2012 P4P Tip Sheet. Table of Contents

Transcription

1 2012 P4P Tip Sheet Table of Contents 1. Adolescent Immunizations 2 2. Childhood Immunizations 3 3. Appropriate Treatment for Children with Upper Respiratory Infection.4 4. Appropriate Testing for Children with Pharyngitis Asthma Medication Ratio.6 6. Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis Use of Imaging Studies for Low Back Pain Human Papillomavirus Vaccine for Female Adolescents (HPV) Chlamydia Screening in Women Evidence-Based Cervical Cancer Screening Coordinated Diabetes Care Eye Exams Coordinated Diabetes Care Blood Pressure Control (<140/90) Coordinated Diabetes Care Cholesterol Management: LDL Screening Coordinated Diabetes Care Cholesterol Management: LDL Control < Coordinated Diabetes Care Nephropathy Monitoring Coordinated Diabetes Care HbA1c Screening Coordinated Diabetes Care HbA1c Control (<8.0%, <7.0%) Coordinated Diabetes Care HbA1c Poor Control (>9.0%) Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Control Colorectal Cancer Screening Breast Cancer Screening Annual Monitoring for Patients on Persistent Medications Proportion of Days Covered by Medications...24 P4P_Detailed_Tip_Sheet_052012_V1 Page 1

2 1. Adolescent Immunizations The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids, and acellular petussis vaccine (Tdap) or one tetanus, diphtheria toxoid vaccine (Td) by their 13 th birthday. This measure can be completed by giving one Tdap and one Meningicoccal vaccine at years during a preadolescent well visit. Please note: Age appropriate antigen series must be completed on or before the child s 13 th birthday. The CDC immunization schedule recommends these be completed at age 11 or 12; however, P4P/HEDIS considers vaccines compliant if administered on or before the child s 13 th birthday. If the adolescents thirteenth birthday is March 2, their visit most likely should occur in February, to ensure the antigen series is administered on or before their 13 th birthday. Review the recommended immunization schedule for adolescents from the academy of pediatrics located at: Ensure that physicians document in the medical record if and why a vaccine is contraindicated for the patient. Those with a contraindication will not be included in the denominator for these measures. Exclusions should be identified using the following codes, or documented where a code is not listed. Immunization Exclusion Description ICD-9-CM Diagnosis Description Any particular Anaphylactic reaction to the vaccine or its vaccine components P4P_Detailed_Tip_Sheet_052012_V1 Page 2

3 Childhood Immunizations Percentage of children age 2 years who were identified as having completed the following antigen series by their second birthday: 4 diphtheria, tetanus, and acellular pertussis (DTap/DT) 3 hepatitis B 4 pneumococcal conjugate vaccines (PCV) 3 polio (IPV) 1 chicken pox (VZV) 1 measles, mumps, rubella (MMR) 3 H influenza type B (HiB) Ensuring that every child receives ALL vaccinations on or before the 2 nd birthday. Provide parents with a copy of the Parents Guide to Childhood Immunizations, which can be found at Find immunization recommendations and additional information, including posters you can download at P4P_Detailed_Tip_Sheet_052012_V1 Page 3

