Introduction to HEDIS ® 2016 Presented by the Quality Improvement Department at Gold Coast Health Plan Ventura County’s Medi-Cal Managed Care Plan Serving.

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Introduction to HEDIS® 2016

Presented by the Quality Improvement Department at Gold Coast Health Plan

Ventura County’s Medi-Cal Managed Care PlanServing Ventura County since July 1, 2011

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Contents

I. What is HEDIS®?II. HEDIS® Measures GCHP Reports

III. HEDIS® Measure DefinitionsIII. Reasons for Low HEDIS® RatesIV. How to Improve your HEDIS® Rates

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What is HEDIS®?

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What is HEDIS®?

HEDIS® is a standardized set of performance measures called Healthcare Effectiveness Data Information Set which are developed and maintained by the National Committee for Quality Assurance (NCQA).

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Who participates in HEDIS®?

• Over 90% of America’s health plans (Medicare, Medicaid, and commercial) participate in HEDIS® quality reviews.

• California’s Medi-Cal Managed Care Plans are mandated by the Department of Health Care Services (DHCS) to report HEDIS® measures annually.

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Purpose of HEDIS®

• Health Plans use HEDIS® reviews to:►Evaluate quality of care and services provided

to health plan members►Evaluate accessibility of care►Develop performance improvement initiatives►Perform outreach to providers and members►Compare performance with other health plans

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Reporting HEDIS® Rates• HEDIS® measures evaluate the previous year’s clinical

data.– For example, most HEDIS® rates reported in 2016 are based on

clinical services performed in 2015. – Some measures, such as Cervical Cancer Screening, look for

services performed up to 5 years prior to the reporting year.

• Results of HEDIS® reviews are reported to DHCS and NCQA in June each year.

• GCHP distributes HEDIS® Provider Report Cards in June & July.

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HEDIS® Timeline Month HEDIS® Meetings HEDIS ®

TrainingData

Integration Runs

HEDIS ® Audit

Activity

Medical Record

Retrieval

Medical Record Review

HEDIS ® Submissions

Measure Improvement

Projects

September X X X

October X X Q3 Run X X

November X X X X

December X X X X

January X X Q4 Run X Roadmap X

February X X X X X X

March X X X X Convenience Samples

X

April X Q1 Run X X X Preliminary Rates

X

May X X X X Medical Record Review

Validations

X

June X X Final Rates X

July X Q2 Run Audit Results

X

August X X

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What does HEDIS® measure?HEDIS® consists of 88 measures across the following 7 domains of care:

1. Effectiveness of Care

2. Access/Availability of Care

3. Experience of Care

4. Utilization and Risk Adjusted Utilization• NCQA combined “Utilization” with “Risk Adjusted Utilization” in 2015.

5. Relative Resource Use• NCQA removed the “Utilization” measures from this domain in 2015. Previously this domain was

titled “Utilization and Relative Resource Use”.

6. Health Plan Descriptive Information

7. Measures Collected Using Electronic Clinical Data Systems • New domain added by NCQA in 2015.

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Clinical Data Reviewed for HEDIS® Reporting

• Claims data• Encounter data• Pharmacy data• Medical records• Member data• Provider data• Supplemental clinic data such as:

• Lab• Vision• Immunization• Electronic medical records

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Two Types of Measures

►Hybrid measures►Population size reviewed: Sample size of up to 411 eligible members

randomly selected ►Requires reviewing claims, encounter, and supplemental data (e.g. labs,

Rx, Vision, CAIR, etc.). ►Require reviewing medical record documentation to validate if members

received the service or care being measured.

►Admin measures►Population sized reviewed: Entire eligible population ►Requires reviewing only claims, encounter and supplemental data (e.g.

labs, Rx, Vision, CAIR, etc.). ►No medical record reviews required.

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HEDIS® Measures GCHP Reports

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HEDIS® Measure Type of Measure Domain Sub-Domain1 Weight Assessment & Counseling for Nutrition &

Physical Activity for Children & AdolescentsHybrid Effectiveness of Care Prevention & Screening

2 Childhood Immunization Status Hybrid Effectiveness of Care Prevention & Screening

3 Immunizations for Adolescents Hybrid Effectiveness of Care Prevention & Screening

4 Cervical Cancer Screening Hybrid Effectiveness of Care Prevention & Screening

5 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Admin Effectiveness of Care Overuse/Appropriateness

6 Use of Imaging Studies for Low Back Pain Admin Effectiveness of Care Overuse/Appropriateness

7 Medication Management for People with Asthma Admin Effectiveness of Care Respiratory Conditions

8 Controlling High Blood Pressure Hybrid Effectiveness of Care Cardiovascular

9 Comprehensive Diabetes Care Hybrid Effectiveness of Care Diabetes

10 Annual Monitoring for Patients on Persistent Medications

Admin Effectiveness of Care Medication Management

11 Children & Adolescent Access to PCPs Admin Access & Availability of Care Access & Availability of Care

12 Prenatal & Postpartum Care Hybrid Access & Availability of Care Access & Availability of Care

13 Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life Hybrid Utilization & Risk Adjusted Utilization

