HEdis Code Quick Reference Guide Disease Management Services
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1 HEdis Code Quick Reference Guide Disease Management Services
2 Respiratory Conditions Appropriate Testing for Children With Pharyngitis (ages 2-18) [Commercial, Medicaid] Appropriate Treatment (no antibiotic) for Children With Upper Respiratory Infection [Commercial, Medicaid] Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis [Commercial, Medicaid] Use of Spirometry Testing in the Assessment and Diagnosis of COPD (ages 40+) Pharmacotherapy Management of COPD Exacerbation Use of Appropriate Medications for People With Asthma [Commercial, Medicaid] Medication Management for People With Asthma [Commercial, Medicaid] Medication Ratio for People With Asthma [Commercial, Medicaid] Codes to identify Outpatient Visit Type Codes to identify Group A Streptococcus Tests UB Revenue LOINC , , , , , , , 99411, 99412, 99420, x, , , 0982, , 87071, 87081, 87430, , Antibiotics should NOT be prescribed for children 3 months-18 years diagnosed with ONLY upper respiratory infection diagnosis. Antibiotics should NOT be prescribed for adults years of age with a diagnosis of acute bronchitis , , , , , , , , , , , , Codes to identify Spirometry Testing Codes to identify Outpatient Visit Codes to identify COPD UB Revenue ICD-9-CM Diagnosis 94010, , 94060, 94070, 94375, , , , , , , , , , 99411, 99412, 99420, 99429, 99455, x, , , 057x- 059x, 0982, , 492, 493.2, 496 Adults 40 and older who had an acute inpatient discharge or ED encounter for COPD exacerbation should be dispensed the following medications: 1. A systemic corticosteroid within 14 days of discharge; and 2. A bronchodilator within 30 days of discharge. Children and adults ages 5-64 diagnosed with persistent asthma should be dispensed at least one asthma controller medication. Asthma controller medications include: antiasthmatic combinations, antibody inhibitor, inhaled steroid combination, inhaled corticosteroid, leukotriene modifier, mast cell stabilizer, methylxanthines. Children and adults ages 5-64 who were identified as having persistent asthma and were dispensed appropriate medications must remain on an asthma controller for at least 75% of the treatment period. Controller medications include: antiasthmatic combinations, antibody inhibitor, inhaled steroid combination, inhaled corticosteroid, leukotriene modifier, mast cell stabilizer, methylxanthines. Children and adults 5-64 years who were identified as having persistent asthma should have a ratio of controller medications to total asthma medications of 0.50 or greater during the year. 1
![Pharmacotherapy Management of COPD Exacerbation Use of Appropriate Medications for People With Asthma [Commercial, Medicaid] Medication Management for People With Asthma [Commercial, Medicaid]](/docs-images/43/16560363/images/page_2.jpg "Medication Ratio for People With Asthma [Commercial, Medicaid] Codes to identify Outpatient Visit Type Codes to identify Group A Streptococcus Tests UB Revenue LOINC 99201-99205, 99211-99215,")
3 Cardiovascular Conditions Cholesterol Management for Patients With Cardiovascular Conditions (ages 18-75) Controlling High Blood Pressure Persistence of Beta Blocker Treatment After a Heart Attack Musculoskeletal Condition Care Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis [Commercial, Medicaid, Medicare] Use of Imaging Studies for Low Back Pain [Commercial, Medicaid] Osteoporosis Management in Women Who Had a Fracture [Medicare] Codes to identify Outpatient Visit Type , , , , , , , , , 99411, 99412, 99420, 99429, 99455, AMI and CABG inpatient codes UB Revenue 051x, , , 057x-059x, 0982, 0983 Ischemic Vascular Disease (IVD)Codes ICD-9-CM Diagnosis 411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, , 440.1, 440.2, 440.4, 444, 445 Percutaneous Coronary Interventions (PCI) Codes /ICD- 9/HCPCS Procedure Codes : 92980, 92982, 92995; ICD-9-CM Proc: 00.66, 36.06, 36.07; HCPCS: G , 83700, 83701, 83704, Codes to identify LDL-C Screening Category II 3048F, 3049F, 3050F LOINC , , , , , , , , , Acute myocardial infarction (AMI)-ICD-9 Dx: 410x1; coronary artery bypass graft (CABG) : , , , , ICD-9 Procedure: 36.1, 36.2, HCPCS: S2205-S2209 Document blood pressure at least once a year on members ages who have a diagnosis of hypertension. Goal: <140/90mm Hg Adults 18 years and older who are discharged with a diagnosis of acute myocardial infarction should receive a beta-blocker treatment for 6 months: Noncardioselective beta-blockers, Cardioselective beta-blockers, Antihypertensive combinations. Adults 18 and older diagnosed with Rheumatoid Arthritis should be dispensed at least one prescription for a disease modifying anti-rheumatic drug (DMARD): 5-Aminosalicylates, Alkylating agents, Aminoquinolones, Anti-rheumatics, Immunomodulators, Immunosuppressive agents, Tetracyclines. Adults ages with a primary diagnosis of low back pain should NOT have an imaging study within 28 days of diagnosis unless clinically indicated. Women 67 and older who suffered a fracture should have a bone mineral density test or be dispensed a drug to treat or prevent osteoporosis within six months of the fracture. Osteoporosis Therapies: Biphosphonates, Estrogens, Other agents, Sex hormone combinations. Codes to identify a Bone Mineral Density Test HCPCS ICD-9-CM Procedure 76977, , 78350, G
