UnitedHealth Premium Physician Designation Program Codes and Medications Demonstrating Compliance with Nationally Endorsed Quality Measures

Transcription

1 UnitedHealth Premium Physician Designation Program s and Medications Demonstrating Compliance with Nationally Endorsed Quality Measures Introduction This document is a reference for use during the online UnitedHealth Premium designation program s reconsideration process to determine if a patient met the clinical standards for measures indicated as non-compliant. This document is specifically referenced within the Reconsideration Quality Worksheet and the online Quality tab screen for nationally endorsed quality measures. Refer to this document for codes and medications that demonstrate compliance with these measures. The document is organized alphabetically by condition and then by measure. Each measure includes a list and description of billing codes and/or medications that satisfy the compliance criteria. The list for each measure may include medications and the following code types as applicable: ICD-9 HCPCS LOINC RVNU POS Definition Current Procedural Terminology () is coding used to describe medical services and procedures. A three to five digit number code describing a diagnosis or medical procedure. The Healthcare Common Procedure Coding System (HCPCS) is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (). Logical Observation Identifiers Names and s (LOINC) are a database and universal standard for identifying medical laboratory observations. s used to identify specific accommodations, ancillary services and billing calculations used by facilities as determined by the National Uniform Billing Committee. Place of Service (POS) s are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Additional helpful definitions: Measure Source ID Symmetry EBM Connect Case ID or Symmetry Procedure Episode Group (PEG ) anchor category ID Rule ID Reference number for Symmetry EBM Connect rules. Note: You may also want to refer to the Evidence-Based Medicine (EBM) Synopses (Pathway: UnitedHealthcareOnline.com > UnitedHealth Premium > Premium Reconsideration > Reconsideration Resources.)

2 Table of Contents Acute Myocardial Infarction (AMI)...3 ADHD...4 Alcohol and Other Drug Dependence Treatment...15 Antidepressant Medical Management...29 Asthma...30 Avoidance of Antibiotic Treatment in adults with Acute Bronchitis...34 Breast Cancer Screening...35 Cardiovascular Disease...36 Cervical Cancer Screening...37 Chlamydia Screening Congestive Heart Failure...42 Coronary Artery Disease...47 Diabetes...50 Diabetes Mellitus...52 Diabetic Retinopathy (NS)...53 Glaucoma Screening...54 Medication Safety Monitoring...57 Migraine Headache...64 Osteoporosis Management...65 Pharyngitis...67 Pregnancy Management...68 Rheumatoid Arthritis...69 Upper Respiratory Infection (Pediatric)...70 Use of Appropriate Imaging for Back Pain...71 Table of Contents 2

3 Acute Myocardial Infarction (AMI) Measure Source (Case) ID: Measure: Medication Patient(s) hospitalized with an acute myocardial infarction (AMI) persistently taking a betablocker for six months after discharge. (Rule ID: ) Acebutolol hydrochloride Atenolol Bendroflumethiazide-nadolol Betapace Betapace AF Betaxolol Blocadren Bystolic Cartrol Carvedilol Coreg Corgard Corzide Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Inderal Inderide InnoPran XL Kerlone Levatol Lopressor Metoprolol succinate ER Metoprolol tartrate Nadolol Normodyne Pindolol Propranolol hydrochloride Sectral Sorine Sotalol hydrochloride Tenoretic Tenormin Timolide Timolol maleate Toprol-XL Trandate Zebeta Ziac Acute Myocardial Infarction (AMI) 3

4 ADHD Measure Source (Case) ID: Measure: Measure: Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription. (Rule ID: ) Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription AND two followup visits during the 31 days through 300 days after the initial. (Rule ID: ) Description Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; ADHD 4

5 Description Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Psychoanalysis Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy ADHD 5

6 Description Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; individual Health and behavior intervention, each 15 minutes, face-to-face; group (two or more patients) Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; two to four patients Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; five to eight patients Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) 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 with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. ADHD 6

7 Description 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes faceto-face with the patient and/or family 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 are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family 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." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, as appropriate.]) ADHD 7

8 Description Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. ADHD 8

9 Description Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit. ADHD 9

10 Description Inpatient consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit Follow-up inpatient consult Follow-up inpatient consult Follow-up inpatient consult Home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three 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 with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-toface with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. ADHD 10

11 Description Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/ or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes face-to-face with the patient and/or family 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 laboratory/diagnostic procedures, new patient; late childhood (age 5 through 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 laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 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 laboratory/diagnostic procedures, established patient; late childhood (age 5 through 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 laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes ADHD 11

12 Description 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 Home visit for individual, family, or marriage counseling HCPCS G0155 G0176 G0177 H0002 H0004 H0031 H0034 H0035 H0036 H0037 H0039 H0040 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 ADHD Description Services of clinical social worker in home health setting, each 15 minutes Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) Behavioral health screening to determine eligibility for admission to treatment program Behavioral health counseling and therapy, per 15 minutes Mental health assessment, by non-physician Medication training and support, per 15 minutes Mental health partial hospitalization, treatment, less than 24 hours Community psychiatric supportive treatment, face-to-face, per 15 minutes Community psychiatric supportive treatment program, per diem Assertive community treatment, face-to-face, per 15 minutes Assertive community treatment program, per diem Comprehensive multidisciplinary evaluation Rehabilitation program, per 1/2 day Comprehensive medication services, per 15 minutes Crisis intervention service, per 15 minutes Behavioral health day treatment, per hour Psychiatric health facility service, per diem Skills training and development, per 15 minutes Comprehensive community support services, per 15 minutes Comprehensive community support services, per diem Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Therapeutic behavioral services, per 15 minutes 12

13 HCPCS H2020 M0064 S0201 S9480 S9484 S9485 Description Therapeutic behavioral services, per diem Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders Partial hospitalization services, less than 24 hours, per diem Intensive outpatient psychiatric services, per diem Crisis intervention mental health services, per hour Crisis intervention mental health services, per diem Description RVNU 0510 Clinic-General 0513 Clinic-Psychiatric Clinic 0515 Clinic-Pediatric Clinic 0516 Clinic-Urgent Care Clinic 0517 Clinic-Family Practice Clinic 0519 Clinic-Other Clinic 0520 Freestanding Clinic-General 0521 Freestanding Clinic-Clinic visit by member to RHC/FQHC 0522 Freestanding Clinic-Home visit by RHC/FQHC Practitioner 0523 Freestanding Clinic-Family Practice Clinic 0526 Freestanding Clinic-Urgent Care Clinic 0527 Freestanding Clinic-Visiting Nurse Service (s) to a Member's Home When in a Home Health Shortage Area 0528 Freestanding Clinic-Visit by RHC/FQHC Practitioner to Other Non-RHC/FQHC Site (e.g. Scene of Accident) 0529 Freestanding Clinic-Other Freestanding Clinic 0770 Preventive Care Services-General 0771 Preventive Care Services-Vaccine Administration 0779 Preventive Care Services-Other Preventive Care Services 0900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-General 0902 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Milieu Therapy 0903 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Play Therapy 0904 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Activity Therapy 0905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Psychiatric 0907 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Community Behavioral Health Program (Day Treatment) 0911 Behavioral Health Treatments/Services-Extension of 090X-Rehabilitation 0912 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Less Intensive ADHD 13