Utilization

14 Ambulatory Care Admin Utilization & Risk Adjusted Utilization

Utilization

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HEDIS® Measure Definitions

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Domain: Effectiveness of Care

Sub-Domain: Prevention & Screening

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Weight Assessment & Counseling for Nutrition & Physical Activity in Children & Adolescents (WCC)

• The percentage of 3 to 17 year old children and adolescents who had an outpatient visit with a PCP or OB/GYN and who received ALL of the following three services during the 2015 measurement year:

► BMI percentile assessment► Counseling for nutrition► Counseling for physical activity

• Three separate rates are reported for each service

• Data reviewed to identify compliance with measure:► Claims and encounter data ► Medical records

• Hybrid Measure

• NCQA’s Changes to the WCC Measure in 2015► Documentation of BMI value for adolescents aged 16-17 is no longer accepted – BMI percentile must be

documented► Documentation of anticipatory guidance related to safety (e.g. wears helmet or water safety) without specific

mention to physical activity recommendations no longer meets criteria for counseling for physical activity.

Codes to Identify WCCDescription ICD-9-CM

DiagnosisICD-10-CM Diagnosis

CPT HCPCS UB Revenue

BMI Percentile, Pediatric <5% V85.51 Z68.51

BMI Percentile, Pediatric 5% to <85%

V85.52 Z68.52

BMI Percentile, Pediatric 85% to <95%

V85.53 Z68.53

BMI Percentile, Pediatric ≥ 95% V85.54 Z68.54

Counseling for Nutrition V65.3 Z71.3 97802-97804 G0270-G0271, G0447, S9449, S9452, S9470, S9449

Counseling for Physical Activity V65.41 G0447, S9451

Outpatient Visits 99201-99205, 99211- 99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456

G0402, G4038, G4039, G0463, T1015

0510-0523, 0526-0529, 0982-0983

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Childhood Immunization Status (CIS)• The percentage of 2-year old children who had the following childhood immunizations

between 42-days after birth and on or before their 2nd birthday:► 4 DTaP (diphtheria, tetanus, and acellular pertussis)► 3 IPV (polio)► 1 MMR (measles, mumps, rubella)► 3 HiB (H influenza type B)► 3 Hep B (Hepatitis B) – newborn Hep B vaccine administered during 8-day period after birth is acceptable► 1 VZV (chicken pox)► 4 PCV (pneumococcal conjugate)

• Eight rates reported:► One rate for each of the seven immunizations► One combo rate reported showing the percentage of children who had all seven immunizations

• Data reviewed to identify compliance with measure:► Claims and encounter data► Medical records► CAIR Immunization Registry

• Hybrid Measure

Codes to Identify CISImmunization CPT ICD-9-CM Diagnosis ICD-10-CM Diagnosis

DTaP 90698, 90700, 90721, 90723

IPV 90698, 90713, 90723

MMR 90707, 90710

Measles and rubella 90708

Measles 90705 055.0, 055.1, 055.2, 055.71, 055.79, 055.8, 055.9

B05.0 – B05.4, B05.81, B05.89, B05.9

Mumps 90704 072.0 – 072.3, 072.71, 072.72, 072.79, 072.8, 072.9

B26.0 – B26.3, B26.81 – B26.85, B26.89, B26.9

Rubella 90706 056.00, 056.01, 056.09, 056.71, 056.79, 056.8, 056.9

B06.00-B06.02, B06.09, B06.81-B06.82, B06.89, B06.9

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Codes to Identify CISImmunization CPT HCPCS ICD-9-CM Diagnosis ICD-10-CM Diagnosis ICD-9-PCS ICD-10-PCS

HiB 90645-90648, 90698, 90721, 90748

Hepatitis B 90723, 90740, 90744, 90747, 90748

G0010 070.20-070.23, 070.30-070.33, V02.61

B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51

99.55 3E0234Z

VZV 90710,90716 052.0-052.2, 052.7-052.9, 053.0, 053.10-053.14, 053.19-053.22, 053.29, 053.71, 053.79, 053.8, 053.9

B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21-B02.24, B02.29-B02.34, B02.39, B02.7 – B02.9

Pneumococcal Conjugate

90669, 90670 G0009

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Immunization for Adolescents (IMA)

• The percentage of 13-year old adolescents who had the following immunizations:► 1 Meningococcal between the member’s 11th and 13th birthday► 1 Tdap/Td between the member’s 10th and 13th birthday

• Three rates are reported:► One rate for each immunization► One combo rate reported showing the percentage of adolescents who had both

immunizations

• Data reviewed to identify compliance with measure:► Claims and encounter data► Medical records► CAIR Immunization Registry

• Hybrid Measure

Codes to Identify IMADescription CPT

Tetanus vaccine 90703

Td vaccine 90714, 90718

Tdap vaccine 90715

Diphtheria vaccine 90719

Meningococcal vaccine 90733, 90734

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Cervical Cancer Screening (CCS)

