2016 HEDIS /QRS/QARR/EES Physician Documentation Guidelines and Administrative Codes

2016 HEDIS /QRS/QARR/EES Physician Documentation Guidelines and Administrative Codes This document contains a description of HEDIS and other quality of care measures and includes suggestions and/or recommendations for appropriate coding and physician documentation in care related to HEDIS quality measures. This document is not intended to be a substitute for plan-recommended Clinical Practice Guidelines. Note: Administrative codes and documentation requirements are drawn from 2015 Healthcare Effectiveness Data and Information Set (HEDIS) Volume 2 Technical Specifications. Codes and measures listed may not be an exhaustive list and may be subject to change with the release of 2016 HEDIS Volume 2 Technical Specifications.

WHAT IS HEDIS? FREQUENTLY ASKED QUESTIONS HEDIS, or Healthcare Effectiveness Data and Information Set, are a set of performance measurements developed by the National Committee for Quality Assurance (NCQA) that assess the quality of care health care organizations provide to their customers. Health Republic is required to report HEDIS and other clinical quality measures to the New York State and federal governments on an annual basis. Information collected for HEDIS reporting includes claims and medical records related to preventative screenings, well visits, treatment for acute and chronic illnesses, access to care, maternity care, behavioral health, and patient satisfaction. The data are used by purchasers and consumers to make informed choices when selecting a plan based on the quality of care provided. WHY ARE MEDICAL RECORDS REQUESTED FOR HEDIS REPORTING? Some HEDIS measures require medical record data for calculation. As a Health Republic/MagnaCare network provider, you may be contacted to provide medical records for HEDIS reporting. HEDIS data collection takes place in the first half of each year (January May). As a participating provider in the Health Republic network, please ensure that your office submits all notes, labs, and consults within the requested timeframes, per the instructions you receive in the request cover letter. Participating provider and network agreements, as well as the member s application for coverage with HRINY, provide for the release of medical record information to HRINY or its designee for quality improvement efforts at no charge. Your cooperation in providing any requested medical records will comply with state and federal laws 1 and will help us improve the quality of care provided and support Health Republic s commitment to providing affordable care that meets the highest nationwide and statewide standards. WHAT IS EES/CAHPS? Many health care organizations, including health plans and provider organizations, use a survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The survey is developed by the Agency for Healthcare Research and Quality (AHRQ) and is adopted by the NCQA for use as part of HEDIS reporting. Health plans participating in the Health Insurance Marketplace must conduct a modified CAHPS survey, called the Qualified Health Plan Enrollee Experience Survey (QHP EES). This survey assesses factors including consumer satisfaction with health care, personal doctors, and specialists. 1 New York State Law requires that Health Republic Insurance of New York and its network physicians comply with HEDIS and QARR initiatives, and that Health Republic report the results to the State. The US Department of Health and Human Services has stated that supplying the requested records to us for HEDIS/QRS/QARR reporting does not violate the HIPAA Privacy Rules [45 CFR.501 and 506(c) (4)]. Page 1 of 11

