21-75 and Females 40-75 who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who met the following criteria:
• Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity statin medication during the year.
• Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
Providers should educate and encourage members to fill and take their medication(s) as prescribed.
Members 40 –75 years of age with diabetes (type 1 and type 2) who do not have clinical atherosclerotic cardiovascular disease (ASCVD) and who had the following:
• Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year.
• Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period.
Providers should educate and encourage members to fill and take their medication(s) as prescribed.
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Diabetes -- Cont’d
Comprehensive Diabetes Care (CDC)
Members ages 18-75 diagnosed with Diabetes: Documentation in the medical record must include the date and result of the following tests or screenings: • Hemoglobin A1c Test
- Hemoglobin A1c Test <8% • Retinal Eye Exam • B/P Controlled at < 140/90mm Hg • Evidence of Medical Attention for Nephropathy.
- Documentation must include a note indicating the date when a urine test was performed and the result of finding: ➢ Microalbumin Testing: 24hr urine for
microalbumin or total protein, timed urine for albumin or protein, spot urine for albumin or protein, urine for microalbumin/creatinine ratio, random urine for protein/creatinine ratio
➢ Evidence of nephropathy: documentation of nephrologist visit, renal transplant, or the following diagnosis: Diabetic nephropathy, ESRD, Chronic renal failure (CRF), Chronic kidney disease (CKD), Renal insufficiency, Proteinuria, Albuminuria, Renal dysfunction, Acute renal failure (ARF), or any form of dialysis
➢ ACE inhibitor/ARB therapy prescribed and noted in the record
Identify Diabetic Exclusions: Steroid induced
Gestational diabetes
Providers should educate and encourage members to fill and take their medication(s) as prescribed.
J0129 Injection, Abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
J0135 Injection, Adalimumab, 20 mg
J0717 Injection, Certolizumab Pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
J1438 Injection, Etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
J1600 Injection, Gold Sodium Thiomalate, up to 50 mg
J1602 Injection, Golimumab, 1 mg, for intravenous use
J1745 Injection Infliximab, 10 mg
J3262 Injection, Tocilizumab, 1 mg
J7502 Cyclosporine, oral, 100 mg
J7515 Cyclosporine, oral, 25 mg
J7516 Cyclosporin, Parenteral, 250 mg
J7517 Mycophenolate Mofetil, oral, 250 mg
J7518 Mycophenolic Acid, oral, 180 mg
J9250 Methotrexate Sodium, 5 mg
J9260 Methotrexate Sodium, 50 mg
J9310 Injection, Rituximab, 100 mg
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Musculoskeletal Conditions -- Cont’d
Osteoporosis Management in Women who had Fracture (OMW)
All women age 67 – 85 years who suffered a fracture and had the appropriate testing or treatment for osteoporosis as defined by any of the following criteria: • A Bone Mineral Density (BMD) test upon diagnosis
of a fracture or within the 180 days after diagnosis
• A BMD test during the inpatient stay for the fracture (applies only to fractures requiring hospitalization)
• Osteoporosis therapy upon diagnosis of a fracture or within the 180 days after diagnosis; and/or,
• A dispensed prescription to treat osteoporosis upon diagnosis of a fracture or within the 180 days after diagnosis.
Bone Mineral Density Tests: CPT: 76977, 77078, 77080, 77081, 77082,
77085, 77086 HCPCS: G0130 (Single energy x-ray
absorptiometry (sex) bone density study, one or more sites; appendicular skeleton (peripheral) (i.e., radius, wrist, heel)
Bone Mineral Density Tests ICD10PCS: BP48ZZ1, BP49ZZ1, BP4GZZ1,
Other Agents: Albandronate, Calcitonin, Denosumab, Raloxifene, Teriparatide
Measures for Medication Management and Care Coordination
Medication Reconciliation Post-Discharge (MRP)
Members age 18 and older for whom medications were reconciled on or within 30 days of discharge (31 total days). • Medication reconciliation can be conducted by a
prescribing practitioner, clinical pharmacist or registered nurse.
• Only documentation in the outpatient chart meets the intent of the measure, but an outpatient visit is not required.
Documentation in the medical record must include evidence of medication reconciliation and the date when it was performed. • Any of the following meets criteria for medication reconciliation:
- the provider reconciled the current medications with the discharge medications. - the current medications with a notation that references the discharge medications
▪ (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications).
- the member’s current medications with a notation that the discharge medications were reviewed.
- list of current medications, list of discharge medications with a notation that both lists were reviewed on the same date of service.
- a notation that no medications were prescribed or ordered upon discharge. - the current medications with evidence that the member was seen post-discharge hospital
follow-up with evidence of medication reconciliation or review. - a discharge summary that states discharge medications were reconciled with the current
medications. The discharge summary must be placed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
Performance
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Performance Measure
Requirements Coding
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Medication Management and Care Coordination -- Cont’d
Transitions of Care (TRC)
Medicare member that are 18 years and older who are admitted to an acute care or nonacute inpatient setting and discharged to their place of residence.
The following 4 areas are assessed • Notification of Inpatient Admission • Receipt of Discharge Information • Patient Engagement After Inpatient Discharge. • Medication Reconciliation Post-Discharge.