4 Appropriate Treatment for Children with Upper Respiratory Infection Percentage of children ages 3 months to 18 years who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Ensure that the following ICI-9-CM Diagnosis codes are used for URI: o 460 Acute nasopharyngitis (common cold) o 465 URI Advocate aids that assist in improving compliance: o Consider prescribing an over-the-counter (OTC) medication that may help alleviate the patient s symptoms, as many patients expect a prescription from their physician for URI. o Visit to download the 2010 AWARE toolkit, which includes an updated treatment summary for acute respiratory tract infections and tools that can be used in physician practices. Illness/pathogen Indications for antibiotic treatment Treatment Antibiotic Nonspecific cough illness/bronchitis > 90% of cases caused by routine When to treat with an antibiotic: nonspecific cough illness. When to treat with an antibiotic: Presents with prolonged unimproving cough Treatment reserved for B. Pertussis, Macrolides (tetracyclines for children older than 8 years.) respiratory viruses (14 days); should clinically differentiate from pneumonia. Pertussis pneumoniae C. pneumoniae, < 10% cases caused by Bordetella may occur in older children (unusual in those younger than five years). M. pneumoniae pertussis, Chlamydia pneumoniae, or Mycoplasma pneumoniae Bronchiolitis/nonspecific URI > 200 viruses, including rhinoviruses, coronaviruses, denoviruses, respiratory syncytial virus, enteroviruses (coxsackieviruses and echoviruses), influenza viruses, and parainfluenza virus Acute bacterial sinusitis S. pneumoniae, nontypeable H. influenze, M. catarrhalis When to treat with an antibiotic: sore throat, sneezing, mild cough, fever (generally less than 102ºF [39º], for less than three days), rhinorrhea, nasal congestion; self limited (typically 5 to 14 days) When not to treat with an antibiotic: Nearly all cases of acute bacterial sinusitis resolve without antibiotics. Antibiotic use should be reserved for moderate symptoms not improving after 10 days or that worsen after five to seven days, and severe symptoms. When to treat with antibiotic: Diagnosis of an acute bacterial sinusitis may be made with symptoms of viral URI (nasal discharge or daytime cough not improved after 10 days, severe illness with fever, purulen nasal discharge, facial pain) not improving after 10 days or that worsen after 5 to 7 days. Diagnosis may include some or all of the following symptoms or signs: nasal discharge, nasal congestion, facial pressure or pain (especially when unilateral and focused in the region of a particular sinus), post nasal discharge, hyposmia, Adequate fluid intake; may advise rest, OTC medications, humidifier Usual antibiotic duration: 10 days. Failure to respond after 72 hours of antibiotics: reevaluate patient and switch to alternate antibiotic. Fiberoptic endoscopy or sinus aspiration for culture may be necessary P4P_Detailed_Tip_Sheet_052012_V1 Page 4 None First-line therapy Amoxicillin (80 to 90 mg per kg per day) Alternative therapy Amoxicillin/clavulanate (80 to 90 mg per kg per day of amoxicillin component), cefpodoxime, cefuroxime, cefdinir, ceftriaxone For beta-lactam allergy: TMP- SMX (Bactrim, Septra), macrolides, Clindamycin

5 anosmia, fever, cough, fatigue, maxillary dental pain, ear pressure or fullness. (Cleocin) Appropriate Testing for Children with Pharyngitis The percentage of children ages 2 to 18 years who were diagnosed with Pharyngitis, dispensed an antibiotic, and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Educate all physicians and appropriate staff regarding the standard of care for children with URI: (adapted from Illness/pathogen Indications for antibiotic treatment Treatment Antibiotic Pharyngitis Streptococcus pyogenes, When not to treat with an antibiotic: respiratory viral causes, conjunctivitis, cough, rhinorrhea, diarrhea uncommon with group A streptococcal infection Group A streptococcal infection: Treatment reserved for patients First-line therapy Penicillin V (Veetids); penicillin G benzathine; routine When to treat with an antibiotic: with positive rapid (Bicillin LA) respiratory antigen test or throat Alternative therapy viruses culture S. pyogenes (group A streptococcal infection). Symptoms and signs: Sore throat, fever, headache, nausea, vomiting, abdominal pain, tonsillophyryngeal erythema, exudates, palatal petechiae, tender enlarged anterior cervical lymph nodes. Confoirm diagnosis with throat culture or rapid antigen testing; negative rapid antigen test results should be confirmed with throat culture. Amoxicillin, oral cephalosporins, clindamycin, macrolides Ensure the following ICD-9CM Diagnosis codes are used for children with pharyngitis: Acute pharyngitis: 462 Acute tonsillitis: 463 Streptococcal sore throat: Note: When ICD-9 Code 466.0, acute bronchitis, is appropriate, clinical guidelines do not support the use of antibiotics. Do not empirically treat patients or their siblings, since this may contribute to antibiotic resistance. Advocating aids that assist in improving compliance: o Use updated summary guidelines that indentify the standard of care and recommendation for appropriate testing for children with phayngitis. o Visit to download the 2010 AWARE toolkit, which includes an updated treatment summary for acute respiratory tract infections and tools that can be used in physician practices. FFS Reimbursement Note: Offices receive an additional $7.50 per test, over their capitation. P4P_Detailed_Tip_Sheet_052012_V1 Page 5

