2016 Pcp Incentive award Program Measures & Tips

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1 2016 Pcp Incentive award Program Measures & Tips Adolescent Preventive Care (APC) Counseling on Depression Document and code assessment, counseling or education about depression for patients turning 12 to 17 years of age in Depression Assessment G F Use every visit as an opportunity to perform these assessments and vaccinate Consider utilizing PHQ-2/PHQ-9 screening tools and possibly build into existing EMR system. Adolescent Well-Care Visits (AWC) Document and code each visit separately, ensuring at least 1 comprehensive well-care visit with a PCP or OB/GYN at any point during the year for children/ adolescents turning years of age in Medical record must include the following documentation: 1. A health history 2. A physical developmental history 3. A mental developmental history 4. A physical exam 5. Health education/anticipatory guidance Dx Z Stress the importance of a well-child visit once a year. child and counsel parents/guardians Childhood Immunization Status (CIS) Combo 10 Health Exchange Plan Immunizations completed prior to a child turning 2 years of age in 2016 as follows: DTaP (4) PCV (4) Hep B (3) Hib (3) IPV (3) Rotavirus (2/3) VZV (1) Hep A (1) MMR (1) Influenza (2) The number in parentheses () represents the number of vaccinations required for completion. Requirements: Dates of immunizations are required for compliance. All events must occur 14 days apart (except MMR). DTaP, IPV, Hib, PCV, Rotavirus - Child must be 42 days old but <2 years old. Influenza: - Child must be 180 days (6 months) old, but <2 years old. Evidence Requirements Evidence of antigen or combination vaccine (for all vaccinations in measure) if MMR, Hep A/B, VZW, OR Documented history of illness, OR a seropositive test result for each antigen Immunization DTAP 90700, 90698, HEPB 90744, 90723, IPV 90698, 90713, VZV 90716, MMR 90707, PCV 90670, 90669, G0009 HIB 90648, 90698, Rotavirus HEPA FLU 90685, 90655, Send a claim for each visit AND for the related immunization. The vaccines in this measure are covered under the Vaccines for Children (VFC) program, therefore they will not be paid for; however, codes should be submitted with a $0 charge for compliance with quality measures. Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_FLY_28270_PCP IncentAwardPrgm 4/16

2 Follow-Up Care for Children Prescribed ADHD Medication (ADD) Initiation Phase Human Papillomavirus Vaccine for Female Adolescents (HPV) Health Exchange Plan Documentation of a follow-up visit with any practitioner with prescribing authority, within 30 days of when the first ADHD medication was dispensed for children turning 6-12 years of age in UBREV For female patients turning 13 years of age in 2016: 3 doses of HPV vaccine (with different dates of service) at any time on or between the patient s 9 th and 13 th birthdays. Document dates of immunizations. They are required in order to be compliant Collaboration between medical and behavioral health providers and pharmacists is vital for success. Arrange for follow-up visit within 2 weeks of first prescription. Stress importance of HPV vaccine before becoming sexually active to help prevent cancer. Immunizations for Adolescents (IMA) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) Well-Child Visits in the First 15 months of Life (W15) For patients turning 13 years of age in 2016: 1. On or between 11 th and 13 th birthdays: 1 meningococcal conjugate or polysaccharide vaccine AND 2. On or between 10 th and 13 th birthdays: 1 Tdap OR 1 Td OR 1 tetanus vaccine AND 1 diphtheria vaccine Document dates of immunizations. They are required in order to be compliant. TDAP Meningitis Documentation of the following for patients turning 3-17 years of age in 2016: 1. BMI percentile 2. Counseling for nutrition 3. Counseling for physical activity Include service and date in record BMI percentile Nutrition Physical Activity Z6851 (BMI <5th percentile for age) Z713 Z6852 (BMI 5th to <85th percentile) Z6853 (BMI 85th to <95th percentile) G0447 Z6854 (BMI >=95th percentile) G0270 S9451 G0447 S9470 For patients turning 15 months of age in 2016, document and code each visit with a PCP separately, ensuring six or more well-child visits from birth through 15 months old Dx Z Tdap and meningococcal vaccines can be given at the same time. Consider administering both vaccinations at the same time in opposite arms. Evidence of the antigen or combination vaccine is required for combination. The Tdap immunization is required for 6th grade entrance and, beginning in September 2016, the Meningococcal immunization will be required for 7th grade entrance. Use every visit as an opportunity to perform these assessments and vaccinate Schedule a well-child visit in advance and explain the plan of care to parents/ guardians. child. 2

3 Well-Child Visits in the Third, Fourth, Fifth and Sixth years of Life (W34) For patients turning 3-6 years of age in 2016: document and code each visit separately, ensuring a well visit with a PCP each year. Medical record must include the following documentation: 1. A health history 2. A physical developmental history 3. A mental developmental history 4. A physical exam 5. Health education/anticipatory guidance Dx Z Stress the importance of a well-child visit once a year. child and counsel parents/guardians Chlamydia Screening in Women (CHL) HIV/AIDS Comprehensive Care (HCC) Medication Management for People with Asthma (MMA) Breast Cancer Screening (BCS), Medicaid, At least 1 chlamydia test during 2016 for sexually active female patients turning years of age in Two outpatient visits for primary care or HIV-related care during 2016 with at least 1 visit January June and at least 1 more visit July December (Engaged in Care) AND Two viral load tests during 2016 with at least 1 viral load test January June and at least 1 more viral load test July December (Viral Load Monitoring) for patients with HIV/AIDS Examples of codes that meet compliance*: Engaged In Care AND Viral Load Monitoring *Note: Engaged in Care and Viral Load Monitoring are separate sub- measures. Each of the sub-measures requires 2 billed codes per year, per patient to be compliant. Ensure patients with persistent asthma turning 5 to 64 years of age in 2016 remain on an asthma controller medication for 75% of their treatment period (PDC 75%). *Note: this measure is based on pharmacy claims. 1 mammograms within the past 2 years for women turning years of age in HCPCS UBREV G Screen before providing a prescription for birth control pills. Primary care can be provided by all PCPs (family practice, internal medicine, pediatricians and OBGYN) as well as infectious disease providers. Educate patient or parents/guardians on difference between controller and reliever medications. Inhaled short acting beta agonists, systemic corticosteroids, and oral and nasal preparations are not compliant for controller medication prescribing. Educate patient on proper technique for inhalers. Enforce importance of adherence with patient. follow up with patient on completion of screening. Provide script for patient. Highlight the importance of early Assess and help patients overcome any potential barriers to screening. 3