Measure (Adults) Patient Description Documentation Requirements Codes Prevention and Screening Adult BMI Assessment 2 Patients 18 74 years old BMI value recorded in the last two years ICD-9-CM: V85.0-V85.5 Colorectal Cancer Screening 2 Patients 50 75 years old Respiratory Conditions Avoidance of Patients 18 64 years old with a Antibiotic Treatment in diagnosis of acute bronchitis Adults with Acute Bronchitis 1 Medication Management for People with Asthma 1 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 1 Pharmacotherapy Management of COPD Exacerbation 1 Patients 5 64 years old with a diagnosis of persistent asthma Patients 40 years and older with a new diagnosis of COPD or newly active COPD Patients 40 years and older with a new COPD exacerbation who had an acute inpatient discharge or ED encounter Cardiovascular Conditions Controlling High Blood Patients 18 85 years old with a Pressure 2 diagnosis of hypertension Colonoscopy (last 10 years), flexible sigmoidoscopy (last 5 years), or fecal occult blood test (FOBT) (in the 2015 calendar year) No antibiotic prescription dispensed Asthma controller medication dispensed for at least 75% of the treatment period Received appropriate spirometry testing to confirm the diagnosis of COPD Dispensed a systemic corticosteroid within 14 days of acute inpatient discharge/ed encounter Dispensed a bronchodilator within 30 days of acute inpatient discharge/ed encounter Date of diagnosis of hypertension before June 30 of the 2015 calendar year from a problem list, office note, encounter form, diagnostic report, or hospital discharge summary, and Last blood pressure (BP) reading (date & result) in the 2015 calendar year (if elevated, document all BP readings) FOBT: CPT: 82270, 82274 HCPCS: G0328 Flexible Sigmoidoscopy: ICD-9-CM: 45.24 CPT: 45330-45335, 45337-45342, 45345 HCPCS: G0104 Colonoscopy: ICD-9-CM: 45.22, 45.23, 45.25, 45.42, 45.43 CPT: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 HCPCS: G0105, G0121 ICD-9-CM: 466.0 without antibiotic prescription dispensed ICD-9-CM: 493.0x-493.02, 493.1x-493.12, 493.8x-493.82, 493.9x- 493.92 with at least one asthma controller medication dispensed ICD-9-CM: 491.0, 491.1, 491.2x-491.22, 491.8, 491.9, 492.0, 492.8, 493.2x-493.22, 496 CPT: 94010, 94014-94016, 94060, 94070, 94375, 94620 ICD-9-CM: 491.0, 491.1, 491.2x-491.22, 491.8, 491.9, 492.0, 492.8, 493.2x-493.22, 496 with systemic corticosteroid and/or bronchodilator prescription dispensed ICD-9-CM: 401, 401.1, 401.9 with BP <140/90 mm Hg or <150/90 mm Hg Note: Adequate control is defined as meeting any of the following criteria: 1) 18 59 years of age and BP <140/90 mm Hg 2) 60-85 years of age with a diagnosis of diabetes and BP <140/90 mm Hg 3) 60-85 years of age without a diagnosis of diabetes and BP <150/90 mm Hg Page 2 of 11

Measure (Adults) Patient Description Documentation Requirements Codes Cardiovascular Conditions Persistence of Beta- Blocker Treatment Dispensed 180-day course of treatment with beta-blockers After a Heart Attack 1 Diabetes Comprehensive Diabetes Care 2 Retinal Eye Exam Performed HbA1C Testing and Control (<8.0%) Medical Attention for Nephropathy Patients 18 85 years old with a diagnosis of acute myocardial infarction (AMI) who were hospitalized and discharged from 7/1/2014 to 6/30/2015 Patients 18 75 years old with a diagnosis of diabetes ICD-9-CM: 410.x1-410.91 with 180-day course of treatment with beta-blockers Diagnosis of type I or type II diabetes ICD-9-CM: 250.0x-250.9x, 357.2, 362.01-362.07, 366.41, 648.0x Retinal eye exam performed by an eye care professional (optometrist or ophthalmologist) in 2015 or year prior HbA1c testing and result (date and result of last screening in 2015) Medical attention to nephropathy (screening and/or treatment) in 2015 CPT: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 CPT II: 2022F, 2024F, 2026F, 3072F HCPCS: S0620, S0621, S0625, S3000 CPT: 83036, 83037, 3044F, 3045F, 3046F ICD-9-CM: 250.4x-250.43, 403, 403.01, 403.1, 403.11, 403.9, 403.91, 404.0x-404.03, 404.1x-404.13, 404.9x-404.93, 405.01, 405.11, 405.91, 580, 580.4, 580.81, 580.89, 580.9, 581.x-581.3, 581.81, 581.89, 581.9, 582.x-582.2, 582.4, 582.81, 582.89, 582.9, 583.x- 583.2, 583.4, 583.6, 583.7, 583.81, 583.89, 583.9, 584.5-584.9, 585.1-585.6, 585.9, 586-588, 588.1, 588.81, 588.89, 588.9, 753, 753.1x-753.17, 753.19, 791, V42.0x-V45.12 ICD-9-PCS: 38.95, 39.27, 39.42, 39.43, 39.53, 39.93-39.95, 54.98, 55.61, 55.69 CPT: 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 81000-81003, 81005, 82042-82044, 84156, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999,99512, 3060F-3062F, 3066F, 4010F HCPCS: G0257, S2065, S9339 Page 3 of 11

