Measure Name: URI Treatment without Antibiotics for Children Measure Code: URI Lab Data: N

Transcription

1 Measure Name: URI Treatment without Antibiotics for Children Owner: NCQA (URI) Measure Code: URI Lab Data: N Rule Description: General Criteria Summary The percentage of children 3 months -18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. 1. Continuous enrollment: From 30 days prior to the date of the first eligible URI encounter to 3 days after that date (34 days) 2. Index Episode based: Yes 3. Anchor date: Episode date 4. Gaps in enrollment: No 5. Medical coverage: Yes 6. Drug coverage: Yes 7. Attribution time frame: Episode date 8. Exclusions apply: None 9. Age range: 3 months-18 years 10. Intake period: July1 to June 30 (6 months earlier than the measurement year) Summary of changes for No changes Denominator Description: All children aged 3 months to 18 years with an upper respiratory infection (URI) Inclusion Criteria: Children aged 3 months to 18 years during the intake period, who had an URI encounter with no other diagnosis present, no antibiotic medication prescribed or refilled within 30 days prior to the encounter or still active on the date of the encounter, and no competing diagnosis on or within 3 days following the encounter. The intake period is from six months prior to the beginning of the measurement year to six months prior to the end of the measurement year. Eligibility Criteria Condition Description # Evnt Detailed Criteria Timeframe Age is 3 months to 18 Age in Months = 3-11 At least 3 months of age at the beginning of the intake period; years And Age in Years = 1-18 no greater than 18 years of age at the end of the intake period AND Has medical coverage Coverage Indicator Medical = Y From 30 days prior to the date of the first eligible URI encounter to 3 days after that date Page 1

2 AND Has drug coverage Coverage Indicator Drug = Y From 30 days prior to the date of the first eligible URI encounter to 3 days after that date Claim Criteria Condition Description (At least one outpatient visit with only a diagnosis of URI (Claim can only include one diagnosis code) # Evnt Detailed Criteria Timeframe 1 (dx must be on same claim as proc or rev code) Diagnosis Code Principal = Table URI-A: Codes to Identify URI and Diagnosis Code = ~ (missing) And (CPT Procedure Code = Table URI-B: Codes to Identify Outpatient Visit Type From six months prior to the beginning of the measurement year to six months prior to the end of the measurement year OR At least one emergency department visit with only a diagnosis of URI (Claim can only include one diagnosis code, and ER visit cannot be part of an admission)) 1 (dx and place code must be on same claim as proc or rev code) or Revenue Code UB = Table URI-B: Codes to Identify Outpatient Visit Type) Diagnosis Code Principal = Table URI-A: Codes to Identify URI and Diagnosis Code = ~ (missing) and Place of Service Code Medstat <> 21, 25, 51, 55 Table URI Medstat Place of Service And (CPT Procedure Code= Table URI-B: Codes to Identify Emergency Department Visit Type or Revenue Code UB = Table URI-B: Codes to Identify Emergency Department Visit Type ) And Room and Board Flag Code <> 1 on a facility claim with a Date of First Service equal to or one day greater than the Date of First Service on a claim identified through the Page 2

3 AND No antibiotic medication prescribed or refilled within 30 days prior to the URI visit or still active on the date of the visit AND No competing diagnosis on or within 3 days after the URI visit above criteria 1 No new, refilled, or active drug prescriptions where [NDC Number Code = HEDIS 2011 NDC list is available at Measures/HEDIS2013/HEDIS2013FinalNDCLists.aspx A prescription is active if the prescription was filled more than 30 days prior to the URI visit date and the Days Supply is greater than or equal to the number of days between the prescription fill date and the URI visit date. 1 All Diagnosis Codes <> Table URI-C: Codes to Identify Competing Diagnoses During the 90 day period prior to the URI visit date (Note: 90 days is required to determine if there was a mail order prescription filled that is still active on the visit date.) On or up to 3 days following the date of the first eligible URI encounter (Note: Identify all visits that meet the above criteria. Then select the visit with the earliest date and use that as the eligible encounter.) Numerator Description: For each patient who meets the denominator criteria, those who did not receive an antibiotic drug on or up to three days following their URI encounter Inclusion Criteria: Patients who did not have a prescription for an antibiotic drug on or up to three days following the date of their first eligible URI encounter Condition Description # Evnt Detailed Criteria Timeframe No antibiotic medication dispensing events during the 3 day period following the URI encounter 1 NDC Number Code <> Table CWP-C: Antibiotic Medications, HEDIS 2011 NDC list is available at Measures/HEDIS2013/HEDIS2013FinalNDCLists.aspx On or up to 3 days following the date of the first eligible URI encounter Page 3

4 Appendix Table URI-A: Codes to Identify URI ICD-9- CM Diagnosis Description 460 Acute nasopharyngitis (common cold) 465 URI Table URI-B: Codes to Identify Outpatient Visit Type CPT Description: Outpatient visit 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 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 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 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 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 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 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity 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." Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Page 4

5 99242 Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making Office consultation for a new or established patient, which requires these 3 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 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers New Patient, less than 1 year, 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 appropriate immunization New Patient, 1-4 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 appropriate immunizations New Patient, 5-11 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 appropriate immunizations New Patient, 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 appropriate immunizations New Patient, 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 appropriate immunization Established patient, less than 1 year, 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 appropriate immunizations Established patient, 1-4 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 appropriate immunizations Established patient, 5-11 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 appropriate immunizations Established patient, 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 appropriate immunizations Established patient, 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 appropriate immunization Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes 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 Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal) Unlisted preventive medicine service Page 5