14 RVNU Description 0913 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Intensive 0914 Behavioral Health Treatments/Services-Extension of 090X-Individual Therapy 0915 Behavioral Health Treatments/Services-Extension of 090X-Group Therapy 0916 Behavioral Health Treatments/Services-Extension of 090X-Family Therapy 0917 Behavioral Health Treatments/Services-Extension of 090X-Bio Feedback 0919 Behavioral Health Treatments/Services-Extension of 090X-Other Behavioral Health Treatments/ Services 0982 Professional Fees (Extension of 096X and 097X)-Outpatient Services 0983 Professional Fees (Extension of 096X and 097X)-Clinic Description POS 03 Education Facility 05 Indian Health Service Free-Standing Facility 07 Tribal 638 Free-Standing Facility 09 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 22 Outpatient Hospital 33 Custodial Care Facility 49 Independent Clinic 50 Federally Qualified Health Center 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 71 State or Local Public Health Clinic 72 Rural Health Clinic ADHD 14

15 Alcohol and Other Drug Dependence Treatment Measure Source (Case) ID: Measure: Patients between the ages of 13 and 17 who initiated AOD treatment. (Rule ID: ) Measure: Patient(s) between the ages of 13 and 17 who engaged in AOD treatment. (Rule ID: ) Measure: Patient(s) age 18 years or older who initiated AOD treatment. (Rule ID: ) Measure: Patient(s) age 18 years or older who engaged in AOD treatment. (Rule ID: ) Description ICD Alcohol-induced mental disorders Alcohol withdrawal delirium Alcohol-induced persisting amnestic disorder Alcohol-induced persisting dementia Alcohol-induced psychot disorder w/hallucination Idiosyncratic alcohol intoxication Alcohol-induced psychotic disorder w/delusions Other specified alcohol-induced mental disorders Alcohol withdrawal Alcohol induced sleep disorders Other specified alcohol-induced mental disorders Unspecified alcohol-induced mental disorders 292 Drug-induced mental disorders Drug withdrawal Paranoid & or hallucinatory states induced drugs Drug-induced psychotic disorder with delusions Drug-induced psychotic disorder w/hallucinations Pathological drug intoxication Other specified drug-induced mental disorders Drug-induced delirium Drug-induced persisting dementia Drug-induced persisting amnestic disorder Drug-induced mood disorder Drug induced sleep disorders Other specified drug-induced mental disorder Unspecified drug-induced mental disorder Acute alcoholic intoxication unspec drunkenness Acute alcoholic intoxication cont drunkenness Alcohol and Other Drug Dependence Treatment 15

16 Description ICD Acut alcoholic intoxication episodic drunkenness Oth & unspec alcohol dependence unspec drunkenness Other & unspec alcohol dependence cont drunkenness Oth & unspec alcohol depend episodic drunkenness Opioid type dependence unspecified abuse Opioid type dependence continuous abuse Opioid type dependence episodic abuse Sedative hypnotic/anxiolytic dependence unspec Sedative hypnotic/anxiolytic dependence cont Sedative hypnotic/anxiolytic dependence episodic Cocaine dependence unspecified abuse Cocaine dependence continuous abuse Cocaine dependence, episodic abuse Cannabis dependence unspecified abuse Cannabis dependence continuous abuse Cannabis dependence, episodic abuse Amphet & oth psychostimulant dependence unspec abs Amphet & oth psychostimulant dependence cont abs Amphet & oth psychostimulant depend episodic abs Hallucinogen dependence unspecified abuse Hallucinogen dependence continuous abuse Hallucinogen dependence episodic abuse Other spec drug dependence unspec abuse Other specified drug dependence continuous abuse Other specified drug dependence episodic abuse Comb opioid rx w/any oth rx depend unspec abs Comb opioid drug w/any oth drug depend cont abs Comb opioid rx w/any oth rx depend episodic abs Comb drug depend excld opioid drug unspec abs Comb drug depend excluding opioid drug cont abs Comb drug depend excld opioid drug episodic abs Unspecified drug dependence unspecified abuse Unspecified drug dependence continuous abuse Unspecified drug dependence episodic abuse Nondependent alcohol abuse unspec drunkenness Nondependent alcohol abuse cont drunkenness Nondependent alcohol abuse episodic drunkenness Alcohol and Other Drug Dependence Treatment 16

17 Description ICD Nondependent cannabis abuse unspecified Nondependent cannabis abuse continuous Nondependent cannabis abuse episodic Nondependent hallucinogen abuse unspecified Nondependent hallucinogen abuse continuous Nondependent hallucinogen abuse episodic Nondepend sedative hypnot/anxiolytic abs unspec Nondepend sedative hypnotic/anxiolytic abs cont Nondepend sedat hypnot/anxiolytic abs episodic Nondependent opioid abuse unspecified Nondependent opioid abuse continuous Nondependent opioid abuse, episodic Nondependent cocaine abuse unspecified Nondependent cocaine abuse continuous Nondependent cocaine abuse episodic Nondepend amphet/rel act sympathomimet abs uns Nondepend amphet/rel act sympathomimet abs cont Amphetamine/related drug abuse-episodic Nondependent antidepressant type abuse unspec Nondependent antidepressant type abuse cont Nondependent antidepressant type abuse episodic Oth mixed/unspec nondependent drug abuse unspec Other mixed/unspec nondependent drug abuse cont Oth mixed/unspec nondependent drug abs episodic Alcoholic gastritis Alcoholic gastritis without mention hemorrhage Alcoholic gastritis with hemorrhage Acute alcoholic hepatitis Description Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 17

18 Description Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 18

19 Description Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Psychoanalysis Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately minutes Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 2-4 patients Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 5-8 patients Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) Alcohol and Other Drug Dependence Treatment 19

20 Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family 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, five minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Alcohol and Other Drug Dependence Treatment 20

21 Description Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family 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." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, as appropriate.]) Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. Alcohol and Other Drug Dependence Treatment 21

22 Description Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family. Alcohol and Other Drug Dependence Treatment 22

