Quick Reference Guide

Transcription

1 Quick Reference Guide Below is a list of commonly used procedural and diagnostic codes that are acceptable to use for Healthcare Effectiveness Data and Information Set (HEDIS) compliance. Pediatric Measures W15 Well-Child Visits (WCV) Ages 0 15 months W34 Well-Child Visits Ages 3-6 Adolescent Well-Care (AWC) Visits Ages Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) Ages 3-17 Six or more WCV from birth to age 15 months. One WCV every year. Three components of a WCV: 1. Health/developmental history (physical/mental) 2. Physical examination 3. Anticipatory guidance One WCV every year for children ages three to six. Three components of a WCV: 4. Health/developmental history (physical/mental) 5. Physical examination 6. Anticipatory guidance One AWC Visit every year for adolescents ages Three components of an AWC Visit: 7. Health/developmental history (physical/mental) 8. Physical examination 9. Anticipatory guidance At least once during the measurement year, there must be documentation of: 1. Height and weight in the measurement year 2. Body Mass Index (BMI) percentile (ages 3-15) OR: BMI percentile or value (ages 16-17) 1. Counseling for nutrition 2. Counseling for physical activity ICD-9 codes: V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-9 codes: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-9 codes: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 BMI Value ICD-9 codes: V85.0-V85.5 BMI Percentile ICD-9 codes: V85.51 BMI < 5th percentile V85.52 BMI 5th to < 85th percentile V85.53 BMI 85th to < 95th percentile V85.54 BMI > or = to 95th percentile Nutrition Counseling ICD-9 code: V65.3 HCPCS codes: G0270, G0271, S9449, S9452, S9470 Nothing herein is intended to modify the Provider Agreement or otherwise dictate services provided by a provider or otherwise diminish a provider s obligation to provide services to members in accordance with the applicable standard of care. This document is not intended to dictate billing guidelines but rather to provide recommendations. Providers are encouraged to use the most appropriate code(s) based on services provided. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Physical Activity Counseling ICD-9 code: V65.41 HCPCS code: G0270

2 Pediatric Measures Hedis Measure Childhood Immunization (CIS) Ages 0-2 years Complete the referenced number of immunization on or before the child s second birthday: 4 - DTaP / DTP 3 - IPV 3 - Hep B 3 - Hib 1 - Hep A 1 - MMR 1 - VZV 4 - PCV 3 - Rotavirus A2 - Influenza Lead Testing (LSC) Ages 0-2 years At least one lead screening test (capillary or venous) on or before the child s second birthday. CPT code: 8365 Appropriate Testing for Children with Pharyngitis Ages 2-18 Immunization for Adolescents (IMA) Human Papillomavirus Vaccine (HPV) Follow-up after Hospitalization for Mental Illness (FUH) Ages six and older A group A streptococcus test in the seven-day period from three days prior to the Index Episode Start Date (IESD) through three days after the IESD. Adolescents by their 13th birthday should have at least one dose each of the following: 1. One meningococcal conjugate or meningococcal polysaccharide vaccine on or between the member s 11th and 13th birthdays. 2. One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the member s 10th and 13th birthdays. Female adolescents between their 9th and 13th birthdays should have at least three HPV vaccinations with different dates of service. Member should have an outpatient visit follow-up with a mental health practitioner within seven days after discharge from the hospital. Acceptable codes for Streptococcus Test: 87070, 87071, 87081, 87430, , Meningococcal: 90733, Tdap: TD: 90714, Tetanus: Diphtheria: , CPT codes to identify mental health visits: , , 99078, , , , , , , , , , 99411, 99412, 99510

