UnitedHealth Premium Physician Designation Program Codes and Medications Demonstrating Compliance with Nationally Endorsed Quality Measures

Transcription

1 UnitedHealth Premium Physician Designation Program s and Medications Demonstrating Compliance with Nationally Endorsed Quality Measures Introduction This document is a reference for use during the online UnitedHealth Premium designation program s reconsideration process to determine if a patient met the clinical standards for measures indicated as non-compliant. This document is specifically referenced within the Reconsideration Quality Worksheet and the online Quality tab screen for nationally endorsed quality measures. Refer to this document for codes and medications that demonstrate compliance with these measures. The document is organized alphabetically by condition and then by measure. Each measure includes a list and description of billing codes and/or medications that satisfy the compliance criteria. The list for each measure may include medications and the following code types as applicable: ICD-9 HCPCS LOINC RVNU POS Definition Current Procedural Terminology () is coding used to describe medical services and procedures. A three to five digit number code describing a diagnosis or medical procedure. The Healthcare Common Procedure Coding System (HCPCS) is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (). Logical Observation Identifiers Names and s (LOINC) are a database and universal standard for identifying medical laboratory observations. s used to identify specific accommodations, ancillary services and billing calculations used by facilities as determined by the National Uniform Billing Committee. Place of Service (POS) s are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Additional helpful definitions: Measure Source ID Symmetry EBM Connect Case ID or Symmetry Procedure Episode Group (PEG ) anchor category ID Rule ID Reference number for Symmetry EBM Connect rules. Note: You may also want to refer to the Evidence-Based Medicine (EBM) Synopses (Pathway: UnitedHealthcareOnline.com > UnitedHealth Premium > Premium Reconsideration > Reconsideration Resources.)

2 Table of Contents Acute Myocardial Infarction (AMI)...3 ADHD...4 Alcohol and Other Drug Dependence Treatment...15 Antidepressant Medical Management...29 Asthma...30 Avoidance of Antibiotic Treatment in adults with Acute Bronchitis...34 Breast Cancer Screening...35 Cardiovascular Disease...36 Cervical Cancer Screening...37 Chlamydia Screening Congestive Heart Failure...42 Coronary Artery Disease...47 Diabetes...50 Diabetes Mellitus...52 Diabetic Retinopathy (NS)...53 Glaucoma Screening...54 Medication Safety Monitoring...57 Migraine Headache...64 Osteoporosis Management...65 Pharyngitis...67 Pregnancy Management...68 Rheumatoid Arthritis...69 Upper Respiratory Infection (Pediatric)...70 Use of Appropriate Imaging for Back Pain...71 Table of Contents 2

3 Acute Myocardial Infarction (AMI) Measure Source (Case) ID: Measure: Medication Patient(s) hospitalized with an acute myocardial infarction (AMI) persistently taking a betablocker for six months after discharge. (Rule ID: ) Acebutolol hydrochloride Atenolol Bendroflumethiazide-nadolol Betapace Betapace AF Betaxolol Blocadren Bystolic Cartrol Carvedilol Coreg Corgard Corzide Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Inderal Inderide InnoPran XL Kerlone Levatol Lopressor Metoprolol succinate ER Metoprolol tartrate Nadolol Normodyne Pindolol Propranolol hydrochloride Sectral Sorine Sotalol hydrochloride Tenoretic Tenormin Timolide Timolol maleate Toprol-XL Trandate Zebeta Ziac Acute Myocardial Infarction (AMI) 3

4 ADHD Measure Source (Case) ID: Measure: Measure: Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription. (Rule ID: ) Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription AND two followup visits during the 31 days through 300 days after the initial. (Rule ID: ) Description Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; ADHD 4

5 Description Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Psychoanalysis Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy ADHD 5

6 Description Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; individual Health and behavior intervention, each 15 minutes, face-to-face; group (two or more patients) Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; two to four patients Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; five to eight patients Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. ADHD 6

7 Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes faceto-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, as appropriate.]) ADHD 7

8 Description Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. ADHD 8

9 Description Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit. ADHD 9

10 Description Inpatient consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit Follow-up inpatient consult Follow-up inpatient consult Follow-up inpatient consult Home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-toface with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. ADHD 10

11 Description Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/ or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes face-to-face with the patient and/or family Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes ADHD 11