23 Description Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit Follow-up inpatient consult Follow-up inpatient consult Follow-up inpatient consult Home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. Alcohol and Other Drug Dependence Treatment 23

24 Description Home visit for the evaluation and management of a new patient, which requires these three 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 with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-toface with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least 2 of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Home visit for the evaluation and management of an established patient, which requires at least 2 of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/ or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes face-to-face with the patient and/or family. Alcohol and Other Drug Dependence Treatment 24

25 Description 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 laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, new patient; 65 years and older 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 laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, established patient; 65 years and older 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 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 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 Home visit for individual, family, or marriage counseling Alcohol and Other Drug Dependence Treatment 25

26 HCPCS G0155 G0176 G0177 G0396 G0397 H0001 H0002 H0004 H0005 H0007 Description Services of clinical social worker in home health setting, each 15 minutes Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Alcohol and/or drug assessment Behavioral health screening to determine eligibility for admission to treatment program Behavioral health counseling and therapy, per 15 minutes Alcohol and/or drug services; group counseling by a clinician Alcohol and/or drug services; crisis intervention (outpatient) H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least three days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education H0016 H0020 H0022 H0031 H0034 H0035 H0036 H0037 H0039 H0040 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) Alcohol and/or drug intervention service (planned facilitation) Mental health assessment, by nonphysician Medication training and support, per 15 minutes Mental health partial hospitalization, treatment, less than 24 hours Community psychiatric supportive treatment, face-to-face, per 15 minutes Community psychiatric supportive treatment program, per diem Assertive community treatment, face-to-face, per 15 minutes Assertive community treatment program, per diem Comprehensive multidisciplinary evaluation Rehabilitation program, per 1/2 day Comprehensive medication services, per 15 minutes Crisis intervention service, per 15 minutes Behavioral health day treatment, per hour Psychiatric health facility service, per diem Skills training and development, per 15 minutes Comprehensive community support services, per 15 minutes Comprehensive community support services, per diem Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Therapeutic behavioral services, per 15 minutes Alcohol and Other Drug Dependence Treatment 26

27 HCPCS H2020 H2035 H2036 M0064 S0201 S9480 S9484 S9485 T1006 T1012 Description Therapeutic behavioral services, per diem Alcohol and/or other drug treatment program, per hour Alcohol and/or other drug treatment program, per diem Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders Partial hospitalization services, less than 24 hours, per diem Intensive outpatient psychiatric services, per diem Crisis intervention mental health services, per hour Crisis intervention mental health services, per diem Alcohol and/or substance abuse services, family/couple counseling Alcohol and/or substance abuse services, skills development Description RVNU 0510 Clinic-General 0513 Clinic-Psychiatric Clinic 0515 Clinic-Pediatric Clinic 0516 Clinic-Urgent Care Clinic 0517 Clinic-Family Practice Clinic 0519 Clinic-Other Clinic 0520 Freestanding Clinic-General 0521 Freestanding Clinic-Clinic visit by member to RHC/FQHC 0522 Freestanding Clinic-Home visit by RHC/FQHC Practitioner 0523 Freestanding Clinic-Family Practice Clinic 0526 Freestanding Clinic-Urgent Care Clinic 0527 Freestanding Clinic-Visiting Nurse Service (s) to a Member's Home When in a Home Health Shortage Area 0528 Freestanding Clinic-Visit by RHC/FQHC Practitioner to Other Non-RHC/FQHC Site (e.g. Scene of Accident) 0529 Freestanding Clinic-Other Freestanding Clinic 0770 Preventive Care Services-General 0771 Preventive Care Services-Vaccine Administration 0779 Preventive Care Services-Other Preventive Care Services 0900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-General 0902 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Milieu Therapy 0903 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Play Therapy 0904 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Activity Therapy 0905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Psychiatric Alcohol and Other Drug Dependence Treatment 27

28 RVNU Description 0906 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Chemical Dependency 0907 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Community Behavioral Health Program (Day Treatment) 0911 Behavioral Health Treatments/Services-Extension of 090X-Rehabilitation 0912 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Less Intensive 0913 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Intensive 0914 Behavioral Health Treatments/Services-Extension of 090X-Individual Therapy 0915 Behavioral Health Treatments/Services-Extension of 090X-Group Therapy 0916 Behavioral Health Treatments/Services-Extension of 090X-Family Therapy 0917 Behavioral Health Treatments/Services-Extension of 090X-Bio Feedback 0919 Behavioral Health Treatments/Services-Extension of 090X-Other Behavioral Health Treatments/ Services 0944 Other Therapeutic Services (see also 095X, an extension of 094X)-Drug Rehabilitation 0945 Other Therapeutic Services (see also 095X, an extension of 094X)-Alcohol Rehabilitation 0982 Professional Fees (Extension of 096X and 097X)-Outpatient Services 0983 Professional Fees (Extension of 096X and 097X)-Clinic Description POS 03 Education Facility 05 Indian Health Service Free-Standing Facility 07 Tribal 638 Free-Standing Facility 09 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 22 Outpatient Hospital 33 Custodial Care Facility 49 Independent Clinic 50 Federally Qualified Health Center 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 57 Non-residential Substance Abuse Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic Alcohol and Other Drug Dependence Treatment 28

29 Antidepressant Medical Management Measure Source (Case) ID: Measure: Measure: Medication Patient(s) with a new episode of major depression that remained on an antidepressant medication during the initial 12-week acute treatment phase. (Rule ID: ) Patients with a new episode of major depression that remained on an antidepressant medication during the 6 month acute treatment phase. (Rule ID: ) Amitriptyline Hydrochloride Amitriptyline-Chlordiazepoxide Amitriptyline-Perphenazine Amoxapine Anafranil Aventyl HCl Budeprion SR Budeprion XL BuPROPion Hydrochloride BuPROPion Hydrochloride SR BuPROPion Hydrochloride XL Celexa Citalopram Hydrobromide ClomiPRAMINE Hydrochloride Cymbalta Desipramine Hydrochloride Desyrel Desyrel Dividose Doxepin Hydrochloride Duo-Vil 2-10 Duo-Vil 2-25 Duo-Vil 4-10 Effexor Effexor XR Elavil Emsam Etrafon 2-10 Etrafon 2-25 Etrafon Forte Fluoxetine Hydrochloride Fluvoxamine Maleate Imipramine Hydrochloride Imipramine Pamoate Lexapro Limbitrol Limbitrol DS Luvox Luvox CR Maprotiline Hydrochloride Marplan Mirtazapine Nardil Nefazodone Hydrochloride Norpramin Nortriptyline Hydrochloride Pamelor Parnate Paroxetine Hydrochloride Paroxetine Hydrochloride ER Paxil Paxil CR Pexeva Pristiq Protriptyline Hydrochloride Prozac Prozac Weekly Rapiflux Remeron Remeron SolTab Sarafem Selfemra Sertraline Hydrochloride Serzone Sinequan Surmontil Symbyax Tofranil Tofranil-PM Tranylcypromine Sulfate TraZODONE Hydrochloride Triavil Trimipramine Maleate Vanatrip Venlafaxine Hydrochloride Vivactil Wellbutrin Wellbutrin SR Wellbutrin XL Zoloft Antidepressant Medical Management 29