4 Care for Older Adults (COA) Documentation of the following for patients turning 66 or older in 2016: 1. Medication review 2. Functional status assessment 3. Pain assessment Place completed assessments in patient s medical record. Functional status assessments should include BOTH activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Pain assessment with negative findings qualifies. Medication review must also include a complete medication list. COA Medication Review COA Medication Review COA Medication List 1160F* 1159F* 90863* G8427* 99495** 99496** 99606* *These codes need to be billed with a medication list code on the same DOS. **These codes are utilized for Transitional Care Management services. COA Functional Status Assessment 1170F COA Pain Assessment 1126F 1125F Use every visit as an opportunity to perform these assessments. Cervical Cancer Screening (CCS) Colorectal Cancer Screening (COL) Medicaid, Screening women turning years old in 2016 for cervical cancer with a cervical cytology exam every 3 years, OR: Screening women turning years old in 2016 with a cervical cytology exam and a human papillomavirus (HPV) test every 5 years Cervical cytology must be completed during the measurement period or the 2 years prior. Cervical cytology with HPV co-testing must be completed with service dates 4 days apart. Patients must be 30 years old on both dates of service. Cervical Cytology HPV Test Q For patients turning years of age in 2016: Fecal occult blood test (FOBT, gfobt, ifobt) annually, OR Flexible sigmoidoscopy during 2016 or during the 4 years prior to 2016, OR Colonoscopy during 2016 or during the 9 years prior to 2016 FOBT Flexible Sigmoidoscopy Colonoscopy G highlight the importance of early If a pap smear is done in the office and sent to the lab for cytology, please code for the collection and not the cytology code. follow up regarding its completion. Offer alternative methods of screening Provide script for patient. Highlight the importance of early Assess and help overcome any potential barriers to screening. 4

5 Comprehensive Diabetes Care (CDC) Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) For patients turning years of age in 2016: 1. HbA1c test (<7% or <8%= good control; 9%= poor control). 2. A retinal or dilated eye exam by an optometrist or ophthalmologist during 2016 or a negative retinal or dilated eye exam by an optometrist or ophthalmologist for retinopathy in Nephropathy: urine protein test, ACE/ARB prescription, evidence of treatment for nephropathy for patients with diabetes. Screening HbA1c Control 3044F (HbA1c Level < 7.0) 3045F (HbA1c Level ) 3046F (HbA1c Level > 9.0) Nephropathy Screening 82043, 82044, Eye Exam 92014, 92012, ambulatory prescription dispensed for a disease-modifying anti-rheumatic drug (DMARD) during 2016 for patients with rheumatoid arthritis turning 18 or older in DO NOT use RA code (e.g., M069, M0579, M0589) when ruling out/screening for RA Examples of codes to use for screening purposes: Screening Screening for other musculoskeletal condition (e.g., RA) Effusion of Joint Pain in joint Stiffness of Joint Difficulty in walking, not elsewhere classified Z M25.4X M25.5X M25.6X R26.2 DO NOT use diabetes code when ruling out/ screening for diabetes. Use specific code (Z13.1). HEDIS defines good control as <7% and <8%, based on population. Review chart for missing gaps in care. Discuss observed barriers. Management of Urinary Incontinence in Older Adults (MUI) Documentation of the following for patients turning 65 years of age or older in 2016: 1. Discussed their urinary leakage problem with a health care provider 2. Discussed treatment options for their current urine leakage problem 3. Reported that urine leakage made them change their daily activities or interfered with sleep Unspecified Urinary Incontinence Functional Urinary Incontinence R32 R39.81 Incorporate HOS questions into your visits: In the past six months, have you experienced leaking of urine? How much did leaking of urine make you change your daily activities or interfere with your sleep? Medication Adherence for Diabetes Medications (DIAB) Osteoporosis Management in Women Who Had a Fracture (OMW) Physical Activity in Older Adults (PAO) For patients turning 18 or older in 2016, ensure the patient takes and continues to take their medication for at least 80% of the treatment year (from therapy start date to the end of the measurement year). *Note: this measure is based on pharmacy claims. For female patients turning years of age in 2016: Bone mineral density (BMD) test within six months of fracture, OR Osteoporosis medication therapy within six months of fracture BMD Testing Documentation of the following for patients turning 65 and older in 2016: 1. Doctor s visit in the past 12 months 2. Received advice to start, increase or maintain their level of exercise or physical activity Exercise Counseling Counseling for diet and physical activity CPT/HCPCS Z71.89 G8780 Consider 90-day supply and encourage patient to use mail order pharmacy. Consider generics Review the importance of adherence with your patients. Encourage your patients to use pill reminder applications and organizers. Coordination between the medical health provider and pharmacist is vital for success. Check patient s medication history and document any osteoporosis medications. Incorporate HOS questions into your visits: In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? 5