• Measures the percentage of women, between the ages of 21 to 64, who had one of the following cervical cancer screenings:1. Women, aged 21-64, who had a cervical cytology screening within the

last 3 years

2. Women, aged 30-64, who had a cervical cytology/HPV co-screening within the last 5 years

• One rate reported

• Data reviewed to identify compliance with measure:► Claims and encounter data► Medical records► Labs

• Hybrid Measure

Codes to Identify CCSDescription CPT HCPCS LOINC UB Revenue

Cervical Cancer Screening

88141-88143, 88147-88150, 88152-88154, 88164-88167, 88174-88175

G0123-G0124, G0141-G0145, G0147-G0148, P3000-P3001, Q0091

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

0923

HPV Screening 87620, 87621, 87622 21440-3, 30167-1, 38372-9, 49896-4, 59420-0, 75406-9, 75694-0

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Domain: Effectiveness of Care

Sub-Domain: Respiratory Conditions

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Medication Management for People with Asthma (MMA)

• The percentage of members, 5 to 64 years of age, who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period.

• Two rates are reported► The percentage of members who remained on an asthma controller medication for

at least 50% of their treatment period► The percentage of members who remained on an asthma controller medication for

at least 75% of their treatment period

• Data reviewed to identify compliance with measure:► Claims and encounter data► Pharmacy data

• Administrative measure

Codes to Identify MMADescription ICD-9-CM ICD-10-CM CPT HCPCS UB Revenue

Asthma 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.81, 493.82, 493.90, 493.91, 493.92

J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901-J45.902, J45.909, J45.990, J45.991, J45.998

Outpatient 99201-99205, 99211-99215, 99217-22220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456

G0402, G0438, G0439, G0463, T1015

0510-0517, 0519-0523, 0526-0529, 0982-0983

ED 99281-99285 0450-0452, 0456, 0459, 0981

Acute Inpatient

99221-99223, 99231-99233, 99238-99239, 99251-99255, 99291

0100-0101, 0110-0114, 0119-0124, 0129-0134, 0139-0144, 0149-0154, 0159-0160, 0164, 0167, 0169, 0200-0204, 0206-0214, 0219, 0720-0724, 0729, 0987

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Domain: Effectiveness of Care

Sub-Domain: Cardiovascular

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Controlling High Blood Pressure (CBP)

• The percentage of 18 to 85 year old adults who had a diagnosis of hypertension and whose blood pressure was adequately controlled in 2015 based in the following criteria:► Members 18 to 59 years of age whose BP was < 140/90 ► Members 60 to 85 years of age with diabetes whose BP was <140/90► Members 60 to 85 year of age without diabetes whose BP was <150/90

• One rate reported for all three groups

• Data reviewed to identify compliance with measure:► Medical records

• Hybrid Measure

Codes to Identify CBP

Description ICD-9-CM Diagnosis

ICD-10-CM Diagnosis

CPT HCPCS

Essential Hypertension I10

Malignant Hypertension 401.0

Benign Hypertension 401.1

Hypertension, NOS 401.9

Outpatient Visits 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456

G0402, G0438, G0439, G0463

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Domain: Effectiveness of Care

Sub-Domain: Diabetes

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Comprehensive Diabetes Care (CDC)• The percentage of 18 to 75 year old adults with diabetes (Type 1 & 2) who had the following

six screenings:

• Six rates reported:► Hemoglobin A1c (HbA1c) testing► HbA1c poor control (>9.0%)► HbA1c control (<8.0%)► Diabetic retinal eye exam► Medical attention for nephropathy that includes a nephropathy screening, monitoring test

or evidence of nephropathy. ► Blood Pressure control (<140-90 mm Hg)

• Data reviewed to identify compliance with measure:► Claims and encounter data► Vision claims► Medical records► Labs

• Hybrid Measure

Codes to Identify Members with Diabetes

Description ICD-9-CM ICD-10-CM

Diabetes 250.00. 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04

E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E413.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, 024.012, 024.013. 024.019, 024.02, 024.03, 024.111, 024.112, 024.113, 024.119, 024.12, 024.13, 024.311, 024.312, 024.313, 024.319, 024.32, 024.33, 024.811, 024.812, 024.813, 024.819, 024.82, 024.83

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Codes to Place of Diabetic Services

Description CPT CPT Category II LOINCOutpatient 99201-99205, 99211-99215,

99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456

G0402, G0438, G0439, G0463, T1015

0510-0517, 0519-0523, 0526-0529, 0982-0983

Observation 99217- 99220 ED 99281, 99282, 99823, 99284,

99285 0450, 0451, 0452, 0456, 0459, 0981

Nonacute Inpatient 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337

0118, 0128, 0138, 0148, 0158, 0190-0194, 0199, 0524, 0525, 0550-0552, 0559-0663, 0669