30 Asthma Measure Source (Case) ID: Measure: Patients 5-40 years of age with asthma who had frequency of daytime and nocturnal asthma symptoms assessed in the last 12 months. (Rule ID: ) 1005F Description Asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/survey/questionnaire) (Asthma) Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Asthma 30

31 Description Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family 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 laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Asthma 31

32 Description 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 laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, new 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 laboratory/diagnostic procedures, established patient; late childhood (age 5 through 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 laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, established patient; years Asthma 32

33 Asthma Measure Source (Case) ID: Measure: Measure: Measure: Patient(s) between the ages of 5 and 9 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative. (Rule ID: ) Patient(s) between the ages of 10 and 17 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative. (Rule ID: ) Patient(s) between the ages of 18 and 56 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative. (Rule ID: ) Medication Accolate Advair AeroBid AeroBid-M Aminophylline Asmanex Twisthaler Azmacort Beclovent Bronchial Choledyl SA Cromolyn sodium D-G Difil Dilex-G Dilor Dyfilin GG Dyflex-G Dy-G Dyline GG Dylix Dyphylline Dyphylline-Guaifenesin Dyphyllin-GG Dyphysin Ed-Bron G Elixophyllin Equibron G Flovent Intal Intal Inhaler Jay-Phyl Lufyllin Neothylline Panfil G Pulmicort Flexhaler Pulmicort Respules Pulmicort Turbuhaler Quibron Qvar Singulair Symbicort Theo-24 TheoCap Theochron Theo-Dur Theolair Theolate Theophylline Theo-Time Theo-X Tilade T-Phyl Truxophyllin Uni-Dur Uniphyl Vanceril Xolair Zyflo Asthma 33

34 Avoidance of Antibiotic Treatment in adults with Acute Bronchitis Measure Source (Case) ID: Measure: No compliance criteria Patients with diagnosis of Acute Bronchitis that did not receive a prescription for an antibiotic on or three days after the initiating visit. (Rule ID: ) Avoidance of Antibiotic Treatment in adults with Acute Bronchitis 34

35 Breast Cancer Screening Measure Source (Case) ID: Measure: Patient(s) years of age that had a screening mammogram in last 24 reported months. (Rule ID: ) Description Mammogram, one breast Mammogram, both breasts Mammogram, screening Mammography; unilateral Mammography; bilateral Screening mammography, bilateral (view film study of each breast) Description ICD Xerography of breast Other mammography V76.11 Screening for Mammogram for High-Risk patient V76.12 Other Screening Mammogram HCPCS G0202 G0204 G0206 Description Screening mammography, producing direct digital image, bilateral, all views Diagnostic mammography, producing direct digital image, bilateral, all views Diagnostic mammography, producing direct digital image, unilateral, all views Description RVNU 401 Other Imaging Services-Diagnostic Mammography 403 Other Imaging Services-Screening Mammography Breast Cancer Screening 35

36 Cardiovascular Disease Measure Source (Case) ID: Measure: Patients with an LDL cholesterol test in the last 12 reported months. (Rule ID: ) Description 3048F Most recent LDL-C less than 100 mg/dl (DM) 3049F Most recent LDL-C mg/dl (DM) 3050F Most recent LDL-C greater than or equal to 130 mg/dl (DM) Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) Lipoprotein, blood; electrophoretic separation and quantitation Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy) Lipoprotein, direct measurement; LDL cholesterol Description LOINC Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Lipid HCFA 1996 panel Cholesterol.in LDL Cholesterol.in LDL Cardiovascular Disease 36

37 Cervical Cancer Screening Measure Source (Case) ID: Measure: Patient(s) that had a cervical cancer screening test in last 36 reported months. (Rule ID: ) Description Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision Cytopathology, slides, cervical or vaginal; manual screening under physician supervision Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code[s] for other technical and interpretation services) Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computerassisted rescreening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computerassisted rescreening using cell selection and review under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision Cervical Cancer Screening 37

38 Description LOINC Microscopic observation Microscopic observation General categories Statement of adequacy Microscopic observation Microscopic observation Cytology study comment Study report Cytology report Cytology report Description ICD Cell block and Papanicolaou smear of specimen from female genital tract V72.32 Encounter PAP Cerv Smer Confirm NL Ser FLWABN V76.2 Screening for Malignant Neoplasm of Cervix HCPCS G0123 G0124 G0141 G0143 G0144 G0145 G0147 G0148 P3000 Description Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision Cervical Cancer Screening 38

39 HCPCS P3001 Q0091 Description Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory Description RVNU 0923 Other Diagnostic Services-Pap Smear Cervical Cancer Screening 39

40 Chlamydia Screening Measure Source (Case) ID: Measure: Measure: Patient(s) years of age that had a chlamydia screening test in last 12 reported months. (Rule ID: ) Patient(s) years of age that had a chlamydia screening test in last 12 reported months. (Rule ID: Description Culture, chlamydia, any source Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis Description LOINC Chlamydia sp identified Chlamydia sp identified Chlamydia trachomatis rrna Chlamydia trachomatis Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis DNA Chlamydia trachomatis DNA Chlamydia trachomatis Chlamydia trachomatis Chlamydia trachomatis Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis rrna Chlamydia Screening 40

41 Description LOINC Chlamydia trachomatis rrna Chlamydia trachomatis DNA Chlamydia trachomatis DNA Chlamydia trachomatis DNA Chlamydia trachomatis rrna Chlamydia trachomatis DNA Chlamydia trachomatis rrna Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis Ag Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis rrna Chlamydia trachomatis rrna Chlamydia trachomatis DNA Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis+neisseria gonorrhoeae rrna Chlamydia trachomatis+neisseria gonorrhoeae DNA Chlamydia trachomatis+neisseria gonorrhoeae rrna Chlamydia trachomatis+neisseria gonorrhoeae rrna Chlamydia trachomatis+neisseria gonorrhoeae rrna Chlamydia trachomatis+neisseria gonorrhoeae rrna Chlamydia trachomatis rrna Chlamydia trachomatis rrna Chlamydia trachomatis DNA Chlamydia trachomatis Ag Chlamydia trachomatis Chlamydia sp identified Chlamydia sp identified Chlamydia trachomatis L2 DNA Chlamydia trachomatis DNA Chlamydia trachomatis DNA Chlamydia trachomatis rrna Chlamydia Screening 41

