HEDIS Code Quick Reference Guide Preventive/Ambulatory Services
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1 HEDIS Code Quick Reference Guide Preventive/Ambulatory Services
2 Child/Adolescent Care Well-Child Visits in the First 15 Months of Life [Commercial, Medicaid] Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Adolescent Well-Care Visits (ages 12-21) Childhood Immunization Status (by age 2) Codes to identify Well-Child Visits 0-15 Months HCPCS Diagnosis 99381, 99382, 99391, 99392, G0438, G0439 V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to identify Well-Child Visits 3-6 Years HCPCS Diagnosis 99382, 99383, 99392, G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to identify Adolescent Well-Care Visits HCPCS Diagnosis , G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to identify Childhood Immunizations* Codes for evidence of disease HCPCS Procedure Diagnosis 4-DTaP 90698, 90700, 90721, IPV 90698, 90713, MMR 90707, Measles and rubella Measles Mumps Rubella HiB , 90698, 90721, Hepatitis B 90723, 90740, 90744, 90747, G , 070.3, V VZV 90710, , Pneumococcal conjugate 90669, G Hepatitis A , Rotavirus (two-dose schedule) Rotavirus (three-dose schedule) Influenza 90655, 90657, 90661, G *Pediatric immunization administration codes are: and (for each additional). Please show code for VFC vaccines at $0 so that appropriate credit can be applied. When an evaluation and management service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, Modifier -25 may be appended to the code for the evaluation and management service. EXCLUSIONS: Diagnosis Anaphylactic reaction See complete guide for other exclusions and related codes by vaccine, as applicable. Immunizations for Adolescents Codes to identify Immunizations Procedure EXCLUSIONS: Diagnosis Meningococcal [ages 11-13] 90733, Anaphylactic reaction Tdap [ages 10-13] See complete guide for other contraindication codes by vaccine, as applicable. Td [ages 10-13] 90714, Tetanus [ages 10-13] Diphtheria [ages 10-13] HPV (3) [ages 9-13] 90649,
3 Child/Adolescent Care-continued Lead Screening in Children (by age 2) [Medicaid] Children and Adolescents Access to Primary Care Practitioners (12 months-19 years) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (ages 3-17) Codes to identify Lead Tests LOINC , , , , , , , , Codes to identify Ambulatory or Preventive Care Visits Office or other outpatient services Home services Preventive medicine General medical examination /HCPCS Diagnosis , , , , , , V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, , 99420, 99429/G0438, G0439 V70.9 Codes to identify Outpatient Visits Codes to identify BMI Percentile, Counseling for Nutrition and Counseling for Physical Activity UB Revenue BMI Percentile Nutrition Counseling Physical Activity Counseling , , , , , , , , , 99411, 99412, 99420, 99429, 99455, EXCLUSIONS: Pregnancy 051x, , , 0982, 0983 Dx: V85.5 Diagnosis , V22, V23, V28 Dx: V65.3, HCPCS: G0270- G0271, S9449, S9452, S9470, G0447, : Dx: V65.41, HCPCS: S9451, G0447 Women s Health Breast Cancer Screening (ages 40-69) Cervical Cancer Screening (ages 21-64) Codes to identify Breast Cancer Screening HCPCS Procedure UB Revenue G0202, G0204, G , , 0403 EXCLUSIONS: Procedure Bilateral mastectomy Use Unilateral code WITH bilateral modifier.50 or to indicate the procedure was bilateral and performed during the same 85.42, 85.44, 85.46, operative session. Unilateral mastectomy 19180, 19200, 19220, 19240, (Modifiers: Right=RT, Left=LT) 85.41, 85.43, 85.45, Codes to identify Cervical Cancer Screening HCPCS Procedure UB Revenue LOINC , 88147, 88148, 88150, , , 88174, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q , , , , , , , , , Procedure EXCLUSIONS: Diagnosis Hysterectomy 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, , , 58951, 58953, 58954, 58956, , V67.01, V76.47, V88.01, V88.03,
4 Women s Health-continued Chlamydia Screening in Women (ages 16-24) Codes to identify Chlamydia Screening LOINC 87110, 87270, 87320, , , 560-3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , EXCLUSIONS: UB Revenue LOINC Pregnancy test 81025, 84702, , , , , , , , , , , , , , , , , , , , , , WITH Diagnostic radiology x Retinoid Isotretinoin prescription Pregnancy Care Postpartum Care Prenatal Care Adult Care Adult BMI Assessment (ages 18-74) (Preferred Codes) 57170, 58300, 59400,* 59410,* 59430, 59510,* 59515,* 59610,* 59614,* 59618,* 59622,* , 88147, 88148, 88150, , , 88174, 88175, (*Generally, these codes are used on the date of delivery. Code may be used only if the claim form indicates when postpartum care was rendered.) Category II 0503F Codes to identify Postpartum Visits HCPCS Diagnosis G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 V24.1, V24.2, V25.1, V72.3, V76.2 Procedure UB Revenue 89.26, LOINC , , , , , , , , , Basic Codes to identify Prenatal Care Visits Diagnosis 59400,* 59425,* 59426,* 59510,* 59610,* 59618* (* Generally, these codes are used on the date of delivery. Code is useful only if the claim form indicates when prenatal care was initiated.) WITH 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22, V23, V28 Category II 0500F, 0501F, 0502F Codes to identify Outpatient Visits Codes to identify BMI HCPCS UB Revenue Diagnosis , , , , , , , , V85.0-V85.5 G x, , , 0982, , 99411, 99412, 99420, 99429, 99455, EXCLUSIONS: Diagnosis Pregnancy , V22, V23, V28 3