6 P4P_Detailed_Tip_Sheet_052012_V1 Page 6

7 Asthma Medication Ratio The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medication of.50 or greater during the measurement year. Ensuring that ICD-9 code 493.X is used for asthma. Ensuring use of the controller and reliever medications listed in the table below. Type Description Prescription Antiasthmatic combinations dyphllineguaifenesin guaifenesin-theophylline Potassium iodide-theophylline Inhaled steroid budesonideformoterol fluticasone-salmeterol combinations Inhaled corticosteroids beclomethasone flunisolide mometasone Controller budesonide fluticasone CFC free triamcinolone Leukotriene modifiers montelukast zafirlukast zileuton Long acting, inhaled beta-2 aformoterol formoterol salmeterol antagonist Mast cell stabilizer cromolyn nedocromil Methylxanthines aminophylline oxtriphylline dyphylline theophylline Reliever Short-acting, inhaled beta-2 albuterol metaproterenol agonist levalbuterol pirbuterol Monitor medication use to determine if member is utilizing the appropriate ratio of controller to reliever medication. Ensure the following ICD-9-CM Diagnosis codes are used to identify exclusions for this measure (COPD or emphysema): Exclusion Description ICD-9-CM Diagnosis Emphysema 492, 506.4, 518.1, COPD 491.2, 493.2, 496, Cystic fibrosis Acute respiratory failure P4P_Detailed_Tip_Sheet_052012_V1 Page 7

8 Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis The percentage of adult s ages 18 to 64 with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Ensure that ICD-9 Code is used for acute bronchitis. Do not immediately treat bronchitis with antibiotics, since it is viral in origin, unless the patient has chronic lung disease. If you are treating as a bacterial infection, please consider using one of the diagnoses listed below in place of code for acute bronchitis when antibiotics are prescribed: Diagnosis ICD-9-CM Diagnosis Bacterial infection unspecified Otitis media 382 Acute Sinusitis 461 Acute pharyngitis 034.0, 462 Acute tonsillitis 463 Chronic sinusitis 473 Infections of the pharynx, larynx, tonsils, adenoids , 474, , , , , Pneumonia Prescribing an OTC medication that may help alleviate the patient s symptoms, as many patients expect a prescription from their physician for acute bronchitis. Downloading guidelines and provider tools and resources: o Visit to download the 2010 AWARE toolkit, which includes an updated treatment summary for acute respiratory tract infections and tools that can be used in physician practices. P4P_Detailed_Tip_Sheet_052012_V1 Page 8

9 Use of Imaging Studies for Low Back Pain The percentage of members with a primary diagnosis of low back pain that did not have an imaging study (plain X-ray, MRI, CT, scan) within 28 days of the diagnosis. The guidelines for low back pain without neurological finding is to use conservative measures for at least 28 days before embarking on imaging studies. o Download the clinical practice guideline for LBP at Ensure the following codes are used to identify exclusions for LBP: Exclusion Description ICD-9-CM Diagnosis Cancer , , V10 Trauma , , , , , 929, 952, IV drug abuse , 304.4, Neurologic impairment , P4P_Detailed_Tip_Sheet_052012_V1 Page 9