Measure (Adults) Patient Description Documentation Requirements Codes Musculoskeletal Conditions Disease-Modifying Patients 18 years and older with a Dispensed at least one ambulatory ICD-9-CM: 714.0x-714.2, 714.81 HCPCS: J0129, J0135, J0717, J0718, J1438, J1600, J1602, J1745, Anti-Rheumatic Drugs diagnosis of rheumatoid arthritis prescription for a disease-modifying antirheumatic drug (DMARD) in 2015 J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310 for Rheumatoid Arthritis 1 Use of Imaging Studies for Low Back Pain 1 Behavioral Health Antidepressant Medication Management 1 Follow-Up After Hospitalization for Mental Illness 1 Patients 18 50 years old with a diagnosis of low back pain Patients 18 years and older with a new diagnosis of major depression Patients 6 years and older who were hospitalized for treatment of selected mental illness diagnoses Imaging study (plain X-ray, MRI, CT scan) not performed within 28 days of low back pain diagnosis Dispensed antidepressant medication and remained on antidepressant medication for at least 84 days (12 weeks) Dispensed antidepressant medication and remained on antidepressant medication for at least 180 days (6 months) Received follow-up visit with a mental health practitioner in an outpatient, intensive outpatient, or partial hospitalization visit Low Back Pain Diagnosis: ICD-9-CM: 721.3, 722.1, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5-724.7, 724.71, 724.79, 738.5, 739.3, 739.4, 846-846.3, 846.8, 846.9, 847.2 Imaging Study Codes to Avoid: CPT: 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131-72133, 72141, 72142, 72146-72149, 72156, 72158, 72200, 72202, 72220 ICD-9-CM: 296.2x-296.25, 296.3x-296.35, 298.0, 311 CPT: 90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99281-99285, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99510, 90791, 90792, 90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90857, 90862, 90868-90870, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99251-99255 ICD-9-CM: 295.0x-295.05, 295.1x-295.15, 295.2x-295.25, 295.3x- 295.35, 295.4x-295.45, 295.5x-295.55, 295.6x-295.65, 295.7x- 295.75, 295.8x-295.85, 295.9x-295.95, 296.0x-296.06, 296.1x- 296.16, 296.2x-296.26, 296.3x-296.36, 296.4x-296.46, 296.5x- 296.56, 296.6x-296.66, 296.7, 296.8-296.82, 296.89, 296.9, 296.99, 297-297.3, 297.8, 297.9, 298-298.4, 298.8, 298.9, 299, 299.01, 299.1, 299.11, 299.8, 299.81, 299.9, 299.91, 300.3, 300.4, 301, 301.1, 301.11-301.13, 301.2-301.22, 301.3-301.5, 301.51, 301.59, 301.6-301.8, 301.81-301.84, 301.89, 301.9, 308-308.4, 308.9, 309-309.2, 309.21-309.24, 309.28, 309.29, 309.3, 309.4, 309.8, 309.81-309.83, 309.89, 309.9, 311, 312-312.03, 312.1-312.13, 312.2-312.23, 312.3-312.35, 312.39, 312.4, 312.8, 312.81, 312.82, 312.89, 312.9, 313-313.2, 313.21-313.23, 313.3, 313.8-313.83, 313.89, 313.9, 314, 314.01, 314.1, 314.2, 314.8, 314.9 CPT: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876, 98960, 98961, 98962, 99078, 99201-99205, 99211-99215, 99217-99223, 99231-99233, 99238, 99239, 99241-99245, 99251-99255, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510 HCPCS: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0040, H2000, H2001, H2010-H2019, H2020, M0064, S0201, S9480, S9484, S9485, T1015 Page 4 of 11