42 Congestive Heart Failure Measure Source (Case) ID: Measure: 4009F Patient(s) prescribed ace-inhibitor or angiotensin II receptor antagonist therapy during the measurement year. (Rule ID: ) Description Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy, prescribed (HF, CAD, CKD)1, (DM)2 Medication Amlodipine Benazepril Candesartan Capoten Captopril Enalapril Enalapril maleate Enalaprilat Enalpril Eprosartan Fosinopril Fosinopril Sodium Irbesartan Lisinopril Lorsartan Losartan Moexipril Olmesartan Perindopril Quinapril Quinaprol Ramipril Telmisartan Trandolapril Valsartan Measure: Patient(s) prescribed beta-blocker therapy during the measurement year. (Rule ID: ) 4006F Description Beta-blocker therapy, prescribed (CAD, HF) Medication Acebutolol Atenolol Betapace Betaxolol Bisoprolol Blocadren Brevibloc Cartrol Coreg Corgard Corzide Esmolol Hydrochlorothiazide Inderal Inderide Innopran Kerlone Labetalol Labetolol Levatol Lopressor Metoprol Metoprolol Nadolol Normodyne Pindolol Propranolol Sectral Senormin Sorine Sotalol Tenoretic Tenormin Timolide Timolol Toprol Trandate Visken Zebeta Ziac Congestive Heart Failure 42

43 Measure: Patient(s) with CHF and atrial fibrillation currently taking warfarin. (Rule ID: ) 4012F Description Warfarin therapy prescribed (HF) Medication Coufarin Coumadin Jantoven Panwarfin Sofarin Warfarin Measure: Patient(s) with LVF assessment during the measurement year. (Rule ID: ) 3020F Description Left ventricular function (LVF) assessment (eg, echocardiography, nuclear test, or ventriculography) documented in the medical record (includes: quantitative or qualitative assessment results) (HF) Measure: Patient(s) with evidence of patient education during the measurement year. (Rule ID: ) Description 4003F Patient education, written/oral, appropriate for patients with heart failure, performed (HF) Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Congestive Heart Failure 43

44 Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. Congestive Heart Failure 44

45 Description Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, new patient; 65 years and older 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, 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 laboratory/diagnostic procedures, established patient; 65 years and older Description ICD Malig hypertensive heart disease w/heart failure Ben hypertensive heart disease w/heart failure Hypertensive heart disease unspec w/heart fail Htn hrt & ckd mal w/hf & w/ckd stage 1-iv/uns Htn hrt & ckd malig w/hf & w/ckd stage v/esrd Htn hrt & ckd ben w/hf & w/ckd stage i-iv/uns Htn heart & ckd ben w/hf & ckd stage v/esrd Htn hrt & ckd uns w/hf & w/ckd stage i - iv/uns Htn heart & ckd unspec w/hf & ckd stage v/esrd Congestive Heart Failure 45

46 Description ICD Congestive heart failure unspecified Left heart failure Unspecified systolic heart failure Acute systolic heart failure Chronic systolic heart failure Acute on chronic systolic heart failure Unspecified diastolic heart failure Acute diastolic heart failure Chronic diastolic heart failure Acute on chronic diastolic heart failure Unspec combined systolic & diastolic heart failure Acute combined systolic & diastolic heart failure Chronic comb systolic & diastolic heart failure Acute chronic comb systolic&diastolic heart fail Unspecified heart failure Footer 46

47 Coronary Artery Disease Measure Source (Case) ID: Measure: Patient(s) prescribed lipid-lowering therapy during the measurement year. (Rule ID: ) 4002F Description Statin therapy, prescribed (CAD) Medication Advicor Altocor Altoprev Antara Atromid-S B-3-50 B3-500-Gr Caduet Cholestin Cholestyramine Choloxin Clofibrate Colestid Crestor Eck Niacin Endur-Acin Fenofibrate Gemfibrozil Lescol Lescol Xl Lipidil Supra Lipitor Locholest Lofibra Lopid Lovastatin Mevacor Niacin Niacinol Niacor Niadelay Niaspan Nico-400 Nicobid Tempules Nicolar Nicotinex Nicotinic Acid Pravachol Pravigard Pac Prevalite Probucol Questran Slo-Niacin Tricor Triglide Vytorin Welchol Zetia Zocor Measure: 4006F Patient(s) with a prior myocardial infarction prescribed beta-blocker therapy during the measurement year. (Rule ID: )) Description Beta-blocker therapy, prescribed (CAD, HF) Medication Acebutolol Atenolol Betapace Betaxolol Bisoprolol Blocadren Brevibloc Cartrol Coreg Corgard Corzide Esmolol Hydrochlorothiazide Inderal Inderide Innopran Kerlone Labetalol Labetolol Levatol Lopressor Metoprol Metoprolol Nadolol Normodyne Pindolol Propranolol Sectral Senormin Sorine Sotalol Tenoretic Tenormin Timolide Timolol Toprol Trandate Visken Zebeta Ziac Coronary Artery Disease 47

48 Measure: 4009F Patient(s) with CAD and diabetes and/or CHF prescribed ace-inhibitor or angiotensin II receptor antagonist therapy during the measurement year. (Rule ID: ) Description Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy, prescribed (HF, CAD, CKD)1, (DM)2 Medication Amlodipine Benazepril Candesartan Capoten Captopril Enalapril Enalapril maleate Enalaprilat Enalpril Eprosartan Fosinopril Irbesantan Lisinopril Lorsartan Moexipril Olmesartan Perindopril Quinapril Quinaprol Ramipril Telmisartan Trandolapril Valsartan Measure: Patient(s) prescribed antiplatelet therapy during the measurement year. (Rule ID: ) 4011F Description Oral antiplatelet therapy prescribed (eg, aspirin, clopidogrel/plavix, or combination of aspirin and dipyridamole/aggrenox) (CAD) Medication Acetaminophen Aggrenox Anacin Analgesic Antacid Pain Reliever Arthritis bc Powder Packet Arthritis Pain Relief ASA/Caffeine AS-caff Aspidrox Aspirbar Tablet Aspircaf Aspirin Aspirin/Apap/Cafeine Aspirin/Butalbital/ Caffeine Aspir-mox Aspirtab Aspirtal Aspridrox Asprimox Bayer Plus BC Powder BC Tablet BL eff Pain Relief Buffered Aspirin Bufferin Buffex Butalbital Compound Cama Arthritis Clopidogrel Coat-A-Prin ECK Effervescent Pain Relief Ecofair Ecpirin Effer Pain Relief Efferv Antacid Pain Relief Effervescent Pain/ Antacid Encaprin EQ Effervescent Antacid EQL Antacid & Pain Relief Extraprin Fiorinal Fiormor Fiortal Fortabs Gelpirin Tablet Gemnisyn Genace Gensan GNP Tri-Buffered Aspirin Headache Relief HM Aspridox Idenal Isolin Isollyl Laniroif Lanorinal Magnaprin Medi-Seltzer Efferves Migraine Relief Osco Aspercin P-A-C Pain Relief Efferv Pain Relief Tablet Painaid Pain-Off Pravigard RA Pain Effervescent Saleto Stanback Analgesic Supac Therapy Bayer Valesin Valomag Valumag w/aspirin Vanquish Coronary Artery Disease 48