Notification of Inpatient Admission*** A note in the member’s outpatient medical record that the PCP was notified of an inpatient admission on the day of admission or the following day.
Documentation the outpatient medical record would include any of the following:
• Note showing the PCP or ongoing care provider did the preadmission exam or was notified or a planned admission.
• A phone call, email or fax from the inpt provider or staff. • A phone call, email or fax from or between the ED. • Notification about an admission through:
- A health information exchange - An automated admission - Discharge and transfer (ADT) alert system - Shared electronic medical record system
• Notification from the member’s health plan. • A note or documentation that the member’s PCP or ongoing
care provider admitted the member. • A note or documentation that a specialist admitted the
member to the hospital and notified the member’s PCP or ongoing care provider.
• A note or documentation that the PCP or ongoing care provider placed orders for tests or treatments anytime during inpatient stay.
***Entries showing that the PCP or ongoing care provider performed a preadmission exam or received notification of a planned inpatient admission is not limited to the day of admission or the following
Receipt of Discharge Information
A notation in the member’s outpatient medical record that the PCP was notified of an inpatient discharge on the day of discharge or the following day. • Discharge information may be included in, but not limited to,
a discharge summary or summary of care record or be located in structured field in an EHR.
• At a minimum the following information must be documented in the medical record on the day of discharge or the following day: - Practitioner responsible for the member’s care in the
inpatient stay. - Procedures or treatment provided - Diagnosis at discharge. - Current medication list (including medication allergies). - Testing results, or documentation of pending tests or no
tests pending. - Instructions to the PCP or ongoing care provider for
Transitional Care Management Services CPT: 99495, 99496
Telephone Visits CPT: 98966-98968, 99441-99443
Telehealth Modifier CPT Modifier: 95, GT
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Medication Management and Care Coordination -- Cont’d
Transitions of Care (TRC) --- Cont’d
Patient Engagement After Inpatient Discharge
A visit must be completed and documented in the member’s outpatient medical record within 30 days after the date of discharge and may not be provided on the date of discharge.
• Visit may be provided through:
- Office visits - Visits to the home
- Telehealth - Videoconferencing
• Can be done by a synchronous telehealth visit where real-time interaction occurs between the member and provider via telephone or videoconferencing.
- Documentation in the member’s outpatient medical record must be timely.
Medication Reconciliation Post-Discharge A note in outpatient medical record must include a medication reconciliation occurred between the discharge medications and the medications the member was taking prior to admission.
A notation in the member’s outpatient medical record that medication reconciliation was performed on the date of discharge through 30 days after discharge (31 total days) as evidenced by:
• A note that the member’s current medications with an entry that the provider reconciled the current and discharge medications.
• A note that the current medications with an entry that references the discharge medications (e.g., no change in medications since discharge, same medications at discharge, discontinue all discharge medications).
• A note that the member’s outpatient record of the current medications and that the discharge medications were reviewed.
• Documentation of current medication list, a discharge medication list and an entry that states both lists were reviewed on the same date of service.
• A note of the current medications with evidence that the member was seen for post-discharge hospital follow-up and that the medications were reconciled or review at that visit.
• A note in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. - There discharge summary must be filed in the
outpatient chart on the date of discharge through 30 days after discharge (31 total days).
• A note stating that no medications were prescribed or ordered upon discharge.
Transitional Care Management Services CPT: 99495, 99496
Telephone Visits CPT: 98966-98968, 99441-99443
Telehealth Modifier CPT Modifier: 95, GT
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Medication Management and Care Coordination -- Cont’d Follow-up after Emergency Department Visit for People with High-Risk Multiple Chronic Conditions (FMC) Eligible Chronic Condition Diagnoses
Members age 18 and older who have multiple high-risk chronic conditions who had a follow-up service within 7 days of the ED visit. The visit can be on the date of the ED visit. The following meet criteria for follow-up:
• An outpatient visit (Outpatient Code), with or without a telehealth modifier (Telehealth Modifier Code).
• A telephone visit (Telephone Visits Code).
• Transitional care management services (Transitional Care Management Services Code).
• Case management visits (Case Management Encounter Code).
• Complex Care Management Services (Complex Care Management Services Code).
• An outpatient or telehealth behavioral health visit (Visit Setting Unspecified Code WITH Outpatient POS Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An outpatient or telehealth behavioral health visit (BH Outpatient Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Code WITH Partial Hospitalization POS Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization/Intensive Outpatient Code).
• A community mental health center visit (Visit Setting Unspecified Code WITH Community Mental Health Center POS Code), with or without a telehealth modifier (Telehealth Modifier Code).
• Electroconvulsive therapy (Electroconvulsive Therapy Code) WITH (Ambulatory Surgical Center POS Code; Community Mental Health Center POS Code; Outpatient POS Code; Partial Hospitalization POS Code).
• A telehealth visit (Visit Setting Unspecified Code WITH Telehealth POS Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code).
• IET Stand Alone Visits Code, with or without a telehealth modifier (Telehealth Modifier Code).
