2016 HEDIS & Quality Assurance Reporting Requirements Measures Provider Reference Guide

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1 2016 HEDIS & Quality Assurance Reporting Requirements Measures Provider Reference Guide HEDIS Measure: Test/Care Needed for Compliance Adult BMI Assessment Individuals ages Documentation of BMI and weight every one to two years (2014, ) BMI ICD-9: V85.0, V85.1, V85.21, V85.22, V85.23, V85.24,V85.25 V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.41, V85.42, V85.43, V85.44, V85.45 ICD-10: Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.2, Z68.2, Z68.28, Z68.2, Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45 BMI Percentile ICD-9: V85.51, V85.52, V85.53, V85.54 ICD-10: Z68.51, Z68.52, Z68.53, Z68.54 Adolescent Preventive Care Individuals ages who had at least one outpatient visit with a PCP or OB/GYN in Documentation of the following four components: assessment or counseling or education on risk behaviors and preventive actions associated with sexual activity; on depression; on the risks of tobacco usage; on the risks of substance use (including alcohol) Sexual Activity CPT II: 4293F HCPCS: G0445 Depression CPT II: 1220F, 3085F, 3351F, 3352F, 3353F, 3354F, 3725F HCPCS: G0444, G8431, G8510, G8511, G8930, S3005 Tobacco CPT II: 1000F, 1031F, 1032F, 1033F, 1034F, 1035F, 1036F CPT: 99406, HPCPS: G0436, G0437, S9453 Substance Use CPT II: 3016F, 4290F, 4306F, 4320F CPT: 99408, HCPCS: G0396, G0397, G0443, H0001, H0005, H0006, H0007, H0022, H0046, H0047, H0050, T1007 Cervical Cancer Women ages who were screened for cervical cancer Age cervical cytology every three years date and results Or Age cervical cytology and HPV cotesting with documented date and results CPT II: 3015F CPT: , 88147, 88148, 88150, , , 88174, 88175, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Exclusions: Documentation of total hysterectomy with absence of cervix 1

2 Test/Care Childhood Immunization Status Children 2 years of age in who received these vaccines on or before age 2 4 DTaP, 3 Polio (IPV), 1 MMR, 3 H Influenza Type B (HIB), 3 Hepatitis B, 1 Varicella (VZV), 4 Pneumococcal conjugate (PCV), 1 Hepatitis A, 2 Rotavirus (Rotarix) or 3 Rotavirus (RotaTeq), 2 influenza vaccines DTaP CPT: 90698, 90700, 90721, IPV CPT: 90698, 90713, MMR CPT: HIB CPT: , 90698, 90721, Hep B CPT: 90723, 90740, 90744, 90747, Hep B HCPS: G0010 VCV CPT: 90710, PCV CPT: 90669, HCPS: G0009 Hep A CPT: Rotavirus/Rotarix CPT: RotaTeq CPT: Influenza CPT: 90655, 90657, 90661, 90662, 90673, HCPCS: G0008 Colorectal Cancer Individuals ages who were screened for colorectal cancer One of the following with documentation of date and result: Fecal Occult Blood Test (FOBT) in ; flexible sigmoidoscopy in or four years prior; colonoscopy in or nine years prior Colonoscopy CPT: 44388, 44389, 44390, 44391, 44392, 44393, , 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, HCPCS: G0105, G0121 Flexible Sigmoidoscopy CPT: , , HCPCS: G0104 FOBT CPT: 82270, HCPCS: G0328 Retinal Eye Exam Performed Optometrist/ophthalmologist exam every two years for patients without retinopathy (2014) and/or every year for patients with retinopathy (); date and result Retinal CPT: 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225,92226, 92227, 92228, 92230, 92235, 92240, 92250, HCPCS: S0620, S0621, S3000 Retinal with Eye Care Professional CPT II: 2022F, 2024F, 2026F, S0625 HbA1c Documentation of a hemoglobin (HbA1c) blood test in ; date and result HbA1c Level CPTII: 3045F HbA1c Level Greater Than 9.0 CPT II: 3046F HbA1c Level Less Than 7.0 CPT II: 3044F HbA1c Test CPT: 83036,

3 Test/Care Needed for Compliance Documentation of the most recent Diastolic CPT II: 3079F blood pressure reading in Diastolic Greater than/equal to 90 CPT II: 3080F Blood Pressure <140/90 Diastolic Less than 80 CPT II: 3078F Control Systolic Greater than/equal to 140 CPT II: 3077F <140/90 Systolic Less than 140 CPT II: 3074F, 3075F Documentation of nephropathy Nephropathy Treatment CPT II: 3066F, 4010F screening and/or treatment in Urine Protein Tests CPT: 81000, 81001, 81002, 81003, 81005, 82042, Medical Attention 82043, 82044, for Nephropathy Urine Protein Tests CPT II: 3060F, 3061F, 3062F HCPCS: G0257, S2065, S9339 Weight Individuals ages Documentation of the following in BMI Percentile ICD-9: V85.51, V85.52, V85.53, V85.54 Assessment and 3-17 who had an : BMI percentile NOT BMI ICD-10: Z68.51, Z68.52, Z68.53, Z68.54 Counseling for outpatient visit value AND counseling for Counseling for Nutrition ICD-9: V65.3 Nutrition and with a PCP or nutrition AND counseling for CPT: 97802, 97803, Physical Activity OB/GYN in physical activity HCPCS: G0447, G0270, G0271, S9449, S9452, S9470 ICD-10: Z71.3 Counseling for Physical Activity ICD-9: V65.41 HCPCS: S9451, G0447 Controlling High Individuals ages The documentation of the most Essential Hypertension ICD-9: 401.0, 401.1, 401.9, I10 Blood Pressure diagnosed recent blood pressure in as Exclusions: s with evident ESRD; diagnosis of pregnancy during with hypertension long as it occurred after the ; members who had an admission to a non-acute inpatient setting in and whose blood diagnosis; Ages whose BP pressure (BP) was <140/90; Ages with a was adequately diagnosis of Diabetes whose BP controlled was <140/90; Ages without a diagnosis of diabetes whose BP was <150/90 Human Female Documentation of three doses of HPV Vaccine Administered CPT: 90649, 90650, Papillomavirus adolescents 13 the HPV vaccine by their 13 th Vaccine for Female years of age birthday Adolescents in 3