Inpatient 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99291

0100, 0101, 0110-0114, 0116-0124, 0126-0134, 0136-0144, 0146-0154, 0156-0160, 0164, 0167, 0169-0174, 0179, 0190-0194, 0199-0204, 0206-0214, 0219, 0720-0724, 0729, 0987, 1000-1002

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Codes to Identify HbA1c Screening for Diabetic

Members Description CPT CPT Category II LOINC

HbA1c Tests 83036, 83037 3044F, 3045F, 3046F 17856-6, 4548-4, 4549-2

HbA1c Levels < 7.0 % 3044F

HbA1c Levels 7.0 – 9.0 % 3045F

HbA1c Levels > 9.0 % 3046F

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Codes to Identify Retinal Eye Exams for

Diabetic MembersDescription CPT CPT Category II HCPCS

Diabetic Retinal Screening

67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245

2022F, 2024F, 2026F,

S0620, S0621, S0625, S3000

Negative Diabetic Retinal Screening

3072F

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Codes to Identify Screening/Monitoring

for Nephropathy

Description CPT CPT Category II LOINCNephropathy Screening Test

81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156

3060F, 3061F, 3062F

11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 1753-3, 1754-1, 1755-8, 1757-4, 18373-1, 20454-5, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50561-0, 50949-7, 53121-0, 53525-2, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 57735-3, 5804-0, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 9318-7

Description ICD-9-CM ICD-10-CM CPT Category II

Evidence of Nephropathy Treatment

250.40-250.43, 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00-404.03, 404.10-404.13, 404.90-404.93, 405.01, 405.11, 405.91, 580.0, 580.4, 580.81, 580.89, 580.9, 581.0-581.3, 581.81, 581.89, 581.9, 582.0, 582.1, 582.2, 582.4, 582.81, 582.89, 582.9, 583.0-583.2, 583.4, 583.6, 583.7, 583.81, 583.89, 583.9, 584.5-584.9, 586, 587, 588.0, 588.1, 588.81, 588.89, 588.9, 753.0, 753.10-753.17, 753.19, 791.0

E08.21, E08.22, E08.29, E09.21, E09.22 E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0-N00.9, N01.0-N01.9, N02.0-N02.9, N03.0-N03.9, N04.0-N04.9, N05.0-N05.9, N06.0-N06.9, N07.0-N07.9, N08, N14.0-N14.4, N17.0, N17.1, N17.2, N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0-Q60.6, Q61.00-Q61.02, Q61.11, Q61.19, Q61.2-Q61.5, Q61.8, Q61.9, R80.0-R80.3, R80.8, R80.9

3066F, 4010F

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Codes to Identify Evidence of Nephropathy

Description ICD-9-CM ICD-9-PCS ICD-10-CM ICD-10-PCS CPT HCPCS Revenue Codes

CKD Stage 4 585.4 N18.4

ESRD 585.5, 585.6, V45.11, V45.12

38.95, 39.27, 39.42, 39.43, 39.53, 39.93, 39.94, 39.95, 54.98

N18.5, N18.6, Z91.15, Z99.2

3E1M39Z, 5A1D00Z, 5A1D60Z

36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512

G0257, S9339

0800-0804, 0809, 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859, 0880-0882, 0889

Kidney Transplant

V42.0 55.61, 55.69 Z94.0 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY1072

50300, 50320, 50340, 50360, 50365, 50370, 50380

S2065 0367

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Domain: Effectiveness of Care

Sub-Domain: Medication Management

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Annual Monitoring for Patients on Persistent Medications (MPM)

• The percentage of adults, 18 years of age and older, who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent during the measurement year.

• Four rates are reported for the following therapeutic agents:► Angiotensin Converting Enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)► Digoxin► Diuretics► Total rate

• Data reviewed to identify compliance with measure:► Claims and encounter data► Pharmacy Data► Labs

• Administrative measure

Codes to Identify MPMDescription CPT LOINC

Lab Panel 80047, 80048, 80050, 88053, 80069

Digoxin Level 80162 3563-4, 10535-3

Serum Potassium (K+) 80051, 84132 12812-4, 12813-2, 22760-3, 2823-3, 2824-1, 29349-8, 32713-0, 39789-3, 39790-1, 41656-0, 51618-7, 6298-4

Serum Creatinine (SCr) 82565, 82575 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0, 13447-8, 13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 2160-0, 2163-4, 2164-2, 26752-6, 31045-8, 33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1, 38483-4, 39955-0, 39956-8, 39957-6, 39958-4, 39959-2, 39960-0, 39961-8, 39962-6, 39963-4, 39964-2, 39965-9, 39966-7, 39967-5, 39968-3, 39969-1, 39970-9, 39971-7, 39972-5, 39973-3, 39974-1, 39975-8, 39976-6, 40112-5, 40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2, 40119-0, 40120-8, 40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3, 40128-1, 40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2, 40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5, 40269-3, 40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3, 51619-5, 51620-3, 59826-8, 59834-2, 62425-4

41

42

Domain: Effectiveness of Care

Sub-Domain: Overuse/Appropriateness

NCQA Added New Sub-Domain in 2015

43

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)

• The percentage of 18 to 64 year old adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.