ED Visit CPT: 99281-99285 UBREV: 0450-0452, 0456, 0459, 0981
ED Procedure Code CPT: See CPT Code Book
ED POS: 23
Mental and Behavioral Disorders ICD10CM: See ICD10CM Code Book
Providers should outreach and encourage patients to schedule an office visit. Patients should also receive a call reminding the member about the appointment.
Codes to Identify Preventive/Ambulatory Health Services
Office or other outpatient services CPT: 99201-99205, 99211-99215, 99241-
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependency Treatment (IET)
Members 13 years and older during the year with a new episode of alcohol or other drug (AOD) abuse or dependence who received the following:
• Initiation of AOD Treatment: Members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter OR partial hospitalization, telehealth or medication treatment within 14 days of the diagnosis.
• Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or medication treatment within 34 days of the initiation visit.
Any of the Following Code Treatment Combinations Meet Criteria for Initiation and/or Engagement:
An outpatient visit, telehealth, intensive outpatient visit or partial hospitalization with a diagnosis of AOD abuse or dependence. Any of the following code combinations
- IET Stand Alone Visits Code WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code, with or without a telehealth modifier (Telehealth Modifier Code).
In Inpatient Stay UBREV: 0101, 0110-0114, 0116-0124, 0126-0134,
Other Drug Abuse and Dependence ICD10CM: See ICD10CM Code Book for Values
Performance
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Access/Availability of Care -- Cont’d
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependency Treatment (IET) --- Cont’d
Any of the Following Code Treatment Combinations Meet Criteria for Initiation and/or Engagement: -- cont’d
- IET Visits Group 1 Code WITH IET POS Group 1 Code and with one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code, with or without a telehealth modifier (Telehealth Modifier Code).
- IET Visits Group 2 Code WITH IET POS Group 2 Code and WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code, with or without a telehealth modifier (Telehealth Modifier Code).
• A detoxification visit (Detoxification Code) WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
• An ED visit (ED Code) WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
• An observation visit (Observation Code) WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
• An acute or nonacute inpatient discharge WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
- For all acute and nonacute inpatient stays use the Inpatient Stay Code.
• A telephone visit (Telephone Visits Code) WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
• An online assessment (Online Assessments Code) WITH one of the following: Alcohol Abuse and Dependence Code, Opioid Abuse and Dependence Code, Other Drug Abuse and Dependence Code.
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Behavioral Health Antidepressant Medication Management (AMM)
Members 18 years of age and older who had a diagnosis of major depression and who was treated with an antidepressant treatment.
Two rates are reported. • Effective Acute Phase Treatment - members who remained on
an antidepressant medication for at least 84 days (12 weeks). • Effective Continuation Phase Treatment - members who
remained on an antidepressant medication for at least 180 days (6 months).
Members who had any of the following met criteria: • An acute or nonacute inpatient stay (Inpatient Stay Code)
WITH any diagnosis of major depression (Major Depression Code).
• An outpatient visit with any diagnosis of major depression: Visit Setting Unspecified Code WITH Outpatient POS Code WITH Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• An outpatient visit with any diagnosis of major depression: BH Outpatient Code WITH Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization with any diagnosis of major depression: Visit Setting Unspecified Code WITH Partial Hospitalization POS Code WITH Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization with any diagnosis of major depression: Partial Hospitalization/Intensive Outpatient Code WITH Major Depression Code.
• A community mental health center visit with any diagnosis of major depression: Visit Setting Unspecified Code WITH
Community Mental Health Center POS Code WITH Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• Electroconvulsive therapy with any diagnosis of major depression: Electroconvulsive Therapy Code WITH Major Depression Code.
• Transcranial magnetic stimulation visit with any diagnosis of major depression: Transcranial Magnetic Stimulation Code WITH Major Depression Code.
• A telehealth visit with any diagnosis of major depression: Visit Setting Unspecified Code WITH Telehealth POS Code WITH
Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code) WITH any diagnosis of major depression (Major Depression Code).
• An ED visit (ED Code) WITH any diagnosis of major depression (Major Depression Code).
• An ED visit with any diagnosis of major depression: Visit Setting Unspecified Code WITH ED POS Code WITH Major Depression Code, with or without a telehealth modifier (Telehealth Modifier Code).
• A telephone visit (Telephone Visits Code) WITH any diagnosis of major depression (Major Depression Code).
Major Depression ICD10CM: F32.0, F32.1, F32.2, F32.3, F32.4, F32.9,
Partial Hospitalization POS: 52 Telehealth POS: 02 Community Health Center POS: 53 ED POS: 23
Performance
Measures
Performance Measure
Requirements Coding
Page 16
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Behavioral Health -- Cont’d Follow-up after Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)
Members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who were seen in the emergency department (ED) visits and had a follow up visit for AOD. Two rates are reported:
7-Day Follow-Up A follow-up visit with any practitioner, with a principal diagnosis of AOD within 7 days after the ED visit (8 total days). Include visits that occur on the date of the ED visit.
30-DayFollow-Up A follow-up visit with any practitioner, with a principal diagnosis of AOD within 30 days after the ED visit (31 total days). Include visits that occur on the date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
• IET Stand Alone Visits Code WITH a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code), with or without a telehealth modifier (Telehealth Modifier Code).