10 Human Papillomavirus Vaccine for Female Adolescents (HPV) The percentage of female adolescents 13 years of age who had three doses of human Papillomavirus (HPV) vaccine by their 13 th birthday. Please note: At least three HPV vaccinations with different dates of service, on or between the member s 9 th and 13 th birthdays. HPV vaccines administered prior to the 9 th or after 13 th birthday cannot be counted. Ensure the following codes are used identify HPV immunizations: Immunization CPT HPV (females only) 90649, Ensure the following code is used to identify exclusions for HPV: Immunization Description ICD-9-CM Diagnosis Any particular Anaphylactic reaction to the vaccine or its vaccine components P4P_Detailed_Tip_Sheet_052012_V1 Page 10

11 Chlamydia Screening in Women The percentage of women ages 16 to 24 who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. Have staff collect a urine specimen for all females ages 16 to 24 before the patient is seen by the physician. The physician can then determine if the patient is appropriate for screening. A urine sample is all that is necessary for screening; a pelvic exam not necessary. For the urine Chlamydia screen, use CPT Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique via Quest lab o If the physician does not have significant information on sexual history, the urine collected should be sent for Chlamydia screening via Quest lab. Evidence shows that 80% of all females 19 years of age and older are sexually active Aids to assist with improving compliance: o Download the CDC Chlamydia fact sheet at It can be distributed to sexually active females ages 16 to 24, as well as used to educate physicians and office staff regarding CHL. The sheet should also be posted in exam rooms and areas where physicians write orders. o Download the CDC 2010 STD treatment guidelines at P4P_Detailed_Tip_Sheet_052012_V1 Page 11

12 Evidence-Based Cervical Cancer Screening for Average-Risk Asymptomatic Women (ECS) Women ages 21 years and older who received cervical cancer screening in accordance with evidence-based standards. Three separate overall rates are calculated for this measure based on the same eligible population: Rate 1: Appropriately Screened Women who were screened for cervical cancer according to evidence-based guidelines. A higher rate indicates better performance. This rate will be publicly reported and scored. Rate 2: Not Screened Women who should have been screened for cervical cancer, but were not, based on the available data. A lower rate indicates better performance. Additional outreach could be done to encourage these women to come in for a Pap test. Rate 3: Screened Too Frequently Women who received more cervical cancer screenings than necessary according to evidence-based guidelines. A lower rate indicates better performance. This provides an educational opportunity to reach out to physicians to reinforce the most current evidence and guidelines, and to discuss potential overuse. Evidenced based guideline: Initiation of cervical cancer screening is recommended approximately 3 years after first sexual intercourse or age 21, which ever comes first. The interval for screening the average risk, asymptomatic woman is every 3 years. Routine screening is NOT recommended for women who have a total hysterectomy for a benign condition unless there was prior history of cervical intraepithelial neoplasia grade 2/3. The routine screening for cervical cancer for women older than 65 is not recommended if they have had 3 or more documented, consecutive, normal results on their last cytology. Recommendations and rationale for screening can be found at Ensure the appropriate codes are used to indicate screening. Appropriate screening is once every three years for patients without the exclusions listed below: Exclusion Description ICD-9- CM Diagnosis Dysplasia Nonspecific abnormal Pap test 795.0, Cervical cancer 180, 233.1, V10.41 Diethylstilestrol (DES) exposure HIV 042, V08, HPV 079.4, , Immunodeficiency, including genetic (congenital) immunodeficiency syndromes 279 Aids to assist with improving compliance: P4P_Detailed_Tip_Sheet_052012_V1 Page 12

