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Provider STAR Ratings Quick Reference Guide 2020 Dates of Service Updated January 1, 2020 MHP00176_20200109 1
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Page 1: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

Provider STAR Ratings

Quick Reference Guide

2020 Dates of Service

Updated January 1, 2020

MHP00176_20200109 1

Page 2: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Adult BMI (Body Mass Index) Assessment (ABA) (Administrative/Hybrid) DESCRIPTION: Percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. DATES OF SERVICE: Jan 01 - Dec 31 of CY or year prior EXCLUSIONS: Members who have a diagnosis of pregnancy during the measurement year or the year prior.

1 2 3 4 5 CPT for Office Visit

AND

ICD -10 CM Diagnosis < 78% ≥ 78% to < 92% ≥ 92% to < 96% ≥ 96% to < 99% ≥ 99% 99201 - 99205, 99211 - 99215, 99241 - 99245,

99341 - 99345, 99347 - 99350, 99381 - 99387, 99391 - 99397, 99401 - 99404, 99411, 99412, 99429, 99455, 99456, 99483

Z68.1, Z68.20 - Z68.39 Z68.41 - Z68.45, Z68.51 - Z68.54

Weighted Value: 1 *Telehealth Applicable

Breast Cancer Screening (BCS) (Administrative-Claims Data Only) DESCRIPTION: Percentage of women 50-74 years of age as of December 31 who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. DATES OF SERVICE: October 1 of two years prior to CY - December 31 of CY EXCLUSIONS: Women who had a bilateral mastectomy, or two unilateral mastectomies. Any patient 66 years and older with advanced illness and frailty or who live in long - term nusing home settings. Note: This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or diagnostic screenings because they are not appropriate methods for primary breast cancer screening.

1 2 3 4 5

OR

HCPCS for Mammo < 50% ≥ 50% to < 66% ≥ 66% to < 76% ≥ 76% to < 83% ≥ 83%

CPT for Mammo

77055 - 77057, 77061 - 77063, 77065 - 77067

G0202, G0204, G0206 Weighted Value: 1 *Telehealth Applicable

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Page 3: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Care for Older Adults (COA)- Advance Care Planning (SNP only) (Administrative/Hybrid) DESCRIPTION: Percent of adults 66 years old and older who have active advance care planning such as Advanced Directive, Actionable Medical Orders, Living Will, Power of Attorney, Health Care Proxy, or Surrogate Decision Maker. Evidence of advance care planning must include: (1) An advance care plan in the medical record. (2) Advance care planning discussion with the provider documented and dated. (3) Notation that the member has previously executed an advanced care plan that meets criteria. DATES OF SERVICE: Jan 01- Dec 31 of CY THIS IS NOT A STAR RATINGS MEASURE CPT for ACP

OR

CPT Category II for

OR

HPCPS for ACP

No Thresholds applicable* 99483, 99497 1123F, 1124F, 1157F, 1158F

S0257

Care for Older Adults (COA)- Functional Status Assessment (SNP only) (Administrative/Hybrid) DESCRIPTION: Percent of adults 66 years old and older who have documentation in the medical record of a functional status assessment during the measurement year. Notations for a complete functional status assessment must include one of the following: (1) Assessment of instrumental activities of daily living (IADL) such as shopping for groceries, driving, using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications or handling finances, etc. OR (2) Assessment of activities of daily living (ADL) such as bathing, dressing, eating, transferring (i.e., getting in and out of chairs), using the toilet and walking OR (3) Results using a standardized functional status assessment tool OR (4) Assessment of three of the following four components A) Cognitive status B) Ambulation status C) Sensory ability (must include hearing, vision, and speech) D) Other functional independence (e.g., exercise, ability to perform job). Important Note: A functional status assessment limited to an acute or single condition, event, or body system (e.g., lower back, leg) DOES NOT meet criteria for a comprehensive functional status assessment. DATES OF SERVICE: Jan 01- Dec 31 of CY

1 2 3 4 5 CPT Category II for FSA < 55% ≥ 55% to < 71% ≥ 71% to < 85% ≥ 85% to < 93% ≥ 93%

1170F Weighted Value: 1 *Telehealth Applicable

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Page 4: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Care for Older Adults (COA)- Medication Review (SNP only) (Administrative/Hybrid) DESCRIPTION: Percent of adults 66 years old and older who have at least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year AND the presence of a medication list in the medical record. A medication list, signed and dated during the measurement year meets criteria.