5 Adult Care-continued Adults Access to Preventive/ Ambulatory Health Services (ages 20-65) Colorectal Cancer Screening (ages 50-75) [Commercial, Medicare, NY Medicaid] Glaucoma Screening in Older Adults (ages 67+) Care of Older Adults (ages 66+) [Medicare SNP] Influenza Vaccine/Pneumonia Vaccine [Commercial, Medicare] Codes to identify ambulatory or preventive care visit Description HCPCS Diagnosis UB Revenue Office or other outpatient services , , x, , , 0982, 0983 Home services , Nursing facility care , 99315, 99316, , 0525 Domiciliary, rest home or custodial care services , Preventive medicine , , , 99411, 99412, G0402, G0438, 99420, G0439 Ophthalmology and optometry 92002, 92004, 92012, S0620, S0621 General medical examination V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to identify Colorectal Cancer Screening Description HCPCS Procedure LOINC , , , , FOBT 82270, G , , , , , , , , , , Flexible sigmoidoscopy , , G Colonoscopy , 44397, G0105, 45355, , G , , 45.23, 45.25, 45.42, EXCLUSIONS: HCPCS Diagnosis Procedure G0213- Colorectal cancer G0215, 153, 154.0, 154.1, 197.5, V10.05 G0231 Total colectomy , , Refer Medicare members 65 years and older who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. Codes to identify Care of Older Adults Category Category II HCPCS Advance Care Planning 1157F, 1158F S0257 Identify Medication Review 1160F (review),1159f (list) 90862, 99605, Functional Status Assessment 1170F Pain Screening 0521F, 1125F, 1126F Annual Influenza vaccine of commercial adults years of age. Annual Influenza vaccine of Medicare adults 65 years of age and older. Pneumococcal vaccination of Medicare members 65 years of age and older. Influenza 90654, 90656, 90660, Pneumonia
6 Adult Care-continued Annual Monitoring for Persistent Medications (ages 18+) Codes to identify Annual Monitoring for Persistent Medications Medications Description LOINC Lab panel 80047, 80048, 80050, 80053, OR Serum potassium (K+) 80051, , , , , , , , , , , , ACE inhibitors or ARBs, Digoxin, or Diuretics AND Serum creatinine (SCr) 82565, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , OR Blood urea nitrogen (BUN) 84520, , , , , , , , , , , Medication Reconciliation Post Discharge [Medicare SNP] Drug-Disease Interaction in the Elderly High-Risk Medications in the Elderly Aspirin Use and Discussion Medical Assistance With Smoking and Tobacco Use Cessation Anticonvulsants Drug serum concentration for phenobarbital Drug serum concentration for phenytoin Drug serum concentration for valproic acid or divalproex sodium Drug serum concentration for carbamazepine , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Adults 66 years and older should have medications reconciled by outpatient provider within 30 days of discharge. Reconciliation can be conducted by a prescribing practitioner, clinical pharmacist or registered nurse. Adults 65 years or older who have evidence of an underlying disease, condition or heath concern should NOT be dispensed an ambulatory prescription for a contraindicated medication. 1. Adults identified with falls or hip fractures should NOT be dispensed an ambulatory prescription for a tricyclic antidepressant or an antipsychotic or sleep agent. 2. Adults diagnosed with dementia or a dispensed dementia medication should NOT be dispensed an ambulatory prescription for a tricyclic antidepressant or anticholinergic agent. 3. Adults diagnosed with chronic renal failure should NOT be dispensed an ambulatory prescription for an NSAID or Cox-2 selective NSAID. Adults 66 years of age and older should not be dispensed high-risk prescriptions as identified in the Beers List. Discuss the risks and benefits of using aspirin in the following populations: Women years of age with at least two risk factors for cardiovascular disease. Men years of age with at least one risk factor for cardiovascular disease. Men years of age, regardless of risk factors. Provide cessation advise to adults 18 years of age and older who are current smokers or tobacco users, discuss or recommend cessation medications, and provide cessation methods or strategies. 5
7 Health Outcomes Survey Measures The Medicare survey measures each member s physical and mental health status at the beginning and the end of a two-year period. Falls Risk Assessment Discuss falls or problems with balance or walking with adults 75 years of age and older or years of age with balance or walking problems, and provide fall risk intervention for these individuals. Management of Urinary Incontinence in Older Adults Discuss urine leakage problem with adults 65 years of age and older who reported having a problem with urine leakage in the past six months, and provide treatment for these individuals. Osteoporosis Testing in Older Women 65 years of age and older should receive a bone density test to check for osteoporosis. Women Physical Activity in Older Adults Speak with adults 65 years of age and older about their level of exercise or physical activity and provide advice to start, increase or maintain their level of exercise or physical activity. Source: HEDIS 2013 Technical Specifications Allowable codes may vary by state. Reimbursement for these services will be per the terms of your agreement. 6
8 Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. or its affiliates / United HealthCare Services, Inc. Doc#: UHC1529c_
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