12 Description Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes Home visit for individual, family, or marriage counseling HCPCS G0155 G0176 G0177 H0002 H0004 H0031 H0034 H0035 H0036 H0037 H0039 H0040 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 ADHD Description Services of clinical social worker in home health setting, each 15 minutes Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) Behavioral health screening to determine eligibility for admission to treatment program Behavioral health counseling and therapy, per 15 minutes Mental health assessment, by non-physician Medication training and support, per 15 minutes Mental health partial hospitalization, treatment, less than 24 hours Community psychiatric supportive treatment, face-to-face, per 15 minutes Community psychiatric supportive treatment program, per diem Assertive community treatment, face-to-face, per 15 minutes Assertive community treatment program, per diem Comprehensive multidisciplinary evaluation Rehabilitation program, per 1/2 day Comprehensive medication services, per 15 minutes Crisis intervention service, per 15 minutes Behavioral health day treatment, per hour Psychiatric health facility service, per diem Skills training and development, per 15 minutes Comprehensive community support services, per 15 minutes Comprehensive community support services, per diem Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Therapeutic behavioral services, per 15 minutes 12

13 HCPCS H2020 M0064 S0201 S9480 S9484 S9485 Description Therapeutic behavioral services, per diem Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders Partial hospitalization services, less than 24 hours, per diem Intensive outpatient psychiatric services, per diem Crisis intervention mental health services, per hour Crisis intervention mental health services, per diem Description RVNU 0510 Clinic-General 0513 Clinic-Psychiatric Clinic 0515 Clinic-Pediatric Clinic 0516 Clinic-Urgent Care Clinic 0517 Clinic-Family Practice Clinic 0519 Clinic-Other Clinic 0520 Freestanding Clinic-General 0521 Freestanding Clinic-Clinic visit by member to RHC/FQHC 0522 Freestanding Clinic-Home visit by RHC/FQHC Practitioner 0523 Freestanding Clinic-Family Practice Clinic 0526 Freestanding Clinic-Urgent Care Clinic 0527 Freestanding Clinic-Visiting Nurse Service (s) to a Member's Home When in a Home Health Shortage Area 0528 Freestanding Clinic-Visit by RHC/FQHC Practitioner to Other Non-RHC/FQHC Site (e.g. Scene of Accident) 0529 Freestanding Clinic-Other Freestanding Clinic 0770 Preventive Care Services-General 0771 Preventive Care Services-Vaccine Administration 0779 Preventive Care Services-Other Preventive Care Services 0900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-General 0902 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Milieu Therapy 0903 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Play Therapy 0904 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Activity Therapy 0905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Psychiatric 0907 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Community Behavioral Health Program (Day Treatment) 0911 Behavioral Health Treatments/Services-Extension of 090X-Rehabilitation 0912 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Less Intensive ADHD 13

14 RVNU Description 0913 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Intensive 0914 Behavioral Health Treatments/Services-Extension of 090X-Individual Therapy 0915 Behavioral Health Treatments/Services-Extension of 090X-Group Therapy 0916 Behavioral Health Treatments/Services-Extension of 090X-Family Therapy 0917 Behavioral Health Treatments/Services-Extension of 090X-Bio Feedback 0919 Behavioral Health Treatments/Services-Extension of 090X-Other Behavioral Health Treatments/ Services 0982 Professional Fees (Extension of 096X and 097X)-Outpatient Services 0983 Professional Fees (Extension of 096X and 097X)-Clinic Description POS 03 Education Facility 05 Indian Health Service Free-Standing Facility 07 Tribal 638 Free-Standing Facility 09 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 22 Outpatient Hospital 33 Custodial Care Facility 49 Independent Clinic 50 Federally Qualified Health Center 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 71 State or Local Public Health Clinic 72 Rural Health Clinic ADHD 14