• One rate reported

• Data reviewed to identify compliance with measure:► Claims and encounter data► Rx data

• Administrative measure

• NCQA’s Changes to the AAB Measure in 2015 ► AAB measure moved from Respiratory Conditions sub-domain to

Overuse/Appropriateness sub-domain

Codes to Identify AAB

Description ICD-9-CM Diagnosis*

ICD-10-CM Diagnosis

CPT HCPCS UB Revenue

Acute Bronchitis

466.0 J20.3-J20.9

Outpatient Visits

99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456

G0402 G0438 G0439 G0463 T1015

0510-0517, 0519-0523, 0526-0529, 0982-0983

Emergency Department Visits

99281 - 99285 0450-0452, 0456, 0459, 0981

44

45

Use of Imaging Studies for Low Back Pain (LBP)

• The percentage of members (any age) with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis.

• One rate reported

• Data reviewed to identify compliance with measure:► Claims and encounter data

• Administrative measure

• NCQA’s Changes to the LBP Measure in 2015► LBP measure moved from Musculoskeletal Conditions sub-domain to

Overuse/Appropriateness sub-domain

Codes to Identify LBPDescription ICD-9-CM Diagnosis ICD-10-CM Diagnosis

Low Back Pain 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5, 724.6, 724.70, 724.71, 724.79, 738.5, 739.3, 739.4, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9, 847.2

M46.46-M46.48, M47.26-M47.28, M47.816-M47.818, M47.896-M47.898, M48.06-M48.08, M51.16, M51.17, M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M51.86, M51.87, M53.2X6 - M53.2X8. M53.3, M53.86 - M53.88, M54.30 - M54.32, M54.40- M54.42, M54.5, M54.89, M54.9, M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A, S33.110D, S33.110S, S33.120A, S33.120D, S33.120S, S33..130A, S33.130D, S33.130S, S33.140A, S33.140D, S33.140S, S33.5XXA, S33.6XXA, S33.8XXA, S33.9XXA, S39.002A, S39.002D, S39.002S, S39.0012A, S39.012D, S39.012S, S39.029A, S39.029D, S39.029S, S39.82XA, S39.82XD, S39.82XS, S39.92XA, S39.92XD, S39.92XS

46

Codes to Identify LBPDescription CPT HCPCS UB Revenue

Osteopathic Manipulative Study 98925 - 98929, 98940 - 98942

Imaging Study 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72158, 72200, 72202, 72220

0320, 0329, 0350, 0352 , 0359, 0610, 0612, 0614, 0619, 0972

Outpatient Visits/Observation 99201 - 99205, 99211 - 99215, 99217 - 9220, 99241 - 99245, 99341 - 99345, 99347 - 99350, 99381 - 99387, 99391 - 99397, 99401 - 99404, 99411 - 99412, 99420, 99429, 99455 - 99456

G0402, G0438, G0439. G0463, T1015

0510 - 0517, 0519 - 0523, 0526 - 0529, 0982 - 0983

Emergency Department Visits 99281 - 99285 0450, 0451, 0452, 0456, 0459, 0981

47

48

Domain: Access and Availability of Care

49

Children & Adolescents’ Access to PCPs (CAP)

• The percentage of members:► 12 months to 6 years old who had a visit with a PCP during the measurement year

(2015)► 7 to 19 years old who had a visit with a PCP during the measurement year (2015) or the

year prior to the measurement year (2014)

• Four rates are reported for the following age groups:► 12 to 24 months ► 25 months to 6 years► 7 to 11 years► 12 to 19 years

• Data reviewed to identify compliance with measure:► Claims and encounter data

• Administrative measure

Codes to Identify CAPDescription ICD-9-CM

DiagnosisICD-10-CM Diagnosis

CPT HCPCS UB REV

Wellness Exams

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

Z00.00 – Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.81-Z02.83, Z02.89, Z02.9

Ambulatory Visit 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429

0510-0517, 0519-0523, 0526-0529, 0982-0983

Wellness Visits G0402, G4038, G4039, G0463, T1015

50

51

Prenatal & Postpartum Care (PPC)• The percentage of women with live birth deliveries, between November

6, 2014 and November 5, 2015, who had prenatal and postpartum care visits.