13 o Implement a reminder and recall process where physicians send post card reminders to patients indicating with ECS is due. This can also be a telephone call to the patient. For those who are past due for their ECS, another post card reminder or call should be generated. Coordinated Diabetes Care Eye Exams The percentage of members years of age with diabetes (type 1 and type 2) who had a retinal eye exam performed during the measurement year. The standard of care for diabetic retinal exams. o Ensure all diabetics receive one of the following: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year, or A Negative retinal exam (no evidence of retinopathy) by and eye care professional in the year prior to the measurement year. An eye exam by an ophthalmologist is a covered medical benefit for diabetics. Some members are used to going to an eye care professional outside of the medical group. Once a diagnosis of diabetes is established, refer the patient to the group s ophthalmologist for regular care. By doing so, you increase the data capture and improve your rates, while ensuring proper care. Ensure the following codes are used to identify diabetes: 250.XX Ensue that the following codes are used to identify eye exams: CPT CPT Category II HCPCS ICD-9-CM ICD-9-CM Procedure Diagnosis 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, , , F, 2024F 2026F, 3072F S0620, S0621, S0625**, S3000 V , 14.9, , 95.11, 95.12, Ensure that all diabetic patients receive an annual retinal eye exam. Visit and download patient education materials regarding diabetic eye care. P4P_Detailed_Tip_Sheet_052012_V1 Page 13

14 Coordinated Diabetes Care: Blood Pressure Control (<140/90) The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes whose blood pressure is <140/90. NOTE: The last BP reading of the year counts toward this measure. It is important to keep track of your diabetics throughout the year and take action when the BP is 140/90 or greater. Following CPT II codes can be used to submit BP reading via claims/encounter submission process: CPT II 3074F 3075F 3077F 3078F 3079F 3080F Description Most recent systolic blood pressure less than 130 mm Hg Most recent systolic blood pressure mm Hg Most recent systolic blood pressure greater than or equal to 140 mm Hg Most recent diastolic blood pressure less than 80 mmg Hg Most recent diastolic blood pressure mmg Hg Most recent diastolic blood pressure greater than or equal to 90 mm Hg Ensure that action is taken when the BP is 140/90 or greater. Ensure the following codes are used to identify diabetes: 250.XX Download information regarding diabetes and blood pressure control, as well as diabetes in general, at and Note: A BP of 140/90 is not compliant. The reading must be less than the target BP, such as 138/88. P4P_Detailed_Tip_Sheet_052012_V1 Page 14

15 Coordinated Diabetes Care: Cholesterol Management LDL Screening The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who had an LDL screening during the measurement year. Ensure LDL screening occurs at least annually. Ensure the following codes are used to identified diabetes: 250.XX Download information regarding diabetes and LDL screening, as well as diabetes in general, at and Aids to assist with improving compliance: o Send post card reminders to patients from their physician indication when LDL screening is due. Include a lab order sheet with the post card reminder so that the patient can have lab tests completed prior to seeing their physician. Phone call reminders may also be used, but you will need to make arrangements for the patient to pick up the voucher/order sheet. o Develop and distribute patient education tools specific to this measure. P4P_Detailed_Tip_Sheet_052012_V1 Page 15

16 Coordinated Diabetes Care: Cholesterol Management LDL Control <100 The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who had LDL-C control <100 mg/dl. NOTE: The last screening of the year counts toward this measure. It is important to keep track of your diabetics throughout the year and take action when the LDL is 100 or greater. Ensure that action is taken when LDL is 100 or greater. Ensure the following codes are used to identify diabetes: 250.XX Download information regarding diabetes and LDL screening, as well as diabetes in general, at and NOTE: In order to pass on this measure, the LDL must be 99 or less Aids to assist with improving compliance: o Develop a medication sheet that can be customized for each patient, listing the meds they are currently taking and when they should take them. o If appropriate, recommend these patients to a dietician or nutritional consultant who can educate them on a low cholesterol diet and assist them with meal planning. o Send post card reminders to patients from their physician indicating when LDL screening is due. Include a lab order sheet with the post card reminder, so that the patient can have LDL screening completed prior to seeing their physician. Phone call reminders may also be used, but you will need to make arrangements for the patient to pick up the voucher/order sheet. P4P_Detailed_Tip_Sheet_052012_V1 Page 16