15 Alcohol and Other Drug Dependence Treatment Measure Source (Case) ID: Measure: Patients between the ages of 13 and 17 who initiated AOD treatment. (Rule ID: ) Measure: Patient(s) between the ages of 13 and 17 who engaged in AOD treatment. (Rule ID: ) Measure: Patient(s) age 18 years or older who initiated AOD treatment. (Rule ID: ) Measure: Patient(s) age 18 years or older who engaged in AOD treatment. (Rule ID: ) Description ICD Alcohol-induced mental disorders Alcohol withdrawal delirium Alcohol-induced persisting amnestic disorder Alcohol-induced persisting dementia Alcohol-induced psychot disorder w/hallucination Idiosyncratic alcohol intoxication Alcohol-induced psychotic disorder w/delusions Other specified alcohol-induced mental disorders Alcohol withdrawal Alcohol induced sleep disorders Other specified alcohol-induced mental disorders Unspecified alcohol-induced mental disorders 292 Drug-induced mental disorders Drug withdrawal Paranoid & or hallucinatory states induced drugs Drug-induced psychotic disorder with delusions Drug-induced psychotic disorder w/hallucinations Pathological drug intoxication Other specified drug-induced mental disorders Drug-induced delirium Drug-induced persisting dementia Drug-induced persisting amnestic disorder Drug-induced mood disorder Drug induced sleep disorders Other specified drug-induced mental disorder Unspecified drug-induced mental disorder Acute alcoholic intoxication unspec drunkenness Acute alcoholic intoxication cont drunkenness Alcohol and Other Drug Dependence Treatment 15

16 Description ICD Acut alcoholic intoxication episodic drunkenness Oth & unspec alcohol dependence unspec drunkenness Other & unspec alcohol dependence cont drunkenness Oth & unspec alcohol depend episodic drunkenness Opioid type dependence unspecified abuse Opioid type dependence continuous abuse Opioid type dependence episodic abuse Sedative hypnotic/anxiolytic dependence unspec Sedative hypnotic/anxiolytic dependence cont Sedative hypnotic/anxiolytic dependence episodic Cocaine dependence unspecified abuse Cocaine dependence continuous abuse Cocaine dependence, episodic abuse Cannabis dependence unspecified abuse Cannabis dependence continuous abuse Cannabis dependence, episodic abuse Amphet & oth psychostimulant dependence unspec abs Amphet & oth psychostimulant dependence cont abs Amphet & oth psychostimulant depend episodic abs Hallucinogen dependence unspecified abuse Hallucinogen dependence continuous abuse Hallucinogen dependence episodic abuse Other spec drug dependence unspec abuse Other specified drug dependence continuous abuse Other specified drug dependence episodic abuse Comb opioid rx w/any oth rx depend unspec abs Comb opioid drug w/any oth drug depend cont abs Comb opioid rx w/any oth rx depend episodic abs Comb drug depend excld opioid drug unspec abs Comb drug depend excluding opioid drug cont abs Comb drug depend excld opioid drug episodic abs Unspecified drug dependence unspecified abuse Unspecified drug dependence continuous abuse Unspecified drug dependence episodic abuse Nondependent alcohol abuse unspec drunkenness Nondependent alcohol abuse cont drunkenness Nondependent alcohol abuse episodic drunkenness Alcohol and Other Drug Dependence Treatment 16

17 Description ICD Nondependent cannabis abuse unspecified Nondependent cannabis abuse continuous Nondependent cannabis abuse episodic Nondependent hallucinogen abuse unspecified Nondependent hallucinogen abuse continuous Nondependent hallucinogen abuse episodic Nondepend sedative hypnot/anxiolytic abs unspec Nondepend sedative hypnotic/anxiolytic abs cont Nondepend sedat hypnot/anxiolytic abs episodic Nondependent opioid abuse unspecified Nondependent opioid abuse continuous Nondependent opioid abuse, episodic Nondependent cocaine abuse unspecified Nondependent cocaine abuse continuous Nondependent cocaine abuse episodic Nondepend amphet/rel act sympathomimet abs uns Nondepend amphet/rel act sympathomimet abs cont Amphetamine/related drug abuse-episodic Nondependent antidepressant type abuse unspec Nondependent antidepressant type abuse cont Nondependent antidepressant type abuse episodic Oth mixed/unspec nondependent drug abuse unspec Other mixed/unspec nondependent drug abuse cont Oth mixed/unspec nondependent drug abs episodic Alcoholic gastritis Alcoholic gastritis without mention hemorrhage Alcoholic gastritis with hemorrhage Acute alcoholic hepatitis Description Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 17

18 Description Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 18

19 Description Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Psychoanalysis Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 2-4 patients Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 5-8 patients Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) Alcohol and Other Drug Dependence Treatment 19

20 Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Alcohol and Other Drug Dependence Treatment 20