49 Measure: 1002F Patient(s) assessed for activity and anginal symptoms during the measurement year. (Rule ID: ) Description Anginal symptoms and level of activity assessed (CAD)1 Coronary Artery Disease 49

50 Diabetes Measure Source (Case) ID: Measure: Measure: Patient(s) years of age that had a HbA1c test in last 12 reported months. (Rule ID: ) Patient(s) 5-17 years of age that had a HbA1c test in last 12 reported months. (Rule ID: ) Description 3044F Most recent hemoglobin A A1C (Hb A1C) level less than 7.0% (DM) 3045F Most recent hemoglobin A1C (Hb A1C) level % (DM) 3046F Most recent hemoglobin A1C level greater than 9.0% (DM) 3047F Most recent hemoglobin A1C level <= 9.0% Hemoglobin; glycosylated (A1C) Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use Description LOINC Hemoglobin A1C /Hemoglobin.total Hemoglobin A1C /Hemoglobin.total Hemoglobin A1C /Hemoglobin.total Measure: Patient(s) years of age with a LDL cholesterol in last 12 months. (Rule ID: ) Description 3048F Most recent LDL-C less than 100 mg/dl (DM) 3049F Most recent LDL-C mg/dl (DM) 3050F Most recent LDL-C greater than or equal to 130 mg/dl (DM) Lipid panel. This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), Triglycerides (84478) Lipoprotein, blood; electrophoretic separation and quantitation Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy) Lipoprotein, direct measurement; LDL cholesterol Diabetes 50

51 Description LOINC Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Cholesterol.in LDL Lipid HCFA 1996 panel Cholesterol.in LDL Cholesterol.in LDL Diabetes 51

52 Diabetes Mellitus Measure Source (Case) ID: Measure: 3074F 3075F 3077F 3078F 3079F 3080F Adult(s) aged years with diabetes who had their blood pressure documented in the past year less than 140/80 mm/hg (Rule ID: ) Description Most recent systolic blood pressure less than 130 mm Hg (DM) (HTN, CKD) Most recent systolic blood pressure 130 to 139 mm Hg (DM) (HTN, CKD) Most recent systolic blood pressure >= 140 mm Hg (DM)(HTN, CKD) Most recent diastolic blood pressure < 80 mm Hg (DM) (HTN, CKD) Most recent diastolic blood pressure mm Hg (DM) (HTN, CKD) Most recent diastolic blood pressure >= 90 mm Hg (DM) (HTN, CKD) Diabetes Mellitus 52

53 Diabetic Retinopathy (NS) Measure Source (Case) ID: Measure: Adult(s) with diabetic retinopathy and a dilated macular or fundus exam who had level of severity of retinopathy and presence of macular edema documented. (Rule ID: ) Modifier Description 2021F Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC) 2021F 1P Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC) 2021F 2P Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC) 2021F 3P Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC) 2021F 8P Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC) Diabetic Retinopathy (NS) 53

54 Glaucoma Screening Measure Source (Case) ID: Measure: Patient(s) 67 years of age and older that had an eye exam for glaucoma in the last 24 reported months. (Rule ID: ) 1 Description Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus three or seven equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least two isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least three isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2) Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral Provocative tests for glaucoma, with interpretation and report, without tonography Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Glaucoma Screening 54

55 1 Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three 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 are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. Glaucoma Screening 55

56 Description ICD-9 1 V80.1 Screening for Glaucoma Comprehensive eye examination Extended ophthalmologic work-up Tonography, provocative tests, and other glaucoma testing HCPCS G0117 G0118 S0620 S0621 Description Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist Routine ophthalmological examination including refraction; new patient Routine ophthalmological examination including refraction; established patient 1 Requires code must be submitted by an Optometrist, Ophthalmologist, or Pediatric Opthalmologist Glaucoma Screening 56

57 Medication Safety Monitoring Measure Source (Case) ID: 0 Measure: Patients on ARB/ACE therapy who have a serum potassium and either a creatinine OR BUN in the last 12 reported months. (Rule ID: ) Measure: Patients on digoxin who have a serum potassium and either a creatinine OR BUN in the last 12 reported months. (Rule ID: ) Measure: Patients on a diuretic who have a serum potassium and either a creatinine OR BUN in the last 12 reported months. (Rule ID: ) Description Basic metabolic panel (Calcium, ionized). This panel must include the following: Calcium, ionized (82330) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) Basic metabolic panel (Calcium, total). This panel must include the following: Calcium, total (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) General health panel. This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) Electrolyte panel. This panel must include the following: Carbon dioxide (82374) Chloride (82435) Potassium (84132) Sodium (84295) Comprehensive metabolic panel. This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) Renal function panel. This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) Creatinine; blood Creatinine; clearance Potassium; serum, plasma or whole blood Urea nitrogen; quantitative Urea nitrogen; semiquantitative (eg, reagent strip test) Medication Safety Monitoring 57

58 Description LOINC Creatinine Creatinine renal clearance Creatinine renal clearance Potassium Potassium Urea nitrogen Potassium Urea nitrogen Creatinine^post dialysis Creatinine^pre dialysis Urea nitrogen^post dialysis Urea nitrogen^pre dialysis Creatinine renal clearance/1.73 sq M Potassium^2nd specimen Potassium^3rd specimen Urea nitrogen^baseline Urea nitrogen^70m specimen Urea nitrogen^2h specimen Creatinine renal clearance Creatinine renal clearance Creatinine renal clearance Creatinine renal clearance/1.73 sq M Creatinine renal clearance/1.73 sq M Creatinine renal clearance/1.73 sq M Creatinine renal clearance/1.73 sq M Creatinine Urea nitrogen Creatinine^2H specimen Creatinine^4H specimen Creatinine Potassium Basic metabolic HCFA 1998 panel Basic metabolic HCFA 2000 panel Comprehensive metabolic HCFA 1998 panel Comprehensive metabolic HCFA 2000 panel Electrolytes HCFA 1998 panel Renal function HCFA 2000 panel Medication Safety Monitoring 58