• Two rates are reported:► Prenatal Care: The percentage of women who had a prenatal care visit

during the first trimester or within 42 days of enrollment with their health plan► Postpartum Care: The percentage of women who had a postpartum care visit

between 21 and 56 days after delivery

• Data reviewed to identify compliance with measure:► Claims and encounter data► Medical records

• Hybrid measure

Codes to Identify Members for the Prenatal and Postpartum

Care MeasureDescription ICD-9-CM ICD-10 –CM

Pregnancy Diagnosis

640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22.0-V22.2, V23.0-V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81-V23.87, V23.89, V23.9, V28.0-V28.6, V28.81, V28.82, V28.89, V28.9

O09.0x, O09.1x, O09.21x, O09.29x, O09.3x, O09.4x, O09.51x, O09.52x, O09.61x, O09.62x, O09.7x, O09.81x, O09.82x, O09.89x, O09.9x, O10.1x, O10.21x, O10.31x, O10.41x, O10.91x, O11.x, O12.0x, O12.1x, O12.2x, O13.x, O14.0x, O14.1x, O14.2x, O14.9x, O15.0x, O15.1, O15.9, O16.x, O20.x, O21.x, O22.0x, O22.1x, O22.2x, O22.3x, O22.4x, O22.5x, O22.8Xx, O22.9x, O23.0x, O23.1x, O23.2x, O23.3x, O23.4x, O23.51x, O23.52x, O23.59x, O23.9x, O24.01x, O24.11x, O24.31x, O24.41x, O24.81x, O24.91x, O25.1x, O26.0x, O26.1x, O26.2x, O26.3x, O26.4x, O26.5x, O26.61x, O26.71x, O26.81x, O26.82x, O26.83x, O26.84x, O26.85x, O26.86, O26.87x, O26.89x, O26.9x, O28.x, O29.01x, O29.02x, O29.09x, O29.11x, O29.12x, O29.19x, O29.21x, O29.29x, O29.3Xx, O29.4x, O29.5Xx, O29.6x, O29.8Xx, O29.9x, O30.00x, O30.01x, O30.02x, O30.03x, O30.04x, O30.09x, O30.10x, O30.11x, O30.12x, O30.19x, O30.20x, O30.21x, O30.22x, O30.29x, O30.80x, O30.81x, O30.82x, O30.89x, O30.9x, O31.00Xx, O31.01Xx, O31.02Xx, O31.03Xx, O31.10Xx, O31.11Xx, O31.12Xx, O31.13Xx, O31.20Xx, 031.21Xx, O31.22Xx, O31.23Xx, O31.30Xx, O31.31Xx, O31.32Xx, O31.33Xx, O31.8X1x, O31.8X2x, O31.8X3x, O31.8X9x, O32.0XXx, O32.1XXx, O32.2XXx, O32.3XXx, O32.4XXx, O32.6XXx, O32.8XXx, O32.9XXx, O33.0 - O33.2, O33.3XXx, O33.4XXx, O33.5XXx, O33.6XXx, O33.7-O33.9, O34.0x, O34.1x, O34.2x, O34.3x, O34.4x, O34.51x, O34.52x, O34.53x, O34.59x, O34.6x, O34.7x, O34.8x, O34.9x, O35.0XXx, O35.1XXx, O35.2XXx, O35.3XXx, O35.4XXx, O35.5XXx, O35.6XXx, O35.7XXx, O35.8XXx, O35.9XXx, O36.011x, O36. 012x, O36.013x, O36.019x, O36.091x, O36.092x, O36.093x, O36.099x, O36.111x, O36.112x, O36.113x, O36.119x, O36.191x, O36.192x, O36.193x, O36.20Xx, O36.21Xx, O36.22Xx, O36.23Xx, O36.4XXx, O36.511x, O36.512x, O36.513x, O36.519x, O36.591x, O36.592x, O36.593x, O36.599x, O36.60Xx, O36.61Xx, O36.62Xx, O36.63Xx, O36.70Xx, O36.71Xx, O36.72Xx, O36.73Xx, O36.80Xx, O36.812x, O36.813x, O36.819x, O36.821x, O36.822x, O36.823X, O36.829x, O36.891x, O36.892x, O36.893x, O36.899x, O36.90Xx, O36.91Xx, O36.92Xx, O36.93Xx, O40.1XXx, O40.2XXx, O40.3XXx, O40.9XXx, O41.00Xx, O41.01Xx, O41.02Xx, O41.03Xx, O41.101x, O41.102x, O41.103x, O41.109x, O41.121x, O41.122x, O41.123x, O41.129x, O41.141x, O41.142x, O41.143x, O41.149x, O41.8X1x, O41.8X2x, O41.8X3x, O41.8X9x, O41.90Xx, O41.91Xx, O41.92Xx, O41.93Xx, O42.00, O42.01x, O42.02, O42.10, O42.11x, O42.12, O42.90, O42.91x, O42.92, O43.01x, O43.02x, O43.10x, O43.11x, O43.12x, O43.19x, O43.21x, O43.22x, O43.23x, O43.81x, O43.89x, O43.9x, O44.0x, O44.1x, O45.00x, O45.01x, O45.02x, O45.09x, O45.8Xx, O45.9x, O46.00x, O46.01x, O46.02x, O46.09x, O46.8Xx, O46.9x, O47.0x, O47.1, O47.9, O48.x, O60.0x, O71.0x, O71.1-O71.7, O71.8x, O71.9, O88.01x, O88.11x, O88.21x, O88.31x, O88.81x, O91.01x, O91.03, O91.11x, O91.03, O91.21x, O91.23, O92.01x, O92.03, O92.11x, O92.13, O92.3-O92.6, O92.7x, O98.01x, O98.11x, O98.21x, O98.31x, O98.41x, O98.51x, O98.61x, O98.71x, O98.81x, O98.91x, O99.01x, O99.11x, O99.21-O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.41x, O99.51x, O99.61x, O99.71x, O99.810, O99.820, O99.840-O99.843, O9A.11x, O9A.21x, O9A.31x, O9A.41x, O9A.51x, Z03.7x, Z33.x, Z34.0x, Z34.8x, Z34.9x, Z36