4 Test/Care Needed for Compliance Immunizations for Adolescents Documentation of 1 Diphtheria Vaccine Administered CPT: Adolescents 13 years of age Meningococcal vaccine AND Meningococcal Vaccine Administered CPT: 90733, in 1 Tdap OR 1 Td vaccine Td Vaccine Administered CPT: 90714, Tdap Vaccine Administered CPT: Tetanus Vaccine Administered CPT: Lead in Children 2 years Documentation of at least one Lead Test CPT: Children of age in lead or capillary or venous blood screened for lead test with the date and finding on poisoning or before their 2 nd birthday Medication The percentage of Documentation of any of the Medication Reconciliation CPT: 99495, Reconciliation discharges from following on or within 30 days of Medication Reconciliation CPT II: 1111F, 1159F, 1160F Post-Discharge January 1,, discharge: provider reconciled the through December current and discharge medications 1,, for and were reviewed; individuals age 18 documentation of the current years of age or medications that references the older with the discharge medications (e.g., no most recent changes since discharge; the medication list same at discharge) were reviewed; documentation that no medications were prescribed upon discharge 4

5 Access/Availability of Care Test/Care Prenatal and Women who Timeliness of Prenatal Care: Prenatal Bundled Services CPT: 59400, 59425, 59426, 59510, 59610, Postpartum Care delivered a live Documentation of a prenatal care birth between visit in the 1 st trimester; and must HCPCS: H1001, H1002, H1003, H1004, H1005, T1015 November 6, include one of the following: a Stand Alone Prenatal Visits CPT: , and basic OB/GYN exam; or evidence Stand Alone Prenatal Visits CPT II: 0500F, 0501F, 0502F November 5, that a prenatal care procedure HCPCS: H1000, H1001, H1002, H1003, H1004 was performed or documentation Postpartum Visits CPT: 57170, 58300, 59430, of LMP or EDD with either a Postpartum Visits CPT II: 0503F prenatal risk assessment and HCPCS: G0101 counseling and education or a Postpartum Bundled Services: 59400, 59410, 59510, 59515, 59610, complete obstetrical history 59614, 59618, Postpartum Care: Documentation of a postpartum visit on or between 21 and 56 days after delivery and must include one of the following: Pelvic exam or evaluation of weight, BP, breasts and abdomen and breast feeding status, or notation of postpartum care 5

6 Utilization Test/Care Adolescent Adolescents Documentation of the date of the Well Care CPT: 99384, 99385, 99394, Well Care Visits years of age who visit and the following: HCPCS: G0438, G0439, had at least one A health history; a physical ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 or more well care developmental history; a ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, visits with a PCP mental developmental history; Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, or OB/GYN in a physical exam and health Z02.83, Z02.89, Z02.9 education/anticipatory guidance Frequency of Women who Documentation of prenatal visits Prenatal Bundled Services CPT: 59400, 59425, 59426, 59510, 59610, Prenatal Care delivered a live that occur during the 1 st, 2 nd and birth between 3 rd trimester until delivery HCPCS: H1001, H1002, H1003, H1004, H1005, T1015 November 6, Stand Alone Prenatal Visits CPT: , and Stand Alone Prenatal Visits CPT II: 0500F, 0501F, 0502F November 5, HCPCS: H1000, H1001, H1002, H1003, H1004, and had the expected number of prenatal visits, as recommended by ACOG: Every four weeks for the first 28 weeks of pregnancy Every twothree weeks for the next seven weeks Weekly thereafter until delivery 6

7 Utilization Test/Care Well Child Visits in Children who had Documentation of the date of the Well Care CPT: 99381, 99382, 99391, 99392, the First 15 between one and visit and the following: A health HCPCS: G0438, G0439 Months of Life six or more well history; a physical developmental ICD-9: V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, child visits with a history; a mental developmental V70.9 PCP by the time history; a physical exam and ICD-10: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, they turned 15 Health education/anticipatory Z00.8, Z02.0, Z02.2, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, months of age in guidance Z02.89, Z02.9 Well Child Visits in Children 3 to 6 Documentation of the date of the Well Care CPT: 99382, 99383, 99392, the First 3-6 years years of age who visit and the following: A health HCPCS: G0438, G0439 of Life had one or more history; a physical developmental ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 well child visits history; a mental developmental ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, with a PCP in history; a physical exam and Z02.2, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 health education/anticipatory guidance HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Refer to CPT is a registered trademark of the American Medical Association. HCPCS: Healthcare Common Coding Procedure Coding System Level II. ICD-9CM: Is the International Classification of Diseases, Ninth Revision, Clinical Modification developed by the World Health Organization. ICD-10: Centers for Medicare & Medicaid Services at Quality Assurance Reporting Requirements (QARR) are largely adopted from NCQA HEDIS with New York state-specific measures added to address health issues of particular importance in New York. This document is not inclusive of all codes and measures. The measure descriptions and codes in this document are derived from the 2016 HEDIS Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as appropriate. If you would like to discuss electronic upload or an alternate method of release of records or any other questions, please call our Quality Measurement department at

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