59 Description Creatinine renal clearance Potassium^post dialysis Creatinine/Urea nitrogen Potassium Creatinine renal clearance Sodium & Potassium panel Electrolytes HCFA 1998 & Venous ph panel Creatinine renal clearance panel Creatinine Creatinine renal clearance.predicted Creatinine renal clearance/1.73 sq M.predicted Creatinine renal clearance/1.73 sq M Creatinine renal clearance/1.73 sq M Creatinine Potassium Potassium Creatinine^pre XXX challenge Creatinine^1.5H pre XXX challenge Creatinine^1H pre XXX challenge Creatinine^45M pre XXX challenge Creatinine^30M pre XXX challenge Creatinine^45M post XXX challenge Creatinine^3.5H post XXX challenge Creatinine^3.75H post XXX challenge Creatinine^4H post XXX challenge Creatinine^4.5H post XXX challenge Creatinine^5.25H post XXX challenge Creatinine^5.5H post XXX challenge Creatinine^6.5H post XXX challenge Creatinine^8H post XXX challenge Creatinine^9H post XXX challenge Creatinine^10H post XXX challenge Creatinine^12H post XXX challenge Creatinine^16H post XXX challenge Creatinine^18H post XXX challenge Creatinine^2D post XXX challenge Medication Safety Monitoring 59

60 Description LOINC Creatinine^4D post XXX challenge Creatinine^7D post XXX challenge Creatinine^pre XXX challenge Creatinine^1.5H pre XXX challenge Creatinine^1H pre XXX challenge Creatinine^45M pre XXX challenge Creatinine^30M pre XXX challenge Creatinine^45M post XXX challenge Creatinine^3.5H post XXX challenge Creatinine^4H post XXX challenge Creatinine^8H post XXX challenge Creatinine^9H post XXX challenge Creatinine^10H post XXX challenge Creatinine^12H post XXX challenge Creatinine^16H post XXX challenge Creatinine^18H post XXX challenge Creatinine^2D post XXX challenge Creatinine^4D post XXX challenge Creatinine^7D post XXX challenge Creatinine^baseline Creatinine^30M post XXX challenge Creatinine^1H post XXX challenge Creatinine^1.5H post XXX challenge Creatinine^2H post XXX challenge Creatinine^2.25H post XXX challenge Creatinine^2.5H post XXX challenge Creatinine^3H post XXX challenge Creatinine^5H post XXX challenge Creatinine^6H post XXX challenge Creatinine^1D post XXX challenge Creatinine^baseline Creatinine^30M post XXX challenge Creatinine^1H post XXX challenge Creatinine^1.5H post XXX challenge Creatinine^2H post XXX challenge Creatinine^2.5H post XXX challenge Medication Safety Monitoring 60

61 Description LOINC Creatinine^3H post XXX challenge Creatinine^5H post XXX challenge Creatinine^6H post XXX challenge Creatinine^1D post XXX challenge Potassium Urea nitrogen/creatinine Creatinine Basic metabolic panel & Glomerular filtration rate.predicted Comprehensive metabolic panel & Glomerular filtration rate.predicted Creatinine & Glomerular filtration rate.predicted panel Urea nitrogen^post dialysis/urea nitrogen^pre dialysis Renal function panel & Glomerular filtration rate.predicted Creatinine renal clearance/1.73 sq M.predicted.female Creatinine renal clearance/1.73 sq M.predicted.male Potassium^pre dialysis Creatinine^pre dialysis Creatinine^post dialysis Measure: Patients on a phenobarbital-containing drug who have a phenobarbital level in the last 12 reported months. (Rule ID: ) Description Phenobarbital Description LOINC Phenobarbital.free Phenobarbital Primidone+Phenobarbital Phenobarbital Primidone+Phenobarbital Medication Safety Monitoring 61

62 Measure: Adult patients persistently taking phenytoin medication who received a drug serum concentration test for phenytoin within the last 12 reported months (HEDIS criteria). (Rule ID: ) Description Phenytoin; total Phenytoin; free Description LOINC Phenytoin Phenytoin.free Phenytoin Phenytoin.free Phenytoin free & total panel Phenytoin.bound Measure: Adult patients persistently taking valproic acid/valproate (dipropylacetic acid) medication who received a drug serum concentration test for valproic acid within the last 12 reported months Description Dipropylacetic acid (valproic acid) Description LOINC Valproate Valproate.free Valproate^trough Valproate Valproate.protein bound Valproate.bound/Valproate.total Valproate.free Valproate.free/Valproate.total Medication Safety Monitoring 62

63 Measure: Patients on a carbamazepine-containing drug who have a carbamazepine level in the last 12 reported months. (Rule ID: ) Description Carbamazepine; total Carbamazepine; free Description LOINC Carbamazepine Carbamazepine.free Carbamazepine 10,11-Epoxide Carbamazepine 10,11-Epoxide.free Carbamazepine Carbamazepine 10,11-Epoxide Carbamazepine 10,11-Epoxide.bound Carbamazepine.bound Carbamazepine.free Carbamazepine.free/Carbamazepine.total Carbamazepine free & total panel Carbamazepine 10,11-Epoxide.free Measure: No compliance criteria Patients 65 years of age and older that received one or more high risk medications in the elderly in the last 12 reported months (HEDIS criteria). (Rule ID: ) Medication Safety Monitoring 63

64 Migraine Headache Measure Source (Case) ID: Measure: Adult patient(s) with frequent use of acute medications that also received prophylactic medications. (Rule ID: ) Medication Acebutolol Amitriptyline Amitriptyline Amlodipine besylate Amoxapine Atenolol Benazepril Bepridil Betaxolol Bisoprolol Bisoprolol fumarate Carbamazepine Carteolol Carvedilol Chlordiazepoxide Clevidipine butyrate Clevidipine butyrate Clomipramine Desipramine Diltiazem Divalproex sodium Doxepin Enalapril Esmolol Ethosuximide Ethotoin Felbamate Felodipine Gabapentin Imipramine Imipramine Imipramine Isradipine Labetalol hydrochloride Lacosamide Lamotrigine Levetiracetam Maprotiline Mephenytoin Methsuximide Metoprolol Mibefradil Nadolol Nebivolol Nicardipine Nifedipine Nimodipine Nisoldipine Nortriptyline hydrochloride Olmesartan Oxcarbazepine Paramethadione Penbutolol Perphenazine Phenacemide Phensuximide Phenytoin Pindolol Primidone Propranolol Propranolol Protriptyline hydrochloride Rufinamide Sotalol Tiagabine Timolol Topiramate Trandolapril Trimethadione Trimipramine maleate Valproic acid Valsartan Verapamil Zonisamide Migraine Headache 64