• IET Visits Group 1 Code WITH IET POS Group 1 Code and a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code), with or without a telehealth modifier (Telehealth Modifier Code).
• IET Visits Group 2 Code WITH IET POS Group 2 Code and a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code) WITH a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code).
• A telephone visit (Telephone Visits Code) WITH a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code).
• An online assessment (Online Assessments Code) WITH a principal diagnosis of AOD abuse or dependence (AOD Abuse and Dependence Code).
AOD Abuse and Dependence: ICD10CM: See ICD10CM Code Book
Emergency Department CPT: 99281-99285 UBREV: 0450-0452, 0456, 0459, 0981
IET Visits Group 1 CPT: 90791, 90792, 90832-90834, 90836-90840,
90845, 90847, 90849, 90853, 90875, 90876
IET POS Group 1: 02, 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72
IET Visits Group 2 CPT: 99221-99223, 99231-99233, 99238, 99239,
99251-99255
IET POS Group 2: 02, 52, 53
Telephone Visits CPT: 98966-98968, 99441-99443
Telehealth CPT Modifier: 95, GT
Performance
Measures
Performance Measure
Requirements Coding
Page 17
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Behavioral Health -- Cont’d Follow-up after Hospitalization for Mental Illness (FUH)
Members age 6 and older who were hospitalized for treatment of selected mental illness diagnoses and who had a:
7-Day Follow-Up • A follow-up visit with a Mental Health Practitioner
within 7 days after discharge. Do not include visits that occur on the date of discharge.
30-Day Follow-Up • A follow-up visit with a Mental Health Practitioner
within 30 days after discharge. Do not include visits that occur on the date of discharge.
Two rates are reported for members who had follow-up post discharge.
7-Day follow-up rate 30-Day follow-up rate
For both indicators, any of the following meet criteria for a follow-up visit. • An outpatient visit (Visit Setting Unspecified Code WITH
Outpatient POS Code WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code)
• An outpatient visit (BH Outpatient Code WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Code WITH
Partial Hospitalization POS Code WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization/Intensive Outpatient Code) WITH a mental health practitioner.
• A community mental health center visit (Visit Setting Unspecified Code WITH Community Mental Health Center POS Code WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code).
• Electroconvulsive therapy (Electroconvulsive Therapy Code) WITH (Ambulatory Surgical Center POS Code; Community Mental Health Center POS Code; Outpatient POS Code; Partial Hospitalization POS Code) WITH a mental health practitioner.
• A telehealth visit: Visit Setting Unspecified Code WITH
Telehealth POS Code WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code) WITH a mental health practitioner.
• Transitional care management services (Transitional Care Management Services Code), WITH a mental health practitioner, with or without a telehealth modifier (Telehealth Modifier Code).
Mental Health (MH) Diagnosis ICD10CM: See ICD10CM Code Book
Mental Illness ICD10CM: See ICD10CM Code Book
Intentional Self-Harm ICD10CM: See ICD10CM Code Book
Partial Hospitalization POS: 52 Telehealth POS: 02 Ambulatory Surgical Center POS: 24 Community Health Center POS: 53
Performance
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Performance Measure
Requirements Coding
Page 18
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Behavioral Health -- Cont’d Follow-up after Emergency Department Visit for Mental Illness (FUM)
The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up for mental illness. Two rates are reported: • The percentage of ED visits for which the member
received follow-up within 30 days of the ED visit (31 total days)
• The percentage of the ED visits for which the member received follow-up within 7 days of the ED visit (8 total days)
• 7 Day Follow-Up: A follow-up visit with any practitioner, with a principal diagnosis of a mental health (MH) disorder or with a principal diagnosis of intention self-harm and any diagnosis of a mental health (MH) disorder within 7 days after the ED visit (8 total days). Include visits that occur on the date of the ED visit.
• 30 Day Follow-Up: A follow-up visit with any practitioner, with a principal diagnosis of a mental health (MH) disorder or with a principal diagnosis of intentional self-harm and any diagnosis of a mental health (MH) disorder within 30 days after the ED visit (31 total days). Include visits that occur on the date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
• An outpatient visit (Visit Setting Unspecified Code WITH
Outpatient POS Code) WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An outpatient visit (BH Outpatient Code) WITH a principal
diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization
(Visit Setting Unspecified Code WITH Partial Hospitalization POS Code), WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial hospitalization
(Partial Hospitalization/Intensive Outpatient Code) WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code).
• A community mental health center visit (Visit Setting
Unspecified Code WITH Community Mental Health Center POS Code), WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
WITH (Ambulatory Surgical Center POS Code; Community Mental Health Center POS Code; Outpatient POS Code; Partial Hospitalization POS Code) WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code).
Mental Health (MH) Diagnosis ICD10CM: See ICD10CM Code Book
Mental Illness ICD10CM: See ICD10CM Code Book
Intentional Self-Harm ICD10CM: See ICD10CM Code Book
Partial Hospitalization POS: 52 Ambulatory Surgical Center POS: 24 Community Mental Health Center POS: 53 Telehealth POS: 02
Performance
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Performance Measure
Requirements Coding
Page 19
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Behavioral Health -- Cont’d
Follow-up after Emergency Department Visit for Mental Illness (FUM) -- Cont’d
• A telehealth visit (Visit Setting Unspecified Code WITH
Telehealth POS Code), WITH a principal diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code) WITH a principal
diagnosis of a mental health disorder (Mental Health Diagnosis Code).