DATES OF SERVICE: Jan 01- Dec 31 of CY 1 2 3 4 5

< 63% ≥ 63% to < 77% ≥ 77% to < 87% ≥ 87% to < 95% ≥ 95%

Weighted Value: 1*Telehealth Applicable

CPT for Med Review 90863, 99483 ,99605, 99606

CPT Category II for Med List 1159F

OR

AND OR

CPT Category II for Med Review 1160F

HCPCS for Med List G8427

Care for Older Adults (COA)- Pain Screening (SNP only) DESCRIPTION: Percent of adults 66 years old and older who have at least one pain assessment during the measurement

(Administrative/Hybrid)

year (which may include positive or negative findings for pain). Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal or written)– Face, Legs, Activity, Cry Consolability (FLACC) scale.– Verbal descriptor scales (5–7 Word Scales, Present Pain Inventory).– Pain Thermometer– Pictorial Pain Scales (Faces Pain Scale, Wong-Baker Pain Scale)DATES OF SERVICE: Jan 01- Dec 31 of CY

– Visual analogue scale– Brief Pain Inventory– Chronic Pain Grade– PROMIS Pain Intensity Scale– Pain Assessment in Advanced Dementia (PAINAD) Scale

1 2 3 4 5 < 59% ≥ 59% to < 81% ≥ 81% to < 86% ≥ 86% to < 94% ≥ 94%

Weighted Value: 1 *Telehealth Applicable

CPT Category II for Pain Present

1125F

CPT Category II for No Pain Present OR 1126F

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Page 5: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Colorectal Cancer Screening (COL) (Administrative/Hybrid) DESCRIPTION: Percentage of members 50-75 years of age who had appropriate screening for colorectal cancer. FOBT: Jan 01- Dec 31 of CY or

Flexible Sigmoidoscopy: Jan 01- Dec 31 of CY, or 4 years prior or

CPT for FOBT OR

HCPCS for FOBT

Colonoscopy: Jan 01- Dec 31 of CY, or 9 years prior or 82270, 82274 G0328 CT Colonography: Jan 01- Dec 31 of CY, or 4 years prior or CPT for Flex Sigmoidoscopy

OR HCPCS for Flex Sigmoidoscopy

FIT-DNA (Cologuard) : Jan 01- Dec 31 of CY, or 2 years prior 45330-45335, 45337-45342, 45345-45347, 45349, 45350

G0104

EXCLUSIONS: Diagnosis of colorectal cancer or total colectomy. Any patients 66 years and older with frailty and advanced illness.

CPT for Colonoscopy OR

HCPCS for Colonoscopy

1 2 3 4 5 44388-44394, 44397, 44401-44408, 45355, 45378-45393, 45398

G0105, G0121

< 43% ≥ 43% to < 62% ≥ 62% to < 73% ≥ 73% to < 80% ≥ 80% CPT for CT Colonography

74261, 74262, 74263

Weighted Value: 1*Telehealth Applicable

CPT for FIT-DNA (Cologuard) OR

LOINC for FIT-DNA

(Cologuard) OR

HCPCS for FIT-DNA

(Cologuard 81528 77353-1

77354-9 G0464

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Page 6: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Comprehensive Diabetes Care (CDC) –Blood Sugar Controlled / HbA1c Controlled (Administrative/Hybrid) DESCRIPTION: Percentage of plan members 18-75 years of age with diabetes who had an A1C lab test during the measurement year that showed their average blood sugar under control (<9%). DATES OF SERVICE: Jan 01- Dec 31 of CY EXCLUSIONS: Any patient 66 years old and older with frailty and advanced illness.

1 2 3 4 5 CPT for

OR

LOINC for HbA1c Test

AND

CPT Category II for HbA1c Value

< 37% ≥ 37% to < 61% ≥ 61% to < 72% ≥ 72% to < 85% ≥ 85% HbA1c Test Level Less Than 7.0 3044F

Weighted Value: 3 *Only one of the two visits may be a telephone visit, an onlineassessment or an outpatient telehealth visit.

