AETNA BETTER HEALTH OF MISSOURI
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1 Aetna Better Health of Missouri 10 South Broadway, Suite 1200 St. Louis, MO AETNA BETTER HEALTH OF MISSOURI HEDIS Quick Reference Billing Guide 2014 Diagnosis and/or procedure codes to determine compliance with certain HEDIS measures Child/Adolescent measures Children and Adolescents Access to Primary Care Practitioners Percentage of members 12 months through 6 years of age who had a visit with a PCP during the measurement year and children and adolescents 7 through 19 years of age who had a visit with a PCP during the measurement year or the year prior to the measurement year. Visit procedure codes , , , , , , , , 99411, 99412, 99420, 99429, G0438, G0439 Diagnosis codes V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Annual Dental visit Percentage of members 2 years of age through 21 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the organizations Medicaid contract. CPT procedure codes 70300, 70310, 70320, 70350, HCPCS/CDT codes D0120-D0999, D1110-D2999, D3110-D3999, D4210-D4999, D5110- D5899, D6010-D6205, D7111-D7999, D8010-D8999, D9110-D9999 Well-child visit First 15 months of life Percentage of children who turned 15 months old during the year who had six or more well-child visits with a PCP or Pediatrician in their first 15 months of life. Diagnosis codes V20.2, V20.3, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Procedure codes 99382,, 99392,, G0438, G0439,99383, 99393, Adolescent well-care visits Percentage of members of age who had at least one comprehensive well-care visit with a PCP or OB/Gyn during the year. Diagnosis codes V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Procedure codes , , G0438, G0439 Childhood immunizations Percentage of children 2 yrs old who have received the following vaccinations: (4)DtaP/DT; (3)IPV; (1)MMR; (3 ) Hib; (3) Hep B; (1)VZV; (4) Pneumococcal conjugate; (1) Hep A; (2 or 3) Rotavirus; and (2) Influenza vaccines
2 Immunization CPT/HCPCS Diagnosis codes* DtaP 90698, 90700, 90721, IPV 90698, 90713, MMR 90707, Measles and rubella Measles , 055.1, 055.2, 055.7, , , 055.8, Mumps , 072.1, 072.2, 072.3, 072.7, , ,072.79, 072.8, 072.9, Rubella , , , , 056.7, , , 056.8, 056.9, HiB , 90698, 90721, Hepatitis B 90723, 90740, 90744, 90747, 90748,G0010 V02.61, , , , , , , VZV 90710, , 052.1, 052.2, 052.7, 052.8, 052.9, 053.0, 053.1, , , , , , , , , , , , , 053.8, Pneumococcal 90669, 90670, G0009 Conjugate Hepatitis A , Rotavirus (2 dose schedule) Rotavirus (3 dose schedule) Influenza 90655, 90657, 90661, 90662, G0008 *Indicates evidence of disease. A member who has evidence of disease during the numerator event time is compliant for the antigen. Lead Screening in children Percentage of children 2 years of age who had 1 or more lead blood test for lead poisoning by their 2nd birthday. Procedure codes Adolescent Immunizations Percentage of children age 13, who received the following vaccines: 1 meningococcal & 1 tetanus, diphtheria toxoids, acellular pertussis (TdaP), or 1 tetanus, diphtheria (Td). Immunization CPT codes Meningococcal 90733, TdaP Td 90714, Tetanus Diphtheria 90719
3 Human Pappilomavirus Vaccine for female adolescents (HPV) Percentage of female adolescents 13 yrs of age who had 3 does of the HPV vaccine by their 13th birthday. Procedure codes 90649, Weight Assessment & Counseling for Nurtition and Physical activity for children/adolescents Percentage of members age 3-17 who had an outpatient visit with a PCP or OB/GYN during the year, who had their BMI (value AND percentile required) documented and counseling for nutrition and physical activity. Diagnostic codes Procedure codes BMI V85.0 BMI percentile V85.51, V85.52, V85.53, V85.54 Counseling for nutrition V , G0270, G0271, G0447, S9449, S9452, S9470 V65.41 G0447, S9451 Counseling for physical activity Follow-Up Care for Children Prescribed ADHD Medication Percentage of children newly prescribed ADHD medication who had at least 3 follow-up visits with a 10 month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported: 1. Initiation Phase-percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase; 2. Continuation and Maintenance Phase-percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, remained on the medication for at least 210 days and who, in addition to the Initiation Phase visit, had at least two follow-up visits with a practitioner within 270 days after the Initiation Phase ended. Diagnosis codes , , 298.0, 311 Visit Procedure codes , , , 99078, , , , , , , , , , ,99411, 99412, 99510, G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010- H2020, M0064, S0201, S9480, S9484, S9485 Visit Procedure codes 90791, 90792, 90801, 90802, , , , , ,90845, 90847, 90849, 90853, 90857, 90862, 90875,90876 Visit Procedure codes , , 99238, 99239, With POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33, 49, 50, 71, 72 With POS 52, 53 Available on NCQA website at Appropriate testing for children with Pharyngitis Percentage of children 2 to 18 years of age who were diagnosed with Pharyngitis, dispensed an antibiotic, and received a group A streptococcus test.
