Aug 202009
 

HEDIS® 2010 Measures

 

*Measures that may be collected with medical record review.

We are committed to helping you find ways to save time, positively affect staff efficiencies, and increase patient satisfaction. To that end, we encourage you to use Category II CPT and Category I CPT/HCPC codes when coding certain services and test results used for HEDIS measures. For your convenience, we have posted a list of Category II CPT codes that affect HEDIS measures.

CPT Catagory II Codes.doc

Prevention and Screening

Measure

Screening, test or care needed

* Adult BMI Assessment

Members 18-75 years of age who had an outpatient visit in the measurement year and had their body mass index documented.

Documentation in the medical record must include:

§ Date of the BMI

§ BMI value

Members younger than 19 years, documentation of BMI percentile will meet criteria:

§ BMI percentile documented as a value (75th percentile)

§ BMI percentile plotted on an age- growth chart.

Documentation of height and weight only does not meet HEDIS criteria.

*Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Members 2-17 years of age, who had an outpatient visit with a PCP or OB/GYN and had evidence of the following documented:

§ BMI percentile

§ Counseling for Nutrition

§ Counseling for Physical Activity

BMI Percentile documentation must includes:

§ Date of the BMI and evidence of either

§ BMI percentile

§ BMI percentile plotted on age-growth chart

Counseling for Nutrition documentation must includes:

§ A note indicating the date and evidence of at least one of the following:

§ Engagement in discussion of current nutrition behaviors

§ Checklist indicating nutrition was addressed

§ Counseling or referral for nutrition education

§ Anticipatory guidance for nutrition

Counseling for Physical Activity documentation includes:

§ A note indicating the date and evidence of at least one of the following:

§ Engagement in discussion of current physical activity behaviors

§ Checklist indicating physical activity was addressed

§ Counseling or referral for physical activity education

§ Member received educational materials on physical activity

§ Anticipatory guidance for physical activity

*Childhood Immunization

Vaccines must be completed by the 2nd birthday

§ 4 DTaP/DT (do not count any before 42 days of age)

§ 3 IPV (do not count any before 42 days of age)

§ 1 MMR

§ 2 HiB (do not count any before 42 days of age)

§ 3 Hepatitis B

§ 1 VZV, positive serology, or documented chicken pox disease before 2nd birthday

§ 4 pnemococcal conjugate

§ 2 Hepatitis A

§ 2 or 3 doses (depending on which vaccine is administered of Rotavius

§ 2 influenza (do not count any before 6 months of age)

NOTE: Medical record documentation of “immunizations are up-to-date” is not acceptable.

*Adolescent Immunizations

Vaccines must be completed by the 13th birthday

§ 1 meningococcal conjugate or meningococcal polysaccharide between 11th and 13th birthday

§ 1 Tdap or Td between 10th and 13th birthday

*Lead Screening in

Children (Medicaid only)

Children Age 2

Children who received at least one capillary or venous lead test on or before the child’s 2nd birthday.

 

Breast Cancer Screening

Ages 40-69

Women who have received a mammogram in the measurement year or one year prior.

*Cervical Cancer Screening

Ages 21-64

Women who have received a PAP test within the measurement year or prior two years.

 

*Colorectal Cancer

Screening

Ages 50-75

Adults who received one or more of the following screenings:

§ Colonoscopy in past 10 years

§ Double contrast enema (DCBE) in past 5 years

§ Fecal occult blood test (FOBT) annually

§ Flexible sigmoidoscopy in past 5 years

Chlamydia Screening

Ages 16-24 and presumed sexually active

Women identified by claims or pharmacy data indicating potential sexual activity

§ Annual test for chlamydia

 

Glaucoma Screening on Older Adults(Medicare only)

Age 65 and older

Older adults without a prior diagnosis of glaucoma or glaucoma suspect who received a glaucoma eye exam by an optometrist or ophthalmologist

Respiratory Conditions

Measure

Screening, test or care needed

Appropriate Testing of Children with Pharyngitis Ages 2-18 years

Children diagnosed with pharyngitis that were prescribed an antibiotic and received a Group A streptococcus test 3 days before or after the prescription.