83036, 83037 4548-4, 4549-2, 17856-6

Level ≥ 7.0 to ≤ 8.0 3051F

Level ≥ 8.0 to ≤ 9.0 3052F

Level Greater Than 9.0 3046F

Comprehensive Diabetes Care (CDC)– Diabetes Care – Eye Exam (Administrative/Hybrid) DESCRIPTION: Percentage of plan members 18-75 years of age with diabetes who had an eye exam to check for damage from diabetes during the measurement year or had a negative eye exam in prior year. DATES OF SERVICE: Jan 01- Dec 31 of CY or year prior EXCLUSIONS: Any patient 66 years old and older with frailty and advanced illness.

1 2 3 4 5 CPT for Diabetic Retinal Screening

OR

CPT II for Diabetic Retinal

Screening

OR

HCPCS for Diabetic Retinal

Screening

< 63% ≥ 63% to < 69% ≥ 69% to < 73% ≥ 73% to < 78% ≥ 78% 67028, 67030, 67031, 67036, 67039- 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225- 92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245

Weighted Value: 1 *Only one of the two visits may be a telephone visit, an onlineassessment or an outpatient telehealth visit.

Note: For eye exam performed in the year prior to the measurement year, a copy of the exam must be available and documented as part of the medical record indicating a negative result for Diabetic Retinopathy.

2022F, 2023F, 2024F, 2025F, 2026F, 2033F, 3072F

S0620, S0621, S3000

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HEDIS (Part C) Measures Comprehensive Diabetes Care (CDC)– Kidney Disease Monitoring (Administrative/Hybrid) DESCRIPTION: Percentage of plan members 18-75 years of age with diabetes (type 1 and type 2) who had a urine micro albumin test or evidence of nephropathy during the measurement year or who had received medical attention for nephropathy during the measurement year. DATES OF SERVICE: Jan 01- Dec 31 of CY EXCLUSIONS: Members who do not have a diagnosis of diabetes in any setting, during the measurement year or the prior year. Any patient 66 years old and older with frailty and advanced illness.

1 2 3 4 5 CPT for Nephropathy screening OR

CPT II for Nephropathy screening NA NA ≥ 80% to < 95% ≥ 95% to < 97% ≥ 97% 82042, 82043, 82044, 84156 3060F, 3061F, 3062F

Weighted Value: 1 *Only one of the two visits may be a telephone visit, an onlineassessment or an outpatient telehealth visit.

CPT for Urine microalbumin test OR

CPT Category II for Urine

Note: Only 1 of the actions listed below is required for compliance. Nephropathy screening or Evidence of treatment for nephropathy or Urine albumin or protein test.

Examples of urine tests for protein or albumin: Timed test for albumin or protein or total protein, spot test for albumin or protein, test for albumin/creatinine ratio.

81000-81003, 81005 3062F

CPT for Evidence of treatment for nephropathy (ESRD, Nephrectomy, or

OR

CPT Category II for Evidence of treatment for nephropathy

90935, 90937, 90945, 90947, 90997, 90999, 99512

50340, 50360, 50365, 50370, 50380

3066F, 4010F

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Page 8: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Controlling High Blood Pressure (CBP) (Hybrid – 100% Medical Record Review) DESCRIPTION: Percentage of members 18–85 years of age who had at least two visits on different dates of service with a diagnosis of hypertension (HTN) during the measurement year or the year prior, and whose BP was adequately controlled (BP <140/90 mm Hg). DATES OF SERVICE: Jan 01- Dec 31 of CY EXCLUSIONS: Members 66 years of age and older as of Dec 31 enrolled in an I-SNP and/or living long-term in an institution any time during the measurement year. Any patient 66- 80 with frailty and advanced illness, as well as those 81 years old and older with fraility.

1 2 3 4 5 ICD-10 CM Diagnosis for

HTN

AND

CPT Category II for BP

< 60% ≥ 60% to < 70% ≥ 70% to < 78% ≥ 78% to < 85% ≥ 85%

I10 Systolic < 130 3074F

Weighted Value: This measure is not an active measure in CY 2019 but is expected to return in CY 2020. *Only one of the two visits may be a telephone visit, an onlineassessment or an outpatient telehealth visit.