• An outpatient visit (Visit Setting Unspecified Code WITH
Outpatient POS Code) WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH
any diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An outpatient visit (BH Outpatient Code) WITH a
principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH any diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial
hospitalization (Visit Setting Unspecified Code WITH
Partial Hospitalization POS Code), WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH any diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An intensive outpatient encounter or partial
hospitalization (Partial Hospitalization/Intensive Outpatient Code) WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH
any diagnosis of a mental health disorder (Mental Health Diagnosis Code).
• A community mental health center visit (Visit Setting
Unspecified Code WITH Community Mental Health Center POS Code), WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH any diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
Code) WITH (Ambulatory Surgical Center POS Code; Community Mental Health Center POS Code; Outpatient POS Code; Partial Hospitalization POS Code) WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH any diagnosis of a mental health disorder (Mental Health Diagnosis Code).
• A telehealth visit (Visit Setting Unspecified Code WITH
Telehealth POS Code), WITH a principal diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH
any diagnosis of a mental health disorder (Mental Health Diagnosis Code), with or without a telehealth modifier (Telehealth Modifier Code).
• An observation visit (Observation Code) WITH a principal
diagnosis of intentional self-harm (Intentional Self-Harm Code), WITH any diagnosis of a mental health disorder (Mental Health Diagnosis Code).
Mental Health (MH) Diagnosis ICD10CM: See ICD10CM Code Book
Mental Illness ICD10CM: See ICD10CM Code Book
Intentional Self-Harm ICD10CM: See ICD10CM Code Book
Partial Hospitalization POS: 52 Ambulatory Surgical Center POS: 24 Community Mental Health Center POS: 53 Telehealth POS: 02
Performance
Measures
Performance Measure
Requirements Coding
Page 20
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization Frequency of Selected Procedures (FSP)
This measure reports the frequently performed procedures that often show wide regional variation and have generated concern regarding potentially inappropriate utilization. Counts are reported for the following procedures by age and sex: • Bariatric weight loss surgery • Tonsillectomy • Hysterectomy, abdominal • Hysterectomy, vaginal • Cholecystectomy, open • Cholecystectomy, (laparoscopic) • Back surgery • Percutaneous coronary intervention • Cardiac catheterization • Coronary artery bypass graft • Prostatectomy • Total hip replacement • Total knee replacement • Carotid endarterectomy • Mastectomy • Lumpectomy
Rate are determined through claims
Ambulatory Care (AMB)
Identify outpatient visits using any of the following for all members. Ambulatory Outpatient Visits • Ambulatory Outpatient Visits code, with or
without a telehealth modifier code • Telephone visits code • Online assessments code
ED visits using either of the following: • ED visit code. • A procedure code (ED Procedure Code) WITH
an ED place of service code (ED POS Code). ED visits that result in an inpatient stay DO NOT COUNT.
ED Visit CPT: 99281-99285 UBREV: 0450-0452, 0456, 0459, 0981
ED Procedure Code CPT: See CPT Code Book
ED POS: 23
Performance
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Performance Measure
Requirements Coding
Page 21
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization -- Cont’d Inpatient Utilization – General Hospital / Acute Care (IPU)
This measure summarizes utilization of acute inpatient care and services in the following categories: • Total inpatient • Maternity • Surgery • Medicine
The data is broken down into the following by category: • Age • Discharges • Discharges/1,000 Member Months • Days • Days/1,000 Member Months • Average Length of Stay
Rate are determined through claims
Deliveries Infant Record ICD10CM: Z38.00, Z38.01, Z38.1, Z38.2, Z38.30,
Mental and Behavioral Disorders ICD10CM: See ICD10CM Code Book
Antibiotic Utilization (ABX)
This measure reviews the following data for outpatient utilization of antibiotic prescriptions during the measurement year, stratified by age and gender of:
• Antibiotics dispensed for any duration. • Antibiotics of Concern by Drug Class Medications
Dicloxacillin, Nafcillin, Oxacillin, Penicillin G Benzathine, Penicillin G Potassium, Penicillin G Procaine, Penicillin G Sodium, Penicillin V Potassium, Piperacillin-Tazobactam, Ticarcillin-Clavulanate
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization -- Cont’d
Identification of Alcohol and Other Drug Services (IAD)
This measure summarizes the number and percentage of members with an alcohol and other drug (AOD) claim who received the following chemical dependency services during the year.
Inpatient
Acute and nonacute inpatient admissions, including inpatient detoxification, from either a hospital or a treatment facility use the Inpatient Stay Code.