17 Coordinated Diabetes Care: Nephropathy Monitoring The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement year. Ensure annual Nephropathy screening test for all diabetics (Urine microalbumin). Aids to assist with improving compliance: o Post information regarding the standard of care for monitoring diabetic nephropathy in treatment/exam rooms and areas where physicians write orders. o Download educational documents that can be used to educate diabetics at and o Send post card reminders to patients from their physician indicating when nephropathy monitoring is due. Include a lab order sheet with the post card so that the patient can have lab test completed prior to seeing their physician. Phone call reminders may also be used, but you will need to make arrangements for the patient to pick up the voucher/order sheet. P4P_Detailed_Tip_Sheet_052012_V1 Page 17

18 Coordinated Diabetes Care: HbA1c Screening The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who had Hemoglobin A1c (HbA1c) screening during the measurement year. Ensure annual HbA1c screening test for all diabetics. Ensure the following codes are used to identify diabetes: 250.XX Aids to assist with improving compliance: o Post information regarding the standard of care for HbA1c screening in treatment/exam rooms and areas where physicians write orders. o Download educational document that can be used to educate diabetics at and o Send post card reminders to patients from their physician indicating when HbA1c screening is due. Include a lab order sheet with the post card so that the patient can have HbA1c screening completed prior to seeing their physician. Phone call reminders may also be used, but you will need to make arrangements for the patient to pick up the voucher/order sheet. o Consider referring patients to a health education program for diabetic patients that addresses screening and control. P4P_Detailed_Tip_Sheet_052012_V1 Page 18

19 Coordinated Diabetes Care: HbA1c Control (<8.0%, <7.0%) The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who were tested during the measurement year and identified as having a HbA1c <7 and those with a HbA1c <8. NOTE: The last screening of the year counts toward this measure. It is important to keep track of your diabetics throughout the year and take action when the HbA1c is out of compliance. Ensure that action is taken when HbA1c is >7% Aids to assist with improving compliance: o Post information regarding HbA1c control in treatment/exam rooms and areas where physicians write orders. o Download educational documents that can be used to educate diabetics at and o Develop a medication sheet that can be customized for each patient, listing the meds they are currently taking and when they should take them. o If appropriate, recommend diabetic patients to a dietician or nutritional consultant who can educate them on a diabetic diet and assist them with meal planning. o Consider a referral to endocrinology for insulin initiation. P4P_Detailed_Tip_Sheet_052012_V1 Page 19

20 Coordinated Diabetes Care: HbA1c Poor Control (>9.0%) The percentage of patients ages 18 to 75 years with type 1 and type 2 diabetes who had each screening completed during the measurement year and identified as having HbA1c poor control (>9.0%). NOTE: The last screening of the year counts towards this measure. It is important to keep track of your diabetics throughout the year and take action when the HbA1c is over 9.0% Ensure that action is taken when HbA1c is >9% o If HbA1c is >9, check to see if insulin is prescribed. If not, the next therapeutic step is probably to initiate insulin therapy Ensure the following codes are used to identify diabetes: 250, 357.2, 362.0, , Aids to assist with improving compliance: o Post information regarding HbA1c control in treatment/exam rooms and areas where physicians write orders. o Download educational documents that can be used to educate diabetics at and o Develop a medication sheet that can be customized for each patient, listing the meds they are currently taking and when they should take them. o If appropriate, recommend diabetic patients to a dietician or nutritional consultant who can educate them on a diabetic diet and assist them with meal planning. o Consider a referral to endocrinology for insulin initiation. P4P_Detailed_Tip_Sheet_052012_V1 Page 20