Measure (Adults) Patient Description Documentation Requirements Codes Medication Management Annual Monitoring for Patients on Persistent Medications 1 Patients 18 years and older who received 180 treatment days of ambulatory medication therapy for a select therapeutic agent Access/Availability of Care Initiation and Patients 13 years and older with a Engagement of Alcohol new episode of AOD dependence and Other Drug (AOD) between 1/1/2015 and 11/15/2015 Dependence Treatment 1 Pharmacy Quality Alliance* Proportion of Days Patients 18 years and older who have Covered 1 * been dispensed selected therapeutic agents Received: 1) Annual monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) 2) Annual monitoring for patients on digoxin 3) Annual monitoring for patients on diuretics Received: 1) Initiation of AOD treatment within 14 days of AOD diagnosis through inpatient admission, outpatient visit, intensive outpatient encounter, or partial hospitalization 2) Engagement of AOD Treatment Patients who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit Met proportion of days covered threshold of 80 percent during 2015 for each of the following: 1) Diabetes Medications 2) Renin Angiotensin System (RAS) Antagonists 3) Statins CPT: 80162, 80047, 80048, 80050, 80053, 80069, 82565, 82575, 80051, 84132 ICD-9-CM: 291.x-291.5, 291.8x-291.82, 291.89, 291.9, 303.0x- 303.02, 303.9x-303.92, 304.0x-304.02, 304.1x-304.12, 304.2x- 304.22, 304.3x-304.32, 304.4x-304.42, 304.5x-304.52, 304.6x- 304.62, 304.7x-304.72, 304.8x-304.82, 304.9x-304.92, 305.0x- 305.02, 305.2x-305.22, 305.3x-305.32, 305.4x-305.42, 305.5x- 305.52, 305.6x-305.62, 305.7x-305.72, 305.8x-305.82, 305.9x- 305.92, 535.3, 535.31, 571.1 CPT: 90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99408, 99409, 99411, 99412, 99510, 90791, 90792, 90801, 90802, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, 99233, 90816-90819, 90821-90824, 90826-90829, 99221-99223, 99231, 99232, 99238, 99239, 99251-99255 HCPCS: G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034, H0035, H0036, H0037, H0039, H0040, H2000, H2001, H2010, H2011, H2012, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 Renin Angiotensin System (RAS) Antagonists, Diabetes All Class Medications, or Statins dispensed Page 5 of 11

Measure Patient Description Documentation Requirements Codes (Women s Health) Prevention and Screening Breast Cancer Female patients 40 74 years Received mammogram to screen for breast ICD-9-PCS: 87.36, 87.37 Screening 1 CPT: 77055-77057 cancer between 10/1/13 12/31/15 HCPCS: G0202, G0204, G0206 Cervical Cancer Screening 2 1) Female patients 21-64 years of age 2) Female patients 30-64 years of age Chlamydia Screening in Female patients 16 24 years of age Women 1 who were identified as sexually active Access/Availability of Care Prenatal Care 2 Women who delivered a live birth between 11/6/2014 to 11/5/2015 1) Evidence of cervical cytology within last 3 years (date and result) 2) For women who do not meet the above criteria, evidence of cervical cytology and an HPV test on the same date of service during 2015 or the four years prior to 2015 CPT: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, 87620-87622 HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Received one test for chlamydia during 2015 CPT: 87110, 87270, 87320, 87490, 87491, 87492, 87810 Prenatal Care visit in the first trimester to an OB/GYN practitioner, other prenatal care practitioner, or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation must include the visit date and evidence of one of the following: 1) A basic physical obstetrical examination that includes: Auscultation for fetal heart tone, or Pelvic exam with obstetric observations, or Measurement of fundus height (a standardized prenatal flow sheet may be used), 2) Prenatal Care Procedure: Could be: Screening test/obstetric panel or TORCH antibody panel alone, or A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or Ultrasound/Echography of a pregnant uterus 3) Documentation of LMP or EDD with either prenatal risk assessment & counseling/education, or complete obstetrical history ICD-9-CM: 640.03, 640.83, 640.93, 641.x3-641.33, 641.83, 641.93, 642.x3-642.73, 642.93, 643.03, 643.13, 643.23, 643.83, 643.93, 644.03, 644.13, 645.13, 645.23, 646.x3-646.93, 647.x3-647.63, 647.83, 647.93, 648.x3-648.93, 649.x3-649.73, 651.x3-651.93, 652.x3-652.93, 653.x3-653.93, 654.x3-654.93, 655.x3-655.93, 656.x3-656.93, 657.03, 658.x3-658.43, 658.83, 658.93, 659.x3-659.93, 678.x3-678.13, 679.x3-679.13, V22.0, V22.1, V22.2, V23.0- V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81-V23.87, V23.89, V23.9, V28.0-V28.6, V28.81, V28.82, V28.89, V28.9, 88.78, 514 CPT: 59400, 59425, 59426, 59510, 59610, 59618, 76801, 76805, 76811, 76813, 76815-76821, 76825-76828, 99201-99205, 99211-99215, 99241-99245, 99500, 0500F-0502F HCPCS: G0463, H1000-H1005, T1015 Page 6 of 11