Systolic 130-139 3075F Systolic ≥ 140 3077F Diastolic < 80 3078F

Diastolic 80-89 3079F Diastolic ≥ 90 3080F

Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) (Administrative –Claim/Encounter)

DESCRIPTION: Percentage of plan members who were diagnosed with rheumatoid arthritis and were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). DATES OF SERVICE: Jan 01- Dec 31 of CY EXCLUSIONS: Members 66 years of age and older as of Dec 31 enrolled in an I-SNP and/or living long-term in an institution any time during the measurement year. Any patient 66- 80 with frailty and advanced illness, as well as those 81 years old and older with fraility.

1 2 3 4 5 IF Member Diagnosed with one of the

below Codes: Then Prescribe member one of the following

DMARD's as recommended by CMS

< 60% ≥ 60% to < 74% ≥ 74% to < 79% ≥ 79% to < 84% ≥ 84% ICD -10-CM Diagnosis for Rheumatoid

Arthritis First Line Therapy Medications

Weighted Value: 1 *Telehealth Applicable

M06.9, M05.00, M05.10, M05.60, M05.80

Methotrexate Azathioprine Cyclophosphamide Minocycline

Sulfasalazine Cyclosporine Hydroxychloroquine Leflunomide

Penicillamine Mycophenolate

MHP00176_20200109 8

Page 9: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Osteoporosis Management in Women who had a Fracture (OMW) (Administrative–Claim/Encounter) DESCRIPTION: Percentage of female plan members 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis within 180 days post fracture.

DATES OF SERVICE: Jan 01- Dec 31 of CY

For Fractures please prescribe the member one of the following medications as recommended

Fracture Date Range: July 01 of prior year - Jun 30 of CY Test Performed/Prescription by: July 1st of prior year - Dec 31 of CY by CMS

1 2 3 4 5 < 31% ≥ 31% to < 41% ≥ 41% to < 50% ≥ 50% to < 67% ≥ 67%

Weighted Value: 1*Telehealth Applicable

HCPCS (J Codes) for Osteoporosis Therapy

Prescription Drug

J0897, J1740, J3110, J3489 OR Ibandronate, Alendronate, Risedronate, Raloxifene

CPT for BMD 76977, 77078, 77080, 77081, 7 7082, 77085, 77086

ICD 10-PCS Procedure for BMD BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BQ00ZZ1,

BQ03ZZ1 BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR0GZZ1

Plan All-Cause Readmissions (PCR) (Administrative –Claim/Encounter) DESCRIPTION: Percentage of hospital stays during the measurement year that were followed by an unplanned hospital readmission for any diagnosis within 30 days, for members 65 years of age and older. Discharge during: Jan 01- Dec 1 of CY Readmission: Within 30 days of discharge Exclusions: Hospital stays where the admission day is the same as the discharge date OR Any acute inpatient stays with a discharge date in the 30 days prior to the admission date OR Inpatient stays with discharges for death; acute inpatient stays for pregnancy

1 2 3 4 5

> 10% > 8% to ≤ 10% > 7% to ≤ 8% > 3% to ≤ 7% ≤ 3%

Weighted Value: This measure is not an active measure in CY 2019 but is expected to return in CY 2021. *Telehealth Applicable

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Page 10: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS (Part C) Measures Medication Reconciliation Post-Discharge (MRP) (Administrative –Claim/Encounter) DESCRIPTION: Percentage of discharges during the measurement year for members for whom medications were reconciled within 30 days post discharge.

Discharge during: Jan 01- Dec 1 of CY Readmission or direct transfer: Within 30 days of discharge Exclusions: Hospital stays where the admission day is the same as the discharge date OR Any acute inpatient stays with a discharge date in the 30 days prior to the admission date OR Inpatient stays with discharges for death

1 2 3 4 5 CPT for MRP

OR

CPT Category II for MRP

99483, 99495, 99496 1111F < 48% ≥ 48% to < 62% ≥ 62% to < 71% ≥ 71% to < 84% ≥ 84%

Weighted Value: 1 *Telehealth Applicable

MHP00176_20200109 10

Page 11: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

Pharmacy (Part D) Measures Medication Adherence (Prescription Drug Event [PDE] Data) DESCRIPTION: Percentage of plan members with a diabetes and/or hypertension, and/or cholesterol prescription who fill their prescription to cover 80% or more of the time they are supposed to be taking the medication. DATES OF SERVICE: Jan 01- Dec 31 of CY