 

Appropriate Treatment of Children with Upper Respiratory Infections

Ages 3 months- 18 years

Children diagnosed with URI and were not dispensed an antibiotic prescription within 3 days of URI diagnosis.

 

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Ages 18-64

Adults diagnosed with acute bronchitis who were not dispensed an antibiotic prescription.

 

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

Age 40 and older

Adults with a new (within the measurement year) diagnosis or newly active COPD

who received spirometry testing to confirm diagnosis.

§ Spirometry testing must occur 730 days prior to or 180 days after the diagnosing event.

Pharmacotherapy Management of COPD Exacerbation

Age 40 and older

Adults who had an acute inpatient discharge or an ED encounter with a primary diagnosis of COPD who were dispensed both:

§ A systemic corticosteroid within 14 days of discharge

§ A bronchodilator within 30 days of discharge

Use of Appropriate Medications for People with Asthma

Ages 5-50

Children and adults identified with asthma that received prescription for long-term control of asthma.

NOTE: Long acting beta-2 agonists do not count by themselves. They are considered add-on therapy.

Cardiovascular

Measure

Screening, test or care needed

*Cholesterol Management

for Patients with

Cardiovascular Condition

Ages 18-75

Adults who were discharged alive for any of the following:

§ Acute myocardial infarction (AMI)

§ Coronary artery bypass graft (CABG)

§ Percutaneous transluminal coronary angioplasty (OTCA)

or who had:

§ Diagnosis of ischemic vascular disease for 2 years with each of the following tests in the measurement year: LDL-C screening and LDL-C control and had a LDL-C performed.

Documentation must include data and results of a LDL-C

*Controlling High Blood

Pressure

Ages 18-85

Adults who had a diagnosis of hypertension with blood pressure control (<140/90) in the most recent blood pressure reading in medical chart in the measurement year:

§ The lowest systolic and lowest diastolic reading will be used if there are several BP recorded on the same date the.

§ Home BP readings will be used if documented in the medical chart.

Persistence of Beta-

Blocker Treatment After

Heart Attack

Age 18 and older

Adults who were hospitalized and discharged alive after an acute myocardial infarction who received persistent treatment with beta-blockers for six months after discharge.

 

     


 

Diabetes

Measure

Screening, test or care needed

*Comprehensive Diabetes

Care

Ages 18-75

Adults with annual screening of the following:

  • HbA1c testing
  • HbA1c > 9.0 % = poor control
  • HbA1c <8.0%
  • HbA1c < 7.0 %= good control
  • LDL-C testing
  • LDL-C <100mg/dL
  • Retinal eye exam
  • Nephropathy screening test or evidence of nephropathy
  • Blood pressure < 140/90
  • Blood pressure < 130/80

Musculoskeletal

Measure

Screening, test or care needed

Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

Age 18 and older

Adults who were diagnosed with rheumatoid arthritis that received at least one prescription for a disease modifying anti-rheumatic drug.

Osteoporosis Management in Women who had a Fracture

Age 67 and older

Women who received the following within 6 months of suffering a fracture:

  • Bone mineral density (BMD) test
  • Rx for a drug to treat or prevent osteoporosis

Use of Imaging Studies for Low Back Pain

Age 18 and older

Adults with a primary diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis.

Behavioral Health

Measure

Screening, test or care needed

Antidepressant Medication Management

Age 18 and older

Adults newly diagnosed with depression and treated with an antidepressant who remain on medication. The rates reported are:

§ Effective acute phase: remained on antidepressant for 84 days of the acute treatment phase

§ Effective continuation phase: remained on antidepressant for 180 days

To qualify as a new diagnosis, 2 criteria must be met:

1. A 120-day negative depression diagnosis history on or before the start date

2. A 90-day negative medication history on or before the start date

Follow-up Care for Children Prescribed ADHD Medication

Ages 6-12 years

Children who received an initial prescription for ADHD medication and:

§ At least one follow-up visit with a prescribing practitioner within 30 days of medication initiation

§ Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two visits within four weeks and nine months.