4 Diagnosis codes 460, 465 Procedure codes 87070, 87071, 87081, 87430, , Visit procedure codes , , , , ,, , , 99411, 99412, 99420, 99429, 99455,99456, G0402, G0438, G0439 Appropriate testing for children with Upper Respiratory infection Percentage of children 3 months to 18 years of age with a diagnosis of URI and were not dispensed an antibiotic prescription. Diagnosis codes 460, 463, 465, Visit procedure codes , , , , , , , 99411, 99412, 99420, 99429, 99455,99456, G0402, G0438, G0439 Women s measures Breast Cancer screening Percentage of women years who had a mammogram during the measurement year or the year prior. Procedure codes , G0202, G0204, G0206 Cervical Cancer screening Percentage of women years who received 1 or more pap tests during the year or the 2 years prior to the measurement year. Procedure codes , 88147, 88148, 88150, , ,88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 HPV procedure codes 87620, 87621, Chlamydia screening Percentage of women years who were identified as sexually active who had at least one test for Chlamydia during the measurement year. Procedure codes 87110, 87270, 87320, , Prenatal care Percentage of pregnant women who received a prenatal care visit in the first trimester or within 42 days of enrollment. Procedure codes 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620,59622, 59425, 59426, 76801, 76805, 76811, 76813, , ,80055, 86644, 84494, 86695, 86696, 86762, 86777, 86900, 86901, , , , 99500, 0500F, 0501F, 0502F, H1000, H1001, H1002, H1003, H1004, H1005 Diagnosis codes 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3,
5 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, , 658.x3, 659.x3, 678.x3, 679.x3, V22- V23, V28 Postpartum care Percentage of women who had a postpartum care on or between 21 & 56 days after delivery. Diagnosis codes V24.1, V24.2, V25.1, V72.3, V76.2 Procedure codes 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622, 59430,57170, 58300, , 88147, 88148, 88150, , , 88174, 88175, 99501, 0503F, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 Frequency of Ongoing Prenatal Care Percentage of deliveries who had the following number of expected prenatal care visits: <21% of expected visits, 21%-40% of expected visits, 41%-60% of expected visits, 61%-80% of expected visits, 81% of expected visits. Diagnosis codes V22-V23, V28, 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 Procedure codes 59400, 59510, 59610, 59618, 59425, 59426, 76801, 76805, 76811, 76813, , , 80055, 86644, , 86762, 86777, 86900, 86901, , , , 99500, 0500F, 0501F, 0502F, H1000, H1001, H1002, H1003, H1004,H1005 Adult measures Adults Access to Preventive/Ambulatory health services Percentage of members 20 years of age and older who had an ambulatory ore preventive care visit during the measurement year. Visit procedure codes , , , , , 99411, 99412,99420, 99429, , 99315, 99316, 99318, , , 92002, 92004, 92012, 92014, G0402, G0438, G0439, S0620, S0621 Diagnosis codes V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Adult Body Mass Index (BMI) Assessment Percentage of adults age who had an outpatient visit during the measurement year or the year prior and who had their BMI documented. Diagnosis codes V V85.5 Procedure codes , , , , , , , , 99411, 99412, 99420, 99429,
6 99455, 99456, G0402, G0438, G0439 Diabetes care Percentage of members with diabetes who had each of the following: HbA1C testing; eye exam; LDL-C; screening for diabetic nephropathy monitoring, & blood pressure reading. Diagnostic codes to identify Diabetes 250, 357.2, 362.0, , HbA1c procedure code 83036, 83037, 3044F, 3045F, 3046F LDL-C - procedure codes 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F Eye Exam - procedure codes Must be done by an eye care professional 67028, 67030, 67031, 67036, , 67101, 67105, 67107,67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210,67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014,92018, 92019, 92134, , 92230, 92235, 92240, 92250,92260, , , , S0620, S0621, S F, 2022F, 2024F, 2026F, S0625 Nephropathy Screening Tests 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156,3060F, 3061F, 3062F Blood Pressure Screening CPT II codes Systolic: 3074F, 3075F, 3077F Diastolic: 3078F, 3079F, 3080F Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis not dispensed an antibiotic prescription. Diagnosis codes Visit procedure codes , , , , , , , , 99411, 99412, 99420, 99429, 99455,99456, G0402, G0438, G0439 Use of Appropriate Medications for People With Asthma Percentage of members 5 to 64 years of age who were identified as having persistent asthma and were appropriately prescribed medication. Diagnosis codes 493.0, 493.1, 493.8, Visit procedure codes , , , , 99238,99239, , , 99291, , , , , , 99411, 99412,99420, 99429, 99455, 99456, , G0402, G0438, G0439 Use of Imaging Studies for Low Back Pain Percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis. Diagnosis codes 721.3, , , , , , ,
7 724.2, 724.3,724.5, 724.6, 724.7, 738.5, 739.3, 739.4, 846, Visit procedure codes , , , , , , , 99411, 99412,99420, 99429, 99455, 99456, , G0402, G0438, G0439 Imaging Procedure codes 72010, 72020, 72052, 72100, 72110, 72114, 72120, ,72141, 72142, , 72156, 72158, 72200, 72202, Antidepressant Medication Management Percentage of members 18 and older with a diagnosis of major depression and were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: HEDIS Volume 2 Technical Specifications 2014 reported: 1. Effective Acute Phase Treatment-remained on an antidepressant medication for at least 84 days; 2. Effective Continuation Phase Treatment-remained on antidepressant medication for 180 days. Diagnosis codes , , 298.0, 311 Visit procedure codes , , 99078, , , , , , , , , , , ,99411, 99412, 99510, G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010- H2020, M0064, S0201, S9480, S9484, S9485 Visit procedure codes 90791, 90792, 90801, 90802, , , , , ,90845, 90847, 90849, 90853, 90857, 90862, 90870,90875, 90876, , , 99238, 99239, With POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72
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