Appropriate Treatment for Children with Upper Respiratory Infection

Transcription

1 BCBS ACO Measure Appropriate Treatment for Children with Upper Respiratory Infection HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents BCBS Measure: Page 50 of 234 Dated: 5/27/2015

2 2015 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Appropriate Treatment for Children with Upper Respiratory Infection This measure focuses on not treating children with URI with antibiotics unless they also have a competing diagnosis (table 4.1 and 4.2). The measure looks at the percentage of children 3 months to 18 years of age who: Were given a diagnosis of upper respiratory infection (URI), Had no evidence of competing diagnosis, AND were treated appropriately (i.e., were not dispensed an antibiotic prescription on or 3 days after the episode) A higher score indicates better quality (appropriate treatment of children with URI, i.e., the proportion for whom antibiotics were not prescribed). Key: Performance Met Performance Not Met Excluded from Performance Measurement Rationale: The common cold (or upper respiratory infection [URI]) is a frequent reason for children visiting the doctor's office. Though existing clinical guidelines do not support the use of antibiotics for the common cold, physicians often prescribe them for this ailment. Pediatric clinical practice guidelines do not recommend antibiotics for a majority of upper respiratory tract infections because of the viral etiology of these infections, including the common cold. A performance measure of antibiotic use for URI sheds light on the prevalence of inappropriate antibiotic prescribing in clinical practice and raises awareness of the importance of reducing inappropriate antibiotic use to combat antibiotic resistance in the community. The clinical intent is to ensure that children diagnosed with nonspecific upper respiratory infections are not being inappropriately treated with antibiotics. ELIGILBLE POPULATION Children 3 months - 18 years and: an outpatient or ED visit for URI. NUMERATOR Patients who were NOT prescribed or dispensed a prescription for antibiotic medication on or within 3 days after the URI Episode date. EXCLUSIONS Exclude claims/encounters with more than one diagnosis code. Exclude ED visits that result in an inpatient admission. Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date (refer to the Table 3 below for a list of antibiotic medications). Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis (Table 4.1 and 4.2) on or 3 days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis: Pharyngitis Value Set Competing Diagnosis Value Set Procedure Codes & Code Descriptors Patient NOT prescribed nor dispensed antibiotic HCPCS Code G8708 Or URI patients with documented medical reasons for prescribing or dispensing an antibiotic: HCPCS Code G8709 Or Antibiotic prescribed or dispensed: HCPCS Code G8710 BCBS Measure: Page 51 of 234 Dated: 5/27/2015

3 To Determine the Denominator Step 1: Identify all members who are: aged 3 months 18 years who had: an outpatient visit, an observation visit or an ED visit during the Intake Period Table 1: Codes to Identify Visit Type Description CPT UB Revenue Outpatient , , , , x, , , 077x, 99385, , , 99411, 99412, 99420, 99429, 0982, ED* x, 0981 Source: HEDIS Table URI-B: Codes to Identify Outpatient visits for URI *Do not include ED visits that result in an inpatient admission. Revenue with a diagnosis of URI. Table 2: Codes to Identify URI ICD-9-CM Diagnosis Acute nasopharyngitis (common cold) 460 URI 465 Source: HEDIS Table URI-A: Codes to Identify URI Step 2: Determine all URI Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a URI diagnosis. Exclude claims/encounters with more than one diagnosis. Step 3: Test for Negative Medication History. To determine eligibility, look for any of the listed antibiotic drugs below (Table 3) in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. Exclude Episode Dates where a new or refill prescription for an antibiotic medication (Table 4) was filled 30 days prior to the Episode Date or was active on the Episode Date. BCBS Measure: Page 52 of 234 Dated: 5/27/2015

4 Table 3: Antibiotic Medications Description Prescription Aminopenicillins Amoxicillin Ampicillin Beta-lactamase inhibitors Amoxicillin-Clavulanate First generation cephalosporins Cefadroxil Cephalexin Folate antagonist Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Cefazolin Trimethoprim Clindamycin Azithromycin Clarithromycin Erythromycin Erythromycin Ethylsuccinate Erythromycin lactobionate Erythromycin Stearate Erythromycin-Sulfisoxazole Penicillin G Potassium Penicillin V Potassium Penicillin G Sodium Penicillinase-resistant penicillins Dicloxacillin Quinolones Ciprofloxacin Moxifloxacin Levofloxacin Ofloxacin Second generation cephalosporins Cefaclor Cefuroxime Cefprozil Sulfonamides Sulfamethoxazole-Trimethoprim Sulfisoxazole Tetracyclines Doxycycline Tetracycline Minocycline Cefdinir Ceftibuten Third generation cephalosporins Cefixime Cefditoren Cefpodoxime Ceftriaxone Detailed list available at: Step 4: Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis on or three days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis: Pharyngitis Value Set. Competing Diagnosis Value Set. BCBS Measure: Page 53 of 234 Dated: 5/27/2015