Use the appropriate diagnosis codes for the services listed below to meet the criteria for this measure:
- Alcohol disorder (Alcohol Disorders Code) - Opioid disorder (Opioid Disorders Code) - Other or unspecified drug disorders (Other Drug Disorders
Code)
Intensive Out-Patient And Partial Hospitalization
Intensive outpatient and partial hospitalization claims/encounters using the categories and corresponding codes listed below will meet criteria for this measure: • IAD Stand Alone IOP/PH Code. • Visit Setting Unspecified Code WITH Partial Hospitalization
POS Code • Visit Setting Unspecified Code WITH Community Mental
Health Center POS Code, where the visit is in an intensive outpatient or partial hospitalization setting.
Use the appropriate diagnosis codes for the services listed below to meet the criteria for this measure:
- Alcohol disorder (Alcohol Disorders Code) - Opioid disorder (Opioid Disorders Code) - Other or unspecified drug disorders (Other Drug Disorders
Code)
Note: Only in-person services in the Intensive outpatient and partial hospitalization category will be utilized. All services billed WITH a telehealth modifier (Telehealth Modifier Code) or billed WITH a telehealth POS code (Telehealth POS Code) will be excluded from the Intensive Outpatient and Partial Hospitalization category.
Outpatient or Medication Treatment
Outpatient or Medication Treatment must use the categories and corresponding codes listed below to meet criteria for this measure: • IAD Stand Alone Outpatient Code. • Observation Code. • Visit Setting Unspecified Code WITH Outpatient POS Code. • Visit Setting Unspecified Code WITH Non-residential
Substance Abuse Treatment Facility POS Code. • Visit Setting Unspecified Code WITH Community Mental
Health Center POS Code, must be able to confirm that the visit was in an outpatient setting (this POS code can be used in settings other than outpatient).
Telehealth POS: 02 Non-residential Substance Abuse Tx Facility POS: 57 Community Mental Health Center POS: 53 ED POS: 23 Outpatient POS: 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 71, 72 Partial Hospitalization POS: 52
Performance
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Page 23
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization -- Cont’d Identification of Alcohol and Other Drug Services (IAD) -- Cont’d
DO NOT include observation visits that result in an inpatient stay (Inpatient Stay Code).
Note: Only in-person services in the Outpatient category will be utilized. All services billed WITH a telehealth modifier (Telehealth Modifier Code) or billed WITH a telehealth POS code (Telehealth POS Code) will be excluded from the from the Outpatient category.
Emergency Department
ED visits (ED Code) must use the categories and corresponding codes listed below to meet criteria for this measure: • Visit Setting Unspecified Code WITH ED POS Code. • Visit Setting Unspecified Code WITH Community Mental
Health Center POS Code, must be able to confirm that the visit was in an ED setting (this POS code can be used in settings other than the ED).
Use the appropriate diagnosis codes for the services listed below to meet the criteria for this measure:
- Alcohol disorder (Alcohol Disorders Code) - Opioid disorder (Opioid Disorders Code) - Other or unspecified drug disorders (Other Drug Disorders
Code)
DO NOT include observation visits that result in an inpatient stay (Inpatient Stay Code).
Note: Report only in-person services in the ED category. All services billed WITH a telehealth modifier (Telehealth Modifier Code) or billed WITH a telehealth POS code (Telehealth POS Code) will be excluded from the ED category.
Telehealth Telehealth must use the categories and corresponding codes listed below to meet criteria for this measure: • Telephone Visits Code • Online Assessments Code • IAD Stand Alone Outpatient Code WITH Telehealth Modifier
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization -- Cont’d Mental Health Utilization (MPT)
All members with a principal mental health diagnosis that received the following mental health services during the measurement year:
Inpatient Admission:
• Acute and nonacute inpatient discharges from either a hospital or a treatment facility WITH a mental health principal diagnosis (Mental Health Diagnosis Code WITH an Inpatient Stay Code).
Intensive Outpatient/ Partial Hospitalization
Admission: Any of the following meets criteria, only if the visit does not result in an inpatient admission. (The care must be given in an intensive o/p or partial hospitalization setting only.)
• Partial Hospitalization/Intensive Outpatient Code WITH
a principal mental health diagnosis (Mental Health Diagnosis Code).
• (MPT IOP/PH Group 1 Code; Electroconvulsive Therapy Code; Transcranial Magnetic Stimulation Code) WITH
Partial Hospitalization POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• (MPT IOP/PH Group 1 Code; Electroconvulsive Therapy Code; Transcranial Magnetic Stimulation Code) WITH
Community Mental Health Center POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• MPT IOP/PH Group 2 Code WITH Partial Hospitalization POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code) billed by a mental health practitioner.
• MPT IOP/PH Group 2 Code WITH Community Mental Health Center POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code), where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (this POS code can be used in settings other than intensive outpatient and partial hospitalization) and billed by a mental health practitioner.
Outpatient/ Observation Visits: Any of the following meets criteria, only if the visit does not result in an inpatient admission.
• MPT Stand Alone Outpatient Group 1 Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• MPT Stand Alone Outpatient Group 2 Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code) billed by a mental health practitioner.
• Observation Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code) billed by a mental health practitioner.