Measure Patient Description Documentation Requirements Codes (Women s Health) Access/Availability of Care Postpartum Care 2 Women who delivered a live birth between 11/6/2014 to 11/5/2015 Postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other PCP on or between 21 and 56 days after delivery. Documentation must indicate visit date & evidence of: Pelvic exam, or Examination of breasts (or notation of breastfeeding), abdomen, weight and blood pressure, or Notation of postpartum care: such as, 6 week check, postpartum visit/care, PP care, or preprinted postpartum care form ICD-9-CM: V24.1, V24.2, V25.1, V25.11, V25.12, V25.13, V72.3, V72.31, V72.32, V76.2 CPT: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622, 57170, 58300, 59430, 99501, 0503F HCPCS: G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Measure (Child and Patient Description Documentation Requirements Codes Adolescent Health) Prevention and Screening Weight Assessment & Patients 3 17 years of age Counseling for Nutrition and Physical Activity 2 Evidence of outpatient visit with PCP or OB/GYN containing the following during the 2015 calendar year: 1. BMI percentile (may be a BMI value for adolescents 16-17) BMI date and percentile value (BMI percentile plotted on age-growth chart) Weight date and value Height date and value 2. Counseling for Nutrition (diet) 3. Counseling for Physical Activity (sports participation/exercise) BMI Assessment and Percentile: ICD-9-CM: V85.51-V85.54 Counseling for Nutrition: ICD-9-CM: V65.3 CPT: 97802-97804 Counseling for Physical Activity: ICD-9-CM: V65.41 HCPCS: S9451, G0447 Page 7 of 11

Measure (Child and Patient Description Documentation Requirements Codes Adolescent Health) Prevention and Screening Childhood Patients turning 2 years of age Vaccines administered on or before 2 nd birthday: Immunizations 2 4-DtaP CPT: 90698, 90700, 90721, 90723 3 IPV CPT: 90698, 90713, 90723 3 HIB CPT: 90645-90648, 90698, 90721, 90748 3 Hep B ICD-9-CM: 70, 70.1, 70.2-70.23, 70.3-70.33, V02.61 CPT: 90723, 90740, 90744, 90747, 90748 HCPCS: G0010 1 MMR ICD-9-CM: Measles 55, 55.1, 55.2, 55.7, 55.71, 55.79, 55.8, 55.9; Mumps 72-72.3, 72.7-72.72, 72.79, 72.8, 72.9; Rubella 56, 56.01, 56.09, 56.7, 56.71, 56.79, 56.8, 56.9 CPT: MMR 90707, 90710; MR 90708; Measles 90705; Mumps 90704; Rubella 90706 4 Pneumococcal (PCV) CPT: 90669, 90670 HCPCS: G0009 1 Hep A ICD-9-CM: 70, 70.1 CPT: 90633 2 Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685 HCPCS: G0008 2 or 3 Rotavirus/RV (Rotarix = 2 dose, Rota CPT: 2 dose 90681, 3 dose 90680 Teq = 3 dose) 1 VZV or has had chickenpox ICD-9-CM: 52-52.2, 52.7-52.9, 53-53.14, 53.19, 53.2-53.22, 53.29, 53.7, 53.71, 53.79, 53.8, 53.9 CPT: 90710, 90716 Immunizations for Adolescents 2 (Combination 1) HVP Vaccination for Female Adolescents 2 Non-Recommended Screening in Adolescent Females 1 Patients 13 years of age Female patients 13 years of age Female patients 16-20 years of age Vaccines administered on or before 13 th birthday: 1 MCV/meningococcal vaccine on or between 11th& 13th birthdays, and 1 Tdap or 1 Td vaccine on or between their 10th and 13th birthdays Received 3 doses of human papillomavirus (HPV) vaccine by 13 th birthday Screened unnecessarily for cervical cancer in 2015 (Note: Cervical cancer screening for 16 20 year olds is not clinically recommended) CPT: 90703, 90714, 90715, 90718, 90719, 90733, 90734 CPT: 90649, 90650 Codes to Avoid: CPT: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, 87620-87622 HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Page 8 of 11