Diabetes Medications

1 2 3 4 5 Targeted Population Recommended Adherence Monitoring

< 74% ≥ 74% to < 78% ≥ 78% to < 82% ≥ 82% to < 85% ≥ 85% Members taking diabetes medications in the

following therapeutic classes: Ensure Members are taking their medication as directed

EXCLUSIONS: Members who have one or more prescriptions for insulin in the CY

Weighted Value: 3*Telehealth Applicable

Biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase (DPP)-IV inhibitors, meglitinides, or incretin mimetic agents

Hypertension Medications (RAS antagonists - ACEI & ARBs) 1 2 3 4 5 Targeted Population Recommended Adherence

Monitoring

< 80% ≥ 80% to < 83% ≥ 83% to < 86% ≥ 86% to < 88% ≥ 88% Members taking hypertension medications in

the following therapeutic classes: Ensure Members are taking their medication as directed

EXCLUSIONS: Members who have one or more prescriptions claim for sacubitril/valsartan during the CY

Weighted Value: 3*Telehealth Applicable

ACE (Angiotensin Converting Enzyme), ARB (Angiotensin Receptor Blocker), or Direct Renin Inhibitors

Cholesterol Medications (Statins) 1 2 3 4 5 Targeted Population Recommended Adherence

Monitoring

< 72% ≥ 72% to < 80% ≥ 80% to < 84% ≥ 84% to < 87% ≥ 87% Members taking a cholesterol medication in the

following therapeutic class: Ensure Members are taking their medication as directed

Weighted Value: 3 *Telehealth Applicable

Statin

MHP00176_20200109 11

Page 12: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

Pharmacy (Part D) Measures Statins Use in Persons with Diabetes (SUPD) (Prescription Drug Event [PDE] Data) DESCRIPTION: Percentage of plan members 40-75 years of age who were dispensed at least two diabetes medication fills and received at least one statin medication during the measurement year. DATES OF SERVICE : Jan 01- Dec 31 of CY EXCLUSIONS: Members enrolled in hospice are not included

1 2 3 4 5 Targeted Population Compliance

< 74% ≥ 74% to < 78% ≥ 78% to < 81% ≥ 81% to < 83% ≥ 83% Members with 2 fills of diabetic medication in

the following therapeutic classes: 1 fill of a cholesterol medication in

the following therapeutic class:

Weighted Value: 1*Only one of the two visits may be an outpatient telehealth visit, atelephone visit or an online assessment.

Biguanides, sulfonylureas, meglitinides, alpha- glucosidase inhibitors, thiazolidinediones, incretin mimetics agents, amylin analogs, dipeptidyl peptidase (DPP)-IV inhibitors, insulins, and sodium glucose co-transporter 2 (SGLT2) inhibitors.

Statin

MHP00176_20200109 12

Page 13: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS Measures Hospitalization for Potentially Preventable Complications (HPC) (Administrative –Claim/Encounter) DESCRIPTION: For members 67 years of age and older, the rate of discharges for ambulatory care sensitive conditions (ACSC) per 1,000 members and the risk-adjusted ratio of observed to expected discharges for ACSC by chronic and acute conditions. DATES OF SERVICE : Jan 01- Dec 31 of CY EXCLUSIONS: Members enrolled in hospice are not included

1 2 3 4 5 Targeted Population

> 102% ≤ 102% to > 61% ≤ 61% to > 41% ≤ 41% to > 26% ≤ 26% Members identified as discharged for an

ambulatory care sensitive condition (ACSC)

Chronic ACSC Acute ACSC

Weighted Value: 1*Telehealth Applicable

COPD, Asthma, Hypertension, Heart failure, Diabetes short-term complications, Diabetes long-term complications, Uncontrolled diabetes, Lower-extremity amputation among patients with diabetes

Bacterial pneumonia, Urinary tract infection, Cellulitis, Pressure ulcer

Statin Therapy for Patients With Cardiovascular Disease (SPC) (Prescription Drug Event [PDE] Data) DESCRIPTION: Percentage of males 21–75 years of age and females 40–75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and received at least one high or moderate-intensity statin medication during the measurement year. DATES OF SERVICE : Jan 01- Dec 31 of CY EXCLUSIONS: Members enrolled in hospice are not included

1 2 3 4 5 Targeted Population Compliance

< 75% ≥ 75% to < 79% ≥ 79% to < 83% ≥ 83% to < 87% ≥ 87% Members identified as having

cardiovascular disease by: 1 fill of a cholesterol medication in

the following therapeutic class: Weighted Value: 1*Only one of the two visits may be an outpatient telehealth visit, atelephone visit or an online assessment.