65 Osteoporosis Management Measure Source (Case) ID: Measure: Women 67 years of age or older who were treated or tested for osteoporosis within six months of a fracture. (Rule ID: ) Description CT scan, bone density study Computed tomography, appendicular skeleton Dual energy x-ray study Dual energy x-ray study Dxa bn dnsity stdy 1/>site; vert fx Photodensitometry Ultrasound bone density measurement and interpretation, peripheral site(s), any method Computed tomography, bone mineral density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Computed tomography, bone mineral density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture assessment Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), one or more sites Bone density (bone mineral content) study, one or more sites; single photon absorptiometry Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites Description ICD Bone mineral density studies V82.81 Special screening for Osteoporosis HCPCS G0130 Description Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Osteoporosis Management 65

66 Medication Activella Actonel Alendronate Alora Boniva Calcitonin, Salmon Cenestin Climara Clinagen LA 40 Combipatch Delestrogen Dep gynogen Depo-Estradiol Depogen Divigel Elestrin Enjuvia Esclim Estrace Estraderm Estradiol Estradiol Cypionate Estradiol Estradiol-Norethindrone Acetate Estragyn LA 5 Estrasorb Estratab Estro-Cyp Estrogel Estropipate Evamist Evista Femhrt Femring Femtrace Forteo Fortical Fosamax Gynodiol Gynogen LA 20 Menaval-20 Menest Menostar Miacalcin Norinyl 1/35 Ogen Ortho-Est Premarin Premphase Prempro Reclast Valergen Osteoporosis Management 66

67 Pharyngitis Measure Source (Case) ID: Measure: Patient(s) treated with an antibiotic for pharyngitis that had a group a streptococcus test. (Rule ID: ) Description Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool Culture, presumptive, pathogenic organisms, screening only; Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Streptococcus, group A Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A Description LOINC Streptococcus pyogenes Streptococcus pyogenes identified Streptococcus pyogenes Ag Streptococcus pyogenes Ag Streptococcus pyogenes DNA Streptococcus pyogenes rrna Bacteria identified Streptococcus pyogenes Ag Streptococcus pyogenes Ag Streptococcus pyogenes Ag Streptococcus pyogenes Ag Pharyngitis 67

68 Pregnancy Management Measure Source (Case) ID: Measure: Pregnant women that had HIV testing. (Rule ID: ) Description 3292F HIV testing ordered or documented and reviewed during the first or second prenatal visit (PRENATAL) Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) Antibody; HIV Antibody; HIV Antibody; HIV-1 and HIV-2, single assay Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification Description LOINC 7918 HIV Test 7917 HIV Test 5222 HIV Test 5221 HIV Test HIV Test HIV Test HIV Test HIV Test Pregnancy Management 68

69 Rheumatoid Arthritis Measure Source (Case) ID: Measure: Patient(s) who had a prescription dispensed for a disease modifying anti-rheumatic drug (DMRAD) during the report period. (Rule ID: ) HCPCS J0129 J0135 J1438 J1600 J1745 J7502 J7515 J7516 J9250 J9260 Description Injection, abatacept, 10 mg Injection, adalimumab, 20 mg Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) Injection, gold sodium thiomalate, up to 50 mg Injection infliximab, 10 mg Cyclosporine, oral, 100 mg Cyclosporine, oral, 25 mg Cyclosporine, parenteral, 250 mg Methotrexate sodium, 5 mg Methotrexate sodium, 50 mg Medication Arava Azasan Azathioprine Azulfidine Cuprimine Cyclophosphamide CycloSPORINE Cytoxan Depen Dynacin Enbrel Enbrel Prefilled Syringe Enbrel SureClick Gengraf Gold sodium thiomalate Humira Hydroxychloroquine sulfate Imuran Kineret Leflunomide Methotrexate Minocin Minocycline hydrochloride Myochrysine Myrac Neoral Neosar Orencia Plaquenil Sulfate Remicade Rheumatrex Dose Pack Ridaura Rituxan Sandimmune Solganal Solodyn Sulfasalazine Sulfazine Trexall Vectrin Rheumatoid Arthritis 69

70 Upper Respiratory Infection (Pediatric) Measure Source (Case) ID: Measure: Patients with diagnosis of upper respiratory infection (URI) that did not have a prescription for an antibiotic on or three days after the initiating visit. (Rule ID: ) No compliance criteria Upper Respiratory Infection (Pediatric) 70

71 Use of Appropriate Imaging for Back Pain Measure Source (Case) ID: Measure: Patients with uncomplicated low back pain that did not have imaging studies (Rule ID: ) No compliance criteria Use of Appropriate Imaging for Back Pain 71

72 Important notes about the UnitedHealth Premium Physician Designation Program The information from the Premium physician designation program is not an endorsement of a particular physician or health care professional s suitability for the health care needs of any particular member. UnitedHealthcare does not practice medicine nor provide health care services. Physicians are solely responsible for medical judgments and treatments supplied. The quality and/or cost efficiency designation of a physician does not guarantee the quality of health care services members will receive from a doctor and does not guarantee the outcome of any health care services members will receive. Likewise, the fact that a physician may not be designated by this program does not mean that the physician does not provide quality health care services. All physicians in the UnitedHealthcare Network have met certain minimum credentialing requirements. Regardless of whether a physician has received a designation, members have access to all physicians in the UnitedHealthcare Network, as further described under the member s benefit plan. UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error. There is a risk of error in the claims data used in the evaluation, in the calculations used in the evaluation, and in the way the program determined that an individual physician was responsible for the treatment of the patient s condition. Physicians have the opportunity to review this data and submit a reconsideration request. UnitedHealthcare uses statistical testing to compare a physician s results to expected or normative results. There is a risk of error in statistical tests when applied to the data and a result based on statistical testing is not a guarantee of correct inference or classification. We inform members that it is important that they consider many factors and information from as many sources as possible when selecting a physician. We also inform our members that they may wish to discuss designations with a physician before choosing him or her, or confer with their current physician for advice on selecting other physicians. The information contained in this s and Medications document is subject to change. M /11 ET United HealthCare Services, Inc.