Measure (Child and Adolescent Health) Respiratory Conditions Appropriate Testing Patients 2 18 years of age with a for Children with diagnosis of pharyngitis Pharyngitis 1 Appropriate Testing for Children with Upper Respiratory Infection (URI) 1 Behavioral Health Follow-Up Care for Children Prescribed ADHD Medication 1 Metabolic Monitoring for Children and Adolescents on Antipsychotics 1 Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics 1 Use of Multiple Concurrent Antipsychotics in Children and Adolescents 1 Patient Description Documentation Requirements Codes Patients 3 months 18 years of age with a diagnosis of URI Patients 6 12 years of age with a newly prescribed attentiondeficit/hyperactivity disorder (ADHD) medication Patients 1 17 years of age with two or more antipsychotic prescriptions Patients 1 17 years of age with a new prescription for antipsychotic medication Patients 1 17 years of age Received group A streptococcus (strep) test prior to antibiotic dispensing Did not receive antibiotic medication Received at least three follow-up visits within a 10-month period: 1) Initiation one follow up visit with a prescribing practitioner within 30 days of first ADHD medication dispensing 2) Continuation and Maintenance Remained on ADHD medication for 210 days and had an additional 2 follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase. ICD-9-CM: 34, 462, 463 CPT: 87070, 87071, 87081, 87430, 87650, 87651, 87652, 87880 ICD-9-CM: 460, 465, 465.8, 465.9 without antibiotic medication dispensing CPT: 90804-90815, 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383, 99384, 99393, 99394, 99401-99404, 99411, 99412, 99510, 90801, 90791, 90792, 90802, 90816-90819, 90821-90824, 90826-90829, 90832-90834, 90836-90839, 90840, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99251-99255, 98966-98968, 99441-99443 HCPCS: G0155-G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 Received metabolic testing CPT: 80047, 80048, 80050, 80053, 80061, 80069, 82465, 82947, 82950, 82951, 83036, 83037, 83700, 83701, 83704, 83718, 83721, 84478, 3044F-3046F, 3048F-3050F with antipsychotic medication dispensed Documented evidence of psychosocial care as a first-line treatment Dispensed two or more concurrent antipsychotic medications CPT: 90832-90834, 90836-90840, 90845-90847, 90849, 90853, 90875, 90876, 90880 HCPCS: G0176, G0177, G0409-G0411, H0004, H0035-H0040, H2000, H2001, H2011-H2014, H2017-H2020, S0201, S9480, S9484, S9485 with antipsychotic medication dispensed Multiple antipsychotic medications dispensed Page 9 of 11

Measure (Child and Adolescent Health) Utilization Measures Well-Child Visits in the First 15 Months of Life 1 Well Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life 1 Adolescent Well-Care Visits 1 Patient Description Documentation Requirements Codes Patients 0 15 months old Patients 3 6 years of age Patients 12 21 years old Received 6 or more well visits by 15 months of age with a primary care practitioner (PCP) Received one or more well-child visits with a primary care practitioner (PCP) in 2015 Received at least one well visit in 2015 with a (PCP) or obstetrician/gynecologist (OB/GYN) ICD-9-CM: V20.2, V20.3x-V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 ICD-9-CM: V20.2, V20.3x-V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 ICD-9-CM: V20.2, V20.3x-V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 Note: Health Republic members are surveyed on an annual basis per federal regulation in a survey called, QHP Enrollee Experience Survey. This survey assesses patient experience and satisfaction with services rendered at the provider and plan level and whether patients received appropriate clinical care as indicated below. Measure (Survey) Patient Description Documentation Requirements Codes Enrollee Experience Survey (EES) Clinical Quality Management Medical Assistance Patients 18 years of age and older Evidence of advising smokers and tobacco ICD-9-CM: 305.1, 649.0x, 989.84 CPT: 99406, 99407, S9075, S9453, 99381-99397, 96150-96155, with Smoking and who smoke and/or use tobacco users to quit, discussing cessation 99078 Tobacco Use Cessation medications and strategies for current smokers or tobacco users in 2015 Aspirin Use and Discussion Female patients 56 79 years of age and male patients 46 79 years of age Evidence of discussing risks and benefits of using aspirin with a doctor or other health provider in 2015 Flu Shots for Adults Patients 18 64 years of age Received flu vaccination between 7/1/2015 and 5/8/16 CPT: 99401-99404 ICD-9-CM: V04.81, V06.6 CPT: 90654, 90686, 90688 Page 10 of 11