Follow-up After Hospitalization for Mental Illness

Ages 6 and over

 

Patient discharged from an inpatient mental health admission and receive at least one ne follow-up outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner:

§ within 7 days of discharge;

§ within 30 days after discharge.


 

Medication Management

Measure

Screening, test or care needed

Annual Monitoring for Patients on Persistent Medications

Age 18 and older

 

 

 

 

 

 

 

Adults on persistent medications (at least 180 days) who received the following annual lab test monitoring:

Medications

Annual monitoring lab test(s)

ACE inhibitors/ ARBs

Digoxin

Diuretics

Serum potassium (K+) and either serum creatinine (SCr), or blood urea nitrogen (BUN)

Anticonvulsants:

Carbamazepine

Phenobarbital

Phenytoin

Valproic Acid

Anticonvulsants drug serum concentration

 

Potentially Harmful Drug-Disease Interactions in the Elderly

(Medicare only) Age 65 and older

Older adults who have an underlying disease, condition or health concern and who received an ambulatory prescription for a contraindicated

medication, at the same time or after the diagnosis.

Use of High-Risk Medications in the Elderly (Medicare only)Age 65 and older

Older adults who have received at least one high-risk medication and older adults who have received at least two different high-risk medications.

Measures Collected through CAHPS Health Plan Survey

Measure

Screening, test or care needed

Flu Shots for Adults

Ages 50-64

Adults who received an annual flu shot.

Flu Shots for Older Adults

(Medicare only) Age 65 and older

Older adults who received an annual flu shot.

Medical Assistance with Smoking Cessation

Tobacco users 18 and older

Current smokers who were seen by a practitioner and:

§ Advised to quit smoking

§ Cessation medications were recommended or discussed

§ Cessation strategies were recommended or discussed

 

Pneumonia Vaccination Status for Older Adults (Medicare only)

Age 65 and older

Older adults who received a pneumococcal vaccine.

Access/Availability of Care

Measure

Screening, test or care needed

Adult Access to Preventive/Ambulatory Care

Age 20 and over

Adults with annual ambulatory or preventive care visit.

Children and Adolescents’ Access to PCPs

Age 12 months to 19 years

Children and adolescents with a visit with their primary care physician.

Initiation and Engagement of Alcohol and Other Drug Dependence (AOD) Treatment

Age 13 and older

Adolescents and adults diagnosed with alcohol and other drug dependence who:

  • Initiate treatment within 14 days
  • Receive at least 2 AOD services within 30 days of treatment initiation

Prenatal/ Postpartum Care

Pregnant Women

Women who have received:

  • Prenatal visit within first trimester (or within 42 days of enrollment)
  • Postpartum visit between 21 and 56 days after delivery

 

     


 

Use of Services

Measure

Screening, test or care needed

*Well-child Exams

Ages 0-15 months

6 well-care visits (at least 2 weeks apart) with a PCP. Must show evidence of all of the following:

  • Health and development history (physical and mental)
  • Physical exam
  • Health education/anticipatory guidance

*Well-child Exams

Ages 3-6 years

At least one well-care visit with a PCP or OB/GYN. Must show evidence of all the following:

  • Health and development history (physical and mental)
  • Physical exam
  • Health education/anticipatory guidance

*Adolescent Well-Care Visit

Ages 12-21 years

At least one well-care visit with a PCP or OB/GYN. Must show evidence of all the following:

  • Health and development history (physical and mental)
  • Physical exam
  • Health education/anticipatory guidance

 

 Posted by at 9:42 am

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