• (Visit Setting Unspecified Code; Electroconvulsive Therapy Code; Transcranial Magnetic Stimulation Code) WITH Outpatient POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
Mental Health Diagnosis ICD10CM: See ICD10CM Code Book
ED Visit CPT: 99281-99285 UBREV: 0450-0452, 0456, 0459, 0981
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Utilization -- Cont’d Mental Health Utilization (MPT) -- Cont’d
• (Visit Setting Unspecified Code; Electroconvulsive Therapy Code; Transcranial Magnetic Stimulation Code) WITH Community Mental Health Center POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code), where the organization can confirm that the visit was in an outpatient setting (this POS code can be used in settings other than outpatient).
• (Electroconvulsive Therapy Code; Transcranial Magnetic Stimulation Code) WITH (Ambulatory Surgical Center POS Code) WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
ED Visits: Any of the following meets criteria, only if the visit does not result in an inpatient admission.
• ED Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code) billed by a mental health practitioner.
• Visit Setting Unspecified Code WITH ED POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• Visit Setting Unspecified Code WITH Community Mental Health Center POS Code WITH a principal mental health diagnosis (Mental Health Diagnosis Code), where the organization can confirm that the visit was in an ED setting (this POS code can be used in settings other than the ED).
Telehealth Visits: Any of the following meet criteria.
• Visit Setting Unspecified Code WITH (Telehealth Modifier Code; Telehealth POS Code) WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• MPT IOP/PH Group 1 Code WITH (Telehealth Modifier Code; Telehealth POS Code) WITH a principal mental health diagnosis (Mental Health Diagnosis Code).
• MPT IOP/PH Group 2 Code WITH (Telehealth Modifier Code; Telehealth POS Code) WITH a principal mental health diagnosis (Mental Health Diagnosis Code) billed by a mental health practitioner.
49, 50, 71, 72 Partial Hospitalization POS: 52 Ambulatory Surgical Center POS: 24 Community Mental Health Center POS: 53 Emergency Room POS: 23
Measures for Risk Adjusted Utilization Plan All-Cause Readmissions (PCR)
Members 18 years of age and older: A count of the number of acute inpatient stays during the year that were followed by an unplanned acute readmission for any diagnosis that occurs within 30 days and the predicted probability of an acute readmission.
Rate is determined through claims
Hospitalization Following Discharge from a Skilled Nursing Facility (HFS)
Members 18 years of age and older: The measure reviews: • Number of skilled nursing facility discharges to
the community AND • Are followed by an unplanned acute
hospitalization for any diagnosis within 30 and 60 days.
Rate is determined through claims
Performance
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Requirements Coding
Page 26
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
Members 18 years of age and older: a count of observed to expected acute inpatient and observation stay discharges during the year reported by Surgery, Medicine and Total
Rate is determined through claims
Emergency Department Utilization (EDU)
Members 18 years of age and older: A count of the number of emergency department (ED) visits during the measurement year by age, sex and total of visits.
Rate is determined through claims
Hospitalization for Potentially Preventable Complications (HPC)
Members 67 years of age and older: The rate of discharges for ambulatory care sensitive conditions (ACSC) per 1,000 members by chronic and acute conditions.
The ambulatory care conditions included in this measure are: • Chronic ACSC:
Measures for Overuse / Appropriateness Non-Recommended PSA-Based Screening in Older Men (PSA)
Men 70 years and older who were screened unnecessarily for prostate cancer using prostate- specific antigen (PSA)-based screening. (This is an inverse measure.)
Men who had a diagnosis for which PSA-based testing is clinically appropriate. Any of the following meet criteria:
• Prostate cancer diagnosis (Prostate Cancer Code) any time during the member’s history
• Dysplasia of the prostate (Prostate Dysplasia Code) during the year or the prior year prior.
• A PSA test (PSA Test Exclusion Code) during the prior year to the measurement year, where laboratory data indicate an elevated result (>4.0 nanograms/milliliter [ng/mL]).
• Dispensed a prescription for a 5-alpha reductase inhibitor (5-ARI Medications List) during the year.
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Overuse / Appropriateness -- Cont’d Potentially Harmful Drug-Disease Interactions in the Elderly (DDE)
Members 65 years of age and older who have an underlying disease, condition or health concern and who were dispensed an ambulatory prescription.
Four rates are reported
• RATE 1: Members with a History of Falls and who were dispensed an anticonvulsants, SSRIs, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics or tricyclic antidepressants.
• RATE 2: Members with a Dementia and who were dispensed an antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants, H2 receptor antagonists or anticholinergic agents.
• RATE 3: Members with Chronic Kidney Disease who were dispensed a Cox-2 selective NSAIDs or nonaspirin NSAIDs.
• Total Rate (the sum of the three numerators divided by the sum of the three denominators).
Dementia Medications
Description Prescription
Cholinesterase inhibitors • Donepezil
• Galantamine
• Rivastigmine
Miscellaneous central nervous system agents • Memantine
Table DAE-C: High-Risk Medications with Average Daily Alpha agonists, central: Reserpine (>0.1 mg/day) Cardiovascular, other: Digoxin (>0.125 mg/day) Tertiary TCAs (as single agent or as part of combination products): Doxepin (>6 mg/day)
Performance
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Performance Measure
Requirements Coding
Page 29
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
Measures for Overuse / Appropriateness -- Cont’d
Use of Opioids at High Dosage (UOD)
Members 18 years of age and older: Members receiving prescription opioids for ≥15 days during the measurement year at a high dosage. • Average milligram morphine dose [MME] >120
mg.