![Osteoporosis Management in Women Who Had a Fracture [Medicare] Codes to identify Outpatient Visit Type 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387,](/docs-images/43/16560363/images/page_3.jpg "99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 AMI and CABG inpatient codes UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983 Ischemic Vascular Disease (IVD)Codes")
4 Diabetes Care Diabetes Visit and Diagnosis (ages 18-75) HbA1c Testing Retinal Eye Exams LDL-C Screening Nephropathy Screening Codes to identify Outpatient Visit Type Diabetes Dx UB Revenue ICD-9-CM Diagnosis , , , , , , , , , 99411, 99412, 99420, 99429, 99455, EXCLUSIONS 051x, , , 057x-059x, 082x-085x, 088x, 0982, 0983 ICD-9-CM Diagnosis Polycystic ovaries Steroid induced 249, 251.8, Gestational diabetes HbA1c Levels 250, 357.2, 362.0, , Codes to identify HbA1c Tests Category II Category II LOINC 9% 3044F, 3045F <8% 3044F <7% 3044F 83036, >9% 3046F 8% 3046F 7% 3045F, 3046F F, 3045F, 3046F Refer diabetics for annual retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist). Codes to identify LDL-C Screening Codes to identify LDL-C Levels Category II LOINC Category II 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , , Codes to identify Nephropathy Screening LDL-C <100mg/ dl Category II LOINC 82042, 82043, 82044, F, 3061F 3048F LDL-C 100mg/ dl , , , , 3049F, 3050F , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Evidence of Nephropathy HCPCS ICD-9-CM Diagnosis ICD-9-CM Procedure Urine Macroalbumin Test , ACE Inhibitor/ARB Therapy UB Revenue Category II/ LOINC* 3062F/5804-0, , , , F 3
5 Hedis Code Quick Reference Guide-Disease Management Services Diabetes Care-continued Evidence of Treatment for Nephropathy Blood Pressure Behavioral Health Antidepressant Medication Management (ages 18+) Follow-Up Care for Children Prescribed ADHD Medication (ages 6-12) [Commercial, Medicaid] Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (ages 18-64) [Medicaid] Diabetes Monitoring for People With Diabetes and Schizophrenia (ages 18-64) [Medicaid] HCPCS ICD-9-CM Diagnosis ICD-9-CM Procedure 36147, 36800, 36810, 36815, 36818, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, G0257, S , 403, 404, , , , , 753.0, 753.1, 791.0, V42.0, V , 39.27, 39.42, 39.43, 39.53, , 54.98, UB Revenue 0367, 080x, 082x- 085x, 088x Category II/ LOINC* * A Category II code indicates a positive result for urine macroalbumin; providers must use automated laboratory data to confirm a positive result for tests identified by or LOINC codes. Document blood pressure at least once a year for members ages who have a diagnosis of hypertension. Goal: <140/80mm Hg or <140/90 mm Hg Adults 18 and older diagnosed with a new episode of depression should remain on an antidepressant medication for a minimum of 84 days (12 weeks) and optimally 180 days (six months.) Codes to identify Follow-up Visits 3066F Codes to identify Telephone Visits HCPCS UB Revenue ICD-9-CM Diagnosis , , , 99078, , , , , , , 99383, 99384, 99393, 99394, , 99411, 99412, , 90802, , , , 90845, 90847, 90849, 90853, 90857, 90862, 90875, G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 WITH 0510, 0513, , , , 0900, , 0907, , 0919, 0982, , POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33, 49, 50, 52, 53, 71, , , 99238, 99239, WITH 52, 53 EXCLUSION: Narcolepsy ICD-9-CM Dx: 347 Diabetes Glucose Screening Bipolar Disorder Schizophrenia LOINC ICD-9-CM Diagnosis ICD-9-CM Diagnosis 80047, 80048, 80050, 80053, 80069, 82947, 82950, , , , , , , 296.1, 296.4, 296.5, 296.6, Codes to identify HbA1c Tests Codes to identify LDL-C Screening Schizophrenia Category II 3044F, 3045F, 3046F LOINC , , , , , , 83700, 83701, 83704, Category II 3048F, 3049F, 3050F LOINC , , , , , , , , , ICD-9-CM 295 4
![Medications (ages 18-64) [Medicaid] Diabetes Monitoring for People With Diabetes and Schizophrenia (ages 18-64) [Medicaid] HCPCS ICD-9-CM Diagnosis ICD-9-CM Procedure 36147, 36800, 36810, 36815,](/docs-images/43/16560363/images/page_5.jpg "36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 G0257,")
6 Behavioral Health-continued Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (ages 18-64) [Medicaid] Adherence to Antipsychotic Medications for Individuals With Schizophrenia (ages 19-64) [Medicaid] Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (ages 13+) Codes to identify LDL-C Screening Schizophrenia Category II LOINC ICD-9-CM 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , , Patients ages with schizophrenia who were dispensed an antipsychotic medication should remain on the medication for at least 80% of their treatment period. Codes to identify Initiation and Engagement of Alcohol and Other Drug Dependence Treatment HCPCS UB Revenue , , 99078, , , , , , , , , , 99408, 99409, 99411, 99412, , 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90875, , , , , , 99238, 99239, Source: HEDIS 2013 Technical Specifications Allowable codes may vary by state. Reimbursement for these services will be per the terms of your agreement. G0155, G0176, G0177, G0396, G0397, G0409-G0411, G0443, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012 WITH , 0513, , , , 0900, , , 0919, 0944, 0945, 0982, 0983 POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33, 49, 50, 52, 53, 57, 71, 72 WITH 52, 53 5
7 Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. or its affiliates / United HealthCare Services, Inc. Doc#: UHC1529d_
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