3 Adult BMI Assessment (ABA) Chlamydia Screening (CHL) Women ages Breast Cancer Screening BCS) Women ages Cervical Cancer Screening (CCS) Women ages Documentation of weight and at least one BMI value during measurement year or year prior. Sexually active women ages should have at least one test for Chlamydia each year. Women ages should receive a mammogram screening every one or two years. Women ages receive Pap / cervical cancer screening at least once within every three years. ICD-9 codes: V85.0-V , 87270, 87320, , ICD-9 code: 87.36, , 88147, 88148, 88150, , , 88174, ICD-9 code: Colorectal Cancer Screening (COL) Adults ages Adults ages should be screened for colorectal cancer using any one of these three methods: Fecal occult blood test (FOBT) annually. Flexible sigmoidoscopy during the year 2012 or the four years prior to Colonoscopy during the year 2012 or the nine years prior to CPT codes commonly used for colorectal cancer screening but not limited to: FOBT: CPT 82270, Flexible Sigmoidoscopy: , , ICD-9 code: Colonoscopy: , 44397, 45355, , 45391, ICD-9 codes: 45.22, 45.23, 45.25, 45.42, Controlling High Blood Pressure (CBP) Adults ages Document blood pressure reading every visit for members ages 18 to 85 with a diagnosis of hypertension. Goal: <140 / 90 mm/hg

4 Comprehensive Diabetes Care (CDC) Adults ages Members ages years with diabetes (Type 1 and Type 2) should have the following: Hemoglobin A1c testing annually LDL-C screening annually Retinal or dilated exam by an optometrist/ ophthalmologist annually Nephropathy screening test annually Urine micro-albumin test Therapy with ACE inhibitor or ARB Blood pressure control Hba1c Testing (Goal: <7.0%) 83036, LDL-C Screening (Goal <100) 80061, 83700, 83701, 83704, Eye Exam 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , CPT Codes to Identify Nephropathy Screening Tests 82042, 82043, 82044, CPT Codes to Identify Macroalbumin Test , CPT Codes to Identify Evidence of Treatment for Nephropathy 36147, 36800, 36810, 36815, 36818, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, Use Category II to Identify Evidence of ACE Inhibitor / ARB Therapy (Goal <140 / 80) 4009F Follow-up after Hospitalization for Mental Illness (FUH) Ages 6 and older Glaucoma Screening in Older Adults (GSO) Ages 65 and older Member should have an outpatient visit follow-up with a mental health practitioner within seven days after discharge from the hospital. Members ages 65 and older should have a glaucoma eye exam by an eye care professional at least once within every two years. CPT Codes to Identify Mental Health Visits , , 99078, , , , , , , , , , 99411, 99412, CPT Codes for Glaucoma Screen 92002, 92004, 92012, 92014, , 92100, 92120, 92130, 92140, , ,

5 Care of Older Adults (COA) Ages 66 and older Members ages 66 and older should have each of the following done at least once a year: Advance care planning Medication review Functional status assessment Pain screening Advance Care Planning: 1157F, 1158F Codes to Identify Medication Review: 90862, 99605, Medication List: 1159F Functional Status Assessment: 1170F Medication Reconciliation Post Discharge (MRP) Ages 66 and older Members ages 66 and older should have medications reconciled on or within 30 days of discharge from hospital in an outpatient setting. Pain Screening: 0521F, 1125F, 1126F CPT Code Category II to Identify Medication Reconciliation: 1111F Prenatal and Postpartum Care: Prenatal and Postpartum Care (PPC) Frequency of Prenatal Care (FPC) Prenatal Care Initial Visit: Must occur within the first trimester or within 42 days (six weeks) of enrollment with the health plan. Ongoing Prenatal Care Frequency: Prenatal care visits should occur every four weeks during the first 28 weeks of pregnancy, every two to three weeks until the 36th week of pregnancy, and then every week until the baby is born. The American Council of Obstetricians and Gynecologists (ACOG) guidelines recommend 14 prenatal visits for a 40 week gestation. Example: If the member enrolled during her fourth month (three missed visits prior to enrollment in the organization), the expected number of visits is 14 3 =1.1. Postpartum Visit: Must occur between 21 to 56 days (three to eight weeks) after delivery. The member must meet criteria in Part A or in Part B and Part C. Part A: Any one code CPT: 59400*, 59425*, 59426*, 59510*, 59610*, 59618*, Part B: Any one code CPT: 76801, 76805, 76811, 76813, , ICD-9-CM Diagnosis: 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 ICD-9-CM Procedure: Part C: Any one code CPT: , , Postpartum Care 57170, 58300, 59400*, 59410*, 59430, 59510*, 59515*, 59610*, 59614*, 59618*, 59622*, , 88147, 88148, 88150, , , 88174, 88175, 99501