UOD Opioid Medications
• Butorphanol • Methadone
• Codeine • Morphine
• Dihydrocodeine • Opium
• Fentanyl • Oxycodone
• Hydrocodone • Oxymorphone
• Hydromorphone • Pentazocine
• Levorphanol • Tapentadol
• Meperidine • Tramadol
Use of Opioids from Multiple Providers (UOP)
Members 18 years of age and older: Members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year who received opioids from multiple providers. Three rates are reported.
• Multiple Prescribers: Members receiving prescriptions for opioids from four or more different prescribers during the measurement year.
• Multiple Pharmacies: Members receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
• Multiple Prescribers and Multiple Pharmacies: Members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.
UOP Opioid Medications
• Buprenorphine (transdermal patch & buccal film)
• Butorphanol • Methadone
• Codeine • Morphine
• Dihydrocodeine • Opium
• Fentanyl • Oxycodone
• Hydrocodone • Oxymorphone
• Hydromorphone • Pentazocine
• Levorphanol • Tapentadol
• Meperidine • Tramadol
CAHPS Measures
CPA – CAHPS Health Plan Survey 5.0H, Adult Version
The survey provides information on the experiences of Medicaid members with their health plan and gives a general indication of how well the health plan meets members’ expectations. Results summarize member experiences through ratings, composites and question summary rates.
•Four areas reflect overall satisfaction: 1. Rating of All Health Care. 2. Rating of Personal Doctor. 3. Rating of Specialist Seen Most Often. 4. Rating of Health Plan.
•Five key areas are assessed: 1. Customer Service. 2. Getting Care Quickly. 3. Getting Needed Care. 4. How Well Doctors Communicate. 5. Shared Decision Making.
•Two additional areas are rated: 1. Health Promotion and Education. 2. Coordination of Care.
Performance
Measures
Performance Measure
Requirements Coding
Page 30
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
CAHPS Measures -- Cont’d
MSC – Medical Assistance with Smoking and Tobacco Use Cessation
The three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation. • Advising Smokers and Tobacco Users to Quit: The percentage of members 18 years and older who are current
smokers or tobacco users and who received cessation advice during the measurement year. • Discussing Cessation Medications: The percentage of members 18 years and older who are current smokers or
tobacco users and who discussed or were recommended cessation medications during the measurement year. • Discussing Cessation Strategies: The percentage of members 18 years and older who are current smokers or
tobacco users and who discussed or were provided cessation methods or strategies during the measurement year.
FVO – Flu Vaccinations for Adults Ages 65 and Older
Members 65 years of age and older who received an influenza vaccination between July 1 of the measurement year and the date when the Medicare CAHPS survey was completed.
PNU - Pneumococcal Vaccination Status for Older Adults
Members 65 years of age and older who have ever received one or more pneumococcal vaccinations.
HOS Survey Measures
HOS – Medicare Health Outcomes Survey
This measure provides a general indication of how well a Medicare organization manages the physical and mental health of its members. The survey measures each member’s physical and mental health status at the beginning and the end of a two-year period.
A two-year change score is calculated and each member’s physical and mental health status is categorized as better, the same or worse than expected, considering risk adjustment factors. Organization-specific results are assigned as percentages of members whose health status was better, the same or worse than expected.
FRM – Fall Risk Management The two components of this measure assess different facets of fall risk management.
• Discussing Fall Risk: The percentage of Medicare members 65 years of age and older who were seen by a practitioner in the past 12 months and who discussed falls or problems with balance or walking with their current practitioner.
• Managing Fall Risk: The percentage of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received a recommendation for how to prevent falls or treat problems with balance or walking from their current practitioner.
MUI – Management of Urinary Incontinence in Older Adults The following components of this measure assess the management of urinary incontinence in older adults.
• Discussing Urinary Incontinence: The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who discussed their urinary leakage problem with a health care provider.
• Discussing Treatment of Urinary Incontinence: The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who discussed treatment options for their current urine leakage problem.
• Impact of Urinary Incontinence: The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who reported that urine leakage made them change their daily activities or interfered with their sleep a lot.
Performance
Measures
Performance Measure
Requirements Coding
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Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Codes that Correspond to the HEDIS Quality Measures
11/14/2018
HOS Survey Measures -- Cont’d
OTO – Osteoporosis Testing in Older Women Medicare women 65–85 years of age who report ever having received a bone density test to check for osteoporosis.
PAO – Physical Activity in Older Adults
The two components of this measure assess different facets of promoting physical activity in older adults. • Discussing Physical Activity: The percentage of Medicare members 65 years of age and older who had a doctor’s visit in
the past 12 months and who spoke with a doctor or other health provider about their level of exercise or physical activity.
• Advising Physical Activity: The percentage of Medicare members 65 years of age and older who had a doctor’s visit in the past 12 months and who received advice to start, increase or maintain their level exercise or physical activity.