21 Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening The percentage of members age 18 to 75 years who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) or who had a diagnosis of ischemic vascular disease (IVD), who had LDL-C screening completed during the measurement year. Ensure members with cardiovascular conditions are screened for LDL-C test at least annually. Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Control (< 100 mg/dl) The percentage of members age 18 to 75 years who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) or who had a diagnosis of ischemic vascular disease (IVD), who had LDL Control <100 during the measurement year. Note: The last LDL-C value of the year counts toward this measure. Ensure LDL-C must be < 100, which is 99 is or less. Take action when LDL is 100 or greater. Aids to assist with improving compliance: o Post information regarding LDL-C screening for patients with cardiovascular conditions in treatment/exam rooms and areas where physicians write orders. o Send post card reminders to patients from their physician indicating when LDL screening is due. Include a lab order sheet with the post card reminder so that the patient can have the LDL screening completed prior to seeing their physician. Phone call reminders my also be used, but you will need to make arrangements for the patient to pick up the voucher/order sheet. o If appropriate, recommend these patients to a dietician or nutritional consultant who can educate them on low cholesterol diet and assist them with meal planning. P4P_Detailed_Tip_Sheet_052012_V1 Page 21

22 Colorectal Cancer Screening (COL) The percentage of adults 50 to 75 who had appropriate screening for colorectal cancer during the measurement year, or the year prior to the measurement year. Colorectal Cancer screening can be completed by: o Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gfobt) or immunochemical (ifobt), assume that the required number of samples was returned. o Flexible sigmoidoscopy during the measurement year of the four years prior to the measurement year. o Colonoscopy during the measurement year or the nine years prior to the measurement year. Review information regarding colorectal screening, including the types of screening, that can be found on the National Cancer Institute website at Use aids to assist with improving compliance: o Post information regarding the standard of care for COL, such as the table and types of COL listed above, in treatment/exam rooms and areas where physicians write orders. o Implement a reminder and recall process where physicians send post cared reminders to patients indicating when COL is due. This can also be a telephone call to the patient. For those who are past due for their screening, another post card reminder or call should be generated. A registry can be instrumental in generating patient reminders. o Develop and distribute patient education tools specific to this measure. P4P_Detailed_Tip_Sheet_052012_V1 Page 22

23 Breast Cancer Screening (BCS) The percentage of women ages 40 to 69 who had a mammogram to screen for breast cancer during the measurement year of the year prior. Review the American Cancer Society Guidelines for Early Breast Cancer Detection, 2003 at Send post card reminders to patients from their physician indicating when BCS is due. Include a referral with the post card so that the patient can have the mammogram completed prior to seeing their physician. Phone call reminders may also be used. Identify and report members who have bad a bilateral mastectomy. P4P_Detailed_Tip_Sheet_052012_V1 Page 23

24 Annual Monitoring for Patients on Persistent Medications The percentage of members ages 18 years and older who receive at least a 180-day supply of ambulatory medication therapy for a select therapeutic agents during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the three rates separately and as a total rate. At least one serum potassium (K) and either a serum creatinine (SCr) or a blood urea nitrogen (BUN) therapeutic monitoring test in the measurement year is considered a monitoring event. Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Annual monitoring for members on digoxin Annual monitoring for members on diuretics Annual monitoring for members on anticonvulsants o Appropriate testing for patients on ACE inhibitors, Digoxin and diuretics is a serum potassium and either a serum creatinine or serum blood urea nitrogen o Appropriate testing for members on anticonvulsants is a serum level of the anticonvulsant Implement a reminder and recall process where physicians send post card reminders to patients indicating that they should come in for a check-up and blood work, or send a letter to have patient have blood work done and follow-up as appropriate. P4P_Detailed_Tip_Sheet_052012_V1 Page 24

25 Proportion of Days Covered by Medications The percentage of members 18 years of age and older who met the Proportion of Days Covered (PDC) threshold of 80% for select medications during the measurement period. Proportion of Days Covered for Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB): Members who filled at least two prescriptions for an ACEI/ARB or ACEI/ARB combination on two unique dates of service during the measurement period. Proportion of Days Covered for Statins: Members who filled at least two prescriptions for statin or statin combination on two unique dates of service during the measurement period. Proportion of Days Covered for Oral Diabetes Medications: Members who filled at least two prescriptions for any oral diabetes medication on two unique dates of service during the measurement period. Perform medication reconciliation at each visit. Note: Refer to the IHA website for a comprehensive list of medications and associated codes. P4P_Detailed_Tip_Sheet_052012_V1 Page 25