52

Codes to Identify Members for the Prenatal and Postpartum

Care MeasureDescription ICD-9-CM ICD-9-PCS ICD-10-PCS CPT

Live Deliveries 640.x1, 641.x1, 642.x1, 642.x2, 643.x1, 644.21, 645.x1, 646.x1, 646.x2, 647.x1, 647.x2, 648.x1, 648.x2, 649.x1, 649.x2, 650, 651.x1, 652.x1, 653.x1, 654.x1, 654.x2, 655.x1, 656.01, 656.11, 656.21, 656.31, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.x1, 659.x1, 660.x1, 661.x1, 662.x1, 663.x1, 664.x1, 665.x1, 665.x2, 666.x2, 667.x2, 668.x1, 668.x2, 669.x1, 669.x2, 670.02, 671.x1, 671.x2, 672.02, 673.x1, 673.x2, 674.x1, 674.x2, 675.x1, 675.x2, 676.x1, 676.x2, 678.x1, 679.x1, 679.x2, V27.0, V27.2, V27.3, V27.5, V27.6

72.0, 72.1, 72.21, 72.29, 72.31, 72.39, 72.4, 72.51-72.54, 72.6, 72.71, 72.79, 72.8, 72.9, 73.01, 73.09, 73.1, 73.21, 73.22, 73.3, 73.4, 73.51, 73.59, 73.6, 73.8, 73.91-73.94, 73.99, 74.0-74.2, 74.4, 74.99

10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10D17ZZ, 10D18ZZ, 10D27ZZ, 10D28ZZ, 10E0XZZ

59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622

53

Codes to Identify Prenatal Office Visits

Description CPT CPT Category II HCPCS UB Revenue

Prenatal Bundles Visits Billed on date of delivery

59400, 59425, 59426, 59510, 59610, 59618

H1005

Prenatal Visits 80055, 99201- 99205, 99211-99215, 99241-99245, 99500

0500F, 0501F, 0502F G0463, H1000, H1001, H1002, H1003, H1004, T1015

0514

54

Codes to Identify Prenatal Screenings

Description ICD-9-PCS ICD-10-PCS CPT LOINCPrenatal Ultrasound 88.78 BY49ZZZ,

BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ

76801, 76805, 76811, 76813, 76815-76821, 76825-76828

Antibody Screenings: Taxoplasmy, Rubella, Herpes Simplex, or Cytomegalovirus

86644, 86694, 86695, 86696, 86762, 86777, 86778

10350-7, 11598-0, 12261-4, 12262-2, 13225-8, 13279-5, 13280-3, 13286-0, 13323-1, 13324-9, 13501-2, 13505-3, 13949-3, 14213-3, 15377-5, 16714-8, 16715-5, 16716-3, 16944-1, 16949-0, 16950-8, 16954-0, 16955-7, 16957-3, 16958-1, 17550-5, 17717-0, 17850-9, 17851-7, 19106-4, 21326-4, 21327-2, 21570-7, 22239-8, 22241-4, 22244-8, 22246-3, 22247-1, 22249-7, 22339-6, 22341-2, 22343-8, 22496-4, 22497-2, 22577-1, 22580-5, 22582-1, 22584-7, 23485-6, 23486-4, 23784-2, 24014-3, 24116-6, 24119-0, 24242-0, 25298-1, 25300-5, 25420-1, 25435-9, 25514-1, 25542-2, 25837-6, 25839-2, 26927-4, 27948-9, 30325-5, 30355-2, 31411-2, 31616-6, 32170-3, 32687-6, 32688-4, 32790-8, 32791-6, 32831-0, 32834-4, 32835-1, 32846-8, 33291-6, 33336-9, 34152-9, 34403-6, 34421-8, 34422-6, 34613-0, 35281-5, 35282-3, 36921-5, 40466-5, 40667-8, 40677-7, 40678-5, 40697-5, 40728-8, 40729-6, 40785-8, 40786-6, 41123-1, 41124-9, 41149-6, 41399-7, 41763-4, 42337-6, 42338-4, 42949-8, 43028-0, 43030-6, 43031-4, 43111-4, 43180-9, 43810-1, 44008-1, 44480-2, 44494-3, 44507-2, 45210-2, 45326-6, 47230-8, 47307-4, 47363-7, 47389-2, 47390-0, 47430-4, 48784-3, 49107-6, 49539-0, 49848-5, 50694-9, 50758-2, 5121-9, 5122-7, 5124-3, 5125-0, 5126-8, 5127-6, 51915-7, 51916-5, 51931-4, 5202-7, 5203-5, 5204-3, 5205-0, 5206-8, 5207-6, 5208-4, 5209-2, 5210-0, 52976-8, 52977-6, 52981-8, 52984-2, 52986-7, 5330-6, 5331-4, 5332-2, 5333-0, 5334-8, 5335-5, 53377-8, 53560-9, 5387-6, 5388-4, 5389-2, 5390-0, 5391-8, 56990-5, 56991-3, 57321-2, 59838-3, 63462-6, 7851-9, 7852-7, 7853-5, 7907-9, 7908-7, 7909-5, 7910-3, 7911-1, 7912-9, 7913-7, 8013-5, 8014-3, 8015-0, 8039-0, 8040-8, 9422-7, 9513-3