6 UB Revenue Description: Outpatient visit 0510 CLINIC 0511 CHRONIC PAIN CL 0512 DENTAL CLINIC 0513 PSYCH CLINIC 0514 OB-GYN CLINIC 0515 PEDS CLINIC 0516 URGENT CLINIC 0517 FAMILY CLINIC 0519 OTHER CLINIC 0520 FREESTAND CLINIC 0521 RURAL/CLINIC 0522 RURAL/HOME 0523 FR/STD 0526 FR/STD URGENT CLINIC 0527 FR/STD 0528 FR/STD 0529 OTHER FR/STD CLINIC 0982 PRO FEE/OUTPT 0983 PRO FEE/CLINIC Table URI-B: Codes to Identify Emergency Department Visit Type CPT Description: Emergency department Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care, self limited or minor problems Emergency department visit for the evaluation and management of a patient, which requires these 3 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, low to moderate severity Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care, moderate severity Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care, high severity Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; high severity with threat to life UB Revenue Description: Emergency department visit 0450 EMERG ROOM Page 6

7 0451 ER/EMTALA 0452 ER/BEYOND EMTALA 0456 URGENT CARE 0459 OTHER EMER ROOM 0981 PRO FEE/ER Table URI Medstat Place of Service Place of Service Code Medstat Description 21 Inpatient Hospital 25 Birthing Center 51 Inpatient Psychiatric Facility 55 Residential Subst Abuse Facil Table URI-C: Codes to Identify Competing Diagnoses ICD-9-CM Diagnosis Description: Intestinal infections 001* Cholera 002* Typhoid and parathyphoid fever 003* Other salmonella infections 004* Shigellosis 005* Other food poisoning 006* Amebiasis 007* Other protozoal intestinal diseases 008* Intestinal infection due to other organisms 009* Ill-defined intestinal infections ICD-9-CM Diagnosis Description: Pertussis 033* Whooping cough ICD-9-CM Diagnosis Description: Bacterial infection unspecified Bacterial infection unspecified in conditions classified elsewhere and of unspecified site ICD-9-CM Diagnosis Description: Lyme disease and other arthropod-borne diseases 088* Other arthropod-borne diseases ICD-9-CM Diagnosis Description: Otitis media 382* Suppurative and unspecified otitis media ICD-9-CM Diagnosis Description: Acute sinusitis 461* Acute sinusitis ICD-9-CM Diagnosis Description: Acute pharyngitis Page 7

8 462 Acute pharyngitis Streptococcal sore throat ICD-9-CM Diagnosis Description: Acute tonsillitis 463 Acute tonsillitis ICD-9-CM Diagnosis Description: Chronic sinusitis 473* Chronic sinusitis ICD-9-CM Diagnosis Description: Infections of the pharynx, larynx, tonsils, adenoids 464.1* Acute tracheitis 464.2* Acute laryngotracheitis 464.3* Acute epiglottitis 474* Chronic disease of tonsils and adenoids Cellulitis of pharynx or nasopharynx Parapharyngeal abscess Retropharyngeal abscess Other diseases of pharynx or nasopharynx Cellulitis and perichondritis of larynx Other diseases of larynx Other and unspecified diseases of upper respiratory tract ICD-9-CM Diagnosis Description: Prostatitis 601* Inflammatory diseases of prostate ICD-9-CM Diagnosis Description: Cellulitis, mastoiditis, other bone infections 383* Mastoiditis and related conditions 681* Cellulitis and abscess of finger and toe 682* Other cellulitis and abscess 730* Osteomyelitis, periostitis, and other infections involving bone ICD-9-CM Diagnosis Description: Acute lymphadenitis 683 Acute lymphadenitis ICD-9-CM Diagnosis Description: Impetigo 684 Impetigo ICD-9-CM Diagnosis Description: Skin staph infections 686* Other local infections of skin and subcutaneous tissue ICD-9-CM Diagnosis Description: Pneumonia 481 Pneumococcal pneumonia 482* Other bacterial pneumonia 483* Pneumonia due to other specified organism 484* Pneumonia in infectious diseases classified elsewhere 485 Bronchopneumonia organism unspecified 486 Pneumonia organism unspecified Page 8

9 ICD-9-CM Diagnosis Description: Gonococcal infections and venereal diseases 098* Gonococcal infections 099* Other venereal diseases V01.6 Contact with or exposure to venereal diseases V02.7 Contact with or exposure to other viral diseases V02.8 Contact with or exposure to other communicable diseases ICD-9-CM Diagnosis Description: Syphilis 090* Congenital syphilis 091* Early syphilis, symptomatic 092* Early syphilis, latent 093* Cardiovascular syphilis 094* Neurosyphilis 095* Other forms of late syphilis, with symptoms 096* Late syphilis, latent 097* Other and unspecified syphilis 098* Gonococcal infections 099* Other venereal diseases ICD-9-CM Diagnosis Description: Chlamydia Other specified diseases due to chlamydiae Other specified chlamydial infection Unspecified chlamydial infection ICD-9-CM Diagnosis Description: Inflammatory diseases (female reproductive organs) 131* Trichomoniasis 614* Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum 615* Inflammatory diseases of uterus, except cervix 616* Inflammatory disease of cervix, vagina, and vulva ICD-9-CM Diagnosis Description: Infections of the kidney 590* Infections of kidney ICD-9-CM Diagnosis Description: Cystitis or UTI 595* Cystitis Urinary tract infection, site not specified ICD-9-CM Diagnosis Description: Acne Acne varioliformis Other acne Page 9