Claim/Encounter data OR Pharmacy data

Statin

MHP00176_20200109 13

Page 14: Provider STAR Ratings Quick Reference Guide · 1/1/2020  · Result of assessment using a standardized pain assessment tool, not limited to: – Numeric rating scales (verbal orwritten)

HEDIS 2020 EXCLUSION CODES

UPDATED 01/02/2020

HEDIS MEASURE EXCLUSION DESCRIPTION ICD10 HCPCS CPT(ABA) Adult BMI Pregnancy

(BCS) Breast Cancer Screening Bilateral Mastectomy 0HTV0ZZ

Unilateral Mastectomy With Modifier

0HTU0ZZ, 0HTT0ZZ 19180, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307

(COL) Colorectal Cancer Screening Colorectal Cancer C18.0-C18.9, C19-C21.2, C21.8, C78.5, Z85.038, Z85.048

G0213-G0215, G0231

Total Colectomy 0DTE0ZZ, 0DTE4ZZ 0DTE7ZZ, 0DTE8ZZ

44150-44153, 44155-44158, 44210-44212

(CBP) Controlling Blood Pressure ESRD (ICD10CM) N18.5, N18.6, Z91.15, Z99.2 (ICD10PCS) 3E1M39Z, 5A1D00Z, 5A1D60Z

G0257, S9339 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989,

(CDC) Comprehensive Diabetes Care Diabetes Exclusions E08.00, E08.01, E08.10, E08.11, E08.21, E08.22, E08.29, E08.311, E08.319, E08.321, E08.3211-E08.3213, E08.3219, E08.329- E08.3293, E08.3299, E08.331-E08.3319, E08.339-E08.3393, E08.3399, E08.341-E08.3413, E08.3419 E08.349-E08.3493, E08.3499, E08.351-E08.3513, E08.3519, E08.3521-E08.3523, E08.3529, E08.3531-E08.3533, E08.3539, E08.3541-E08.3543, E08.3549, E08-3551- E08-3553, E08.3599, E08.359-E08.3593, E08.3599, E08.36, E08.37X1-E08.37X3, E08.37X9, E08.39- E08.44, E08.51, E08.52, E08.59, E08.610, E08.618, E08.620- E08.622, E08.628, E08.630, E08.638, E08.641, E08.649, E08.65, E08.69, E08.8, E08.9, E09.00, E09.01, E09.10, E09.11, E09.21, E09.22, E09.29, E09.311, E09.319, E09.321-E09.3213, E09.3219, E09.329-E09.3293, E09.3299, E09.331-E09.3313, E09.3319, E09.339-E09.3393, E09.3399, E09.341-E09.3413, E09.3419, E09.349-E09.3493, E09.3499, E09.351-E09.3513, E09.3519, E09.3521-E09.3523, E09.3529, E09.3531-E09.3533, E09.3539, E09.3541-E09.3543, E09.3549, E09.3551-E09.3553, E09.3559, E09.359-E09.3593, E09.3599, E09.36, E09.37X1-E09.37X3, E09.37X9, E09.39-E09.44, E09.49, E09.51, E09.59, E09.610, E09.618, E09.620-E09.622, E09.628, E09.630, E09.638, E09.641, E09.649, E09.65, E09.69, E09.8, E09.9, O24.410, O24.414, O24.415, O24.419, O24.420, O24.424, O24.425, O24.429, O24.430, O24.434, O24.435, O24.439, O24.911- O24.913, O24.919, O24.92, O24.93

(ART) Rheumatoid Arthritis Management

HIV B20, Z21, B97.35

Pregnancy

MHP00176_20200109 14


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