ABO Screening 86900 883-9, 57743-7Rh Screening 86901 10331-7, 1305-2, 34961-3, 972-0, 978-7ABO and Rh Screening

882-1, 884-7

55

Codes to Identify Postpartum Visits

Description ICD-9-CM ICD-10-CM CPT CPT Category

II

HCPCS LOINC UB Revenue

ICD-9-PCS

Postpartum Visits

V24.1, V24.2, V25.11, V25.12, V25.13, V72.31, V72.32, V76.2

Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2

57170, 58300, 59430, 99501

0503F G0101 89.26

Postpartum Bundled Visits

59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622

Cervical Cytology

88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175

G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

0923

56

57

Domain: Utilization and Risk Adjusted Utilization

NCQA revised domain in 2015 from “Utilization and Relative Resource Use” to “Utilization and Risk

Adjusted Utilization”

58

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34)

• The percentage of 3 to 6 year old children who had one or more well-child visit(s) with a PCP in 2015 and the provider of care assessed and documented ALL of the following:

► Health history► Physical developmental history► Mental developmental history► Physical Exam► Health education/anticipatory guidance

• One rate reported

• Data reviewed to identify compliance with measure:► Claims and encounter data ► Medical records

• Hybrid measure

Codes to Identify W34

Description ICD-9-CM Diagnosis ICD-10-CM Diagnosis CPT HCPCS

Well care exam V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02-6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9

Annual Wellness Visit G0438, G0439

Office Visit 99381-99385, 99391-99395, 99461

59

60

Ambulatory Care (AMB)

• This measures summarizes utilization of ambulatory care in 2015 in the outpatient and emergency department.

• Two rates reported:►Outpatient utilization►Emergency Department utilization

• Data audited to identify compliance with measure:►Claims and encounter data

• Administrative measure

Codes to Identify AMBDescription CPT HCPCS UB Revenue POS

Ambulatory Outpatient Visits

92002, 92004, 92012, 92014, 99201-99205, 99211-99215, 99241-99245, 99304-99310, 99315-99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99461

G0463, T1015 0510-0517, 0519-0529, 0982-0983

Emergency Department

99281-99285 0450-0452, 0456, 0459, 0981

23

61

Codes to Identify AMBDescription CPT UB Revenue POS

Emergency Department Visit

99281-99285 0450-0452, 0456, 0459, 0981

23

ED Procedure Code 10030, 10040, 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, 10180. 11000, 11001, 11004-11006, 11008, 11010-10012, 10042-10047, 10055-10057, 11100, 11101, 11200, 11201, 11300 -11208, 11310-11313, 11400-11406, 11420-11424, 11426, 11440-11446, 11450, 11451,

23

62

63

Reasons for Low HEDIS® Rates

64

Reason for Low HEDIS® Rates

• Clinics did not submit claims or encounter data– No data = No history of services performed

• Coding on claims and encounter data is incomplete or inaccurate– Incomplete or inaccurate coding = No history of services performed

• Delayed claims & encounter submissions• Medical record documentation is incomplete• Patients did not receive annual screenings• Patients with chronic conditions are not monitored• Patients on persistent medications are not monitored• Clinics are not familiar with HEDIS® measure criteria

65

How to Improve your HEDIS® Rates

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How to Improve your HEDIS® Rates

• Timely submission of all claims and encounter data• Complete and accurate coding of all services performed• Document all services and care provided in the medical record

– Include child and adolescent counseling for nutrition and physical activity

• Schedule patients for their annual screenings and check-ups– Children are expected to have annual check-ups

• Continually monitor patients with chronic conditions • Continually monitor patients on persistent medications• Understand the HEDIS® measure criteria and the standard practice

guidelines

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2016 Medical Codes for HEDIS® Reporting

To obtain a complete list of the medical codes used by NCQA to

identify compliance with HEDIS® measures click on the following

link, NCQA’s Quality Rating System HEDIS® Value Set Directory or

visit www.NCQA.org.

HEDIS® Questions?

Please email HEDIS® questions to [email protected]

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