5 Table 4.1: Competing diagnosis codes: similar conditions Description ICD-9-CM Diagnosis Acute pharyngitis 034.0, 462 Acute sinusitis 461 Acute tonsillitis 463 Bacterial infection unspecified Chronic sinusitis 473 Infections of the pharynx, larynx, tonsils, adenoids , 474, , , , , Otitis media 382 Pneumonia Table 4.2: Competing diagnosis codes: other indications for antibiotics Description ICD-9-CM Diagnosis Acne 706.0, Acute lymphadenitis 683 Cellulitis, mastoiditis, other bone infections 383, 681, 682, 730 Chlamydia , , Cystitis or UTI 595, Gonococcal infections and venereal diseases 098, 099, V01.6, V02.7, V02.8 Impetigo 684 Infections of the kidney 590 Inflammatory diseases (female reproductive organs) 131, Intestinal infections Lyme disease and other arthropod-borne diseases 088 Pertussis 033 Prostatitis 601 Skin staph infections 686 Syphilis To Determine the Numerator Patients who were NOT prescribed or dispensed a prescription for antibiotic medication (Table 3) on or within 3 days after the URI Episode date. BCBS Measure: Page 54 of 234 Dated: 5/27/2015

6 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE TO IMPROVE YOUR SCORES ON THIS MEASURE For Upper Respiratory Infections, it is considered a mark of high quality care if these patients were not dispensed an antibiotic when they only have a diagnosis of a URI, which includes either: o Acute Nasopharyngitis common cold (Code 460); or o Upper Respiratory Infection (Code 465) Educating patients on the difference between bacterial and viral infections is a key in the success of this measure. If a member age 2 to 18 has Pharyngitis (which includes Acute Pharyngitis, Acute Tonsillitis, or Streptococcal Sore Throat), and you are prescribing an antibiotic: o Complete a Strep Test. o Document in medical record. o Ensure the code for the strep test is on the claim. o If prescribing an antibiotic for a child with a URI who also has an additional diagnosis other than Pharyngitis - competing diagnosis be sure to document the proper diagnosis code on the claim. This is important because more than 1 diagnosis on the claim, other than Pharyngitis, removes a member from the non- compliant list. This will ensure that you do not get inappropriately counted as prescribing an antibiotic for URI. Use correct diagnosis and procedure codes. Submit claims and encounter data in a timely manner. Use CPT II Codes to reduce medical record requests. You may go to to print education sheets (English/Spanish) to reinforce the decision to parents not to use an antibiotic. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. You will be required to provide the supporting medical record documentation if the ACO is selected for audit following the data collection period. Educational Materials The CDC has an extensive GETSMART campaign that includes patient and provider materials that address inappropriate antibiotic use: BCBS Measure: Page 55 of 234 Dated: 5/27/2015

7 2015 BCBS ACO Reporting Data Collection Form Appropriate Treatment for Children with Upper Respiratory Infection Target Population Age: Patients aged 3 MONTHS-18 YEARS. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient between 3 months- 18 years of age? Continue to Q2 Q2: Was the patient seen for an outpatient or ED visit during the measurement year? Continue to Q3 Q3: Was the patient seen for the outpatient or ED visit during the measurement year and diagnosed with only URI? Continue to Q4 Q4: Was the patient dispensed a prescription for an antibiotic on or within 3 days after the URI Episode date? Continue to Step 2 Q5: Does the child have a history of prescription for an antibiotic filled during the time period from thirty days prior through one day prior to the pharyngitis episode start date.. Excluded from denominator. Continue to Q 6 Step 2 Did you meet the measure? Q6: Determine the reason why the patient was prescribed or dispensed an antibiotic. Medical Reasons: Select this option if the patient had a documented medical reasons for being prescribed or dispensed an antibiotic No Reason Documented Step 3 Reporting Options. Check One: Patient NOT prescribed nor dispensed antibiotic HCPCS Code G8708 URI patients with documented medical reasons for prescribing or HCPCS Code G8709 dispensing an antibiotic Antibiotic prescribed or dispensed HCPCS Code G8710 For Practice Use: Form Completed by: Date: BCBS Measure: Page 56 of 234 Dated: 5/27/2015