KEYS AND ADDITIONAL INFORMATION: DATA COLLECTION METHOD: 1 Administrative data gathered from medical and pharmacy claims, encounter, enrollment, lab, and provider systems. 2 Hybrid data collected from both administrative sources (claims, lab data, etc.) and data collected from the patient(s) medical record. Codes listed for hybrid measures require documentation as applicable in patient charts to be considered valid towards HEDIS measurement. *Proportion of Days Covered (PDC) is a medication use measure put forth by the Pharmacy Quality Alliance (PQA), a not-for-profit organization that aims to improve the quality of medication management. The PDC measure is also endorsed by the National Quality Forum (NQF). GLOSSARY AND RESOURCES HEDIS Healthcare Effectiveness Data and Information Set. HEDIS is a set of measures evaluating health care quality developed by the National Committee for Quality Assurance (NCQA). Both New York State and the federal government use HEDIS specifications as part of their Qualified Health Plan (QHP) quality rating methodologies. http://www.ncqa.org/hedisqualitymeasurement.aspx CAHPS Consumer Assessment of Healthcare Providers and Systems. These surveys are developed by the Agency for Healthcare Research and Quality (AHRQ) as a means of evaluating consumer experiences of care. CAHPS surveys are used to evaluate quality of both providers and health plans. https://cahps.ahrq.gov/index.html EES Enrollee Experience Survey. This survey is developed by the Centers for Medicare and Medicaid Services as a means of evaluating Marketplace enrollee experiences of care in QHPs. https://qhpcahps.cms.gov/ QARR Quality Assurance Reporting Requirements. QARR is a quality rating system developed by the New York State Department of Health (NYSDOH) to allow for consumer evaluation of health plan quality. QARR incorporates many HEDIS specifications for its quality rating methodology, as well as some New York State-specific specifications. http://www.health.ny.gov/health_care/managed_care/reports/eqarr/2014/about.htm http://www.health.ny.gov/health_care/managed_care/qarrfull/qarr_2014/docs/qarr_specifications_manual.pdf QRS Quality Rating System. QRS is a quality rating system developed by The Centers for Medicare and Medicaid Services (CMS) to provide consumers with information regarding the quality of QHPs offered in the insurance marketplaces. QRS incorporates many HEDIS specifications for its quality rating methodology, as well as some specifications developed by bodies such as AHRQ and Pharmacy Quality Alliance (PQA). https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/qrs-scoring-specification.pdf https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/2015-qrs-beta-test-measure-set.pdf ICD-9-CM International Classification of Diseases, Clinical Modification. ICD-9-CM codes are developed by the U.S. National Center for Health Statistics (NCHS). ICD-9-PCS International Classification of Diseases, Procedure Coding System. ICD-9-PCS codes are developed by the U.S. National Center for Health Statistics (NCHS). CPT Current Procedural Terminology codes are developed by the American Medical Association (AMA). HCPCS Healthcare Common Procedure Coding System is used by the Centers for Medicare & Medicaid Services (CMS). NOTE TO PROVIDERS/PROVIDER OFFICES: For questions regarding this document, please contact HRINY at quality@healthrepublicny.org. Page 11 of 11