HEDIS 101 forproviders 2019 improving quality of care

TNPEC-2878-19 September 2019

2

Topics covered

HIPAA 3

What is HEDISreg 4

What is your role in HEDIS 6

Annual HEDIS calendar 7

Types of reviews 8

Medical record request 9

Hybrid and administrative HEDIS measures 10-11

Questions and answers 12

Appendix oneA HEDIS hybrid measures and required documentationB HEDIS administrative measures

14-3637-47

Appendix two mdash HEDIS Physician Documentation Guidelines and Administrative Codes

48-49

Appendix three mdash survey data 50-54

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization

bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers

bull All of our health plan providersrsquo records are protected by this law

3

Health Insurance Portability and Accountability Act (HIPAA)

HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities

bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service

bull HEDIS is a retrospective review of services and performance of care

bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)

bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year

bull A subset of HEDIS measures is collected and reported for the Marketplace product lines

4

What is HEDIS

HEDIS (HĒ DIS)

Healthcare

Effectiveness

Data and

Information

Set

bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided

bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported

bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members

bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards

5

HEDIS results

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

2

Topics covered

HIPAA 3

What is HEDISreg 4

What is your role in HEDIS 6

Annual HEDIS calendar 7

Types of reviews 8

Medical record request 9

Hybrid and administrative HEDIS measures 10-11

Questions and answers 12

Appendix oneA HEDIS hybrid measures and required documentationB HEDIS administrative measures

14-3637-47

Appendix two mdash HEDIS Physician Documentation Guidelines and Administrative Codes

48-49

Appendix three mdash survey data 50-54

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization

bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers

bull All of our health plan providersrsquo records are protected by this law

3

Health Insurance Portability and Accountability Act (HIPAA)

HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities

bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service

bull HEDIS is a retrospective review of services and performance of care

bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)

bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year

bull A subset of HEDIS measures is collected and reported for the Marketplace product lines

4

What is HEDIS

HEDIS (HĒ DIS)

Healthcare

Effectiveness

Data and

Information

Set

bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided

bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported

bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members

bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards

5

HEDIS results

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull Under the HIPAA privacy rule data collection for HEDIS is permitted and does not require patient consent or authorization

bull Please be assured our membersrsquo personal health information is maintained in accordance with all federal and state laws Data is reported collectively without individual identifiers

bull All of our health plan providersrsquo records are protected by this law

3

Health Insurance Portability and Accountability Act (HIPAA)

HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities

bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service

bull HEDIS is a retrospective review of services and performance of care

bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)

bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year

bull A subset of HEDIS measures is collected and reported for the Marketplace product lines

4

What is HEDIS

HEDIS (HĒ DIS)

Healthcare

Effectiveness

Data and

Information

Set

bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided

bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported

bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members

bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards

5

HEDIS results

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull HEDIS is the measurement tool used by the nationrsquos health plans to evaluate their performance in terms of clinical quality and customer service

bull HEDIS is a retrospective review of services and performance of care

bull HEDIS is coordinated and administered by the National Committee for Quality Assurance (NCQA) and used by CMS for monitoring the performance of managed care organizations (MCOs)

bull All MCOs that are NCQA accredited perform HEDIS reviews the same time each year

bull A subset of HEDIS measures is collected and reported for the Marketplace product lines

4

What is HEDIS

HEDIS (HĒ DIS)

Healthcare

Effectiveness

Data and

Information

Set

bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided

bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported

bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members

bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards

5

HEDIS results

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull Receiving all requested medical records helps ensure that our results are an accurate reflection of care provided

bull HEDIS results are audited by an independent NCQA-certified auditor prior to being reported

bull Results are used to measure performance identify quality initiatives and provide educational programs for providers and members

bull Results are reported as part of Medicare Stars NCQA Health Plan Ratings and State and Marketplace Report Cards

5

HEDIS results

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull You play a central role in promoting the health of our members

bull You and your office staff help facilitate the HEDIS process improvement byo Reaching out to new and currently assigned

members for your practice and scheduling annual well exams

o Providing the appropriate care within designated time frames

o Documenting all care in member medical recordso Accurately coding all claims

(Providing accurate information on a claim may reduce the number of records requested)

o Responding to our requests for medical records within five to seven business days

6

What is your role in HEDIS

We appreciate your cooperation and timeliness in submitting the requested medical record information

The records you provide during this process help us validate the quality of care provided to our members

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

7

Annual HEDIS calendar

January-May

Clinical Quality staff initiates medical record requests and collection from providers

June

Results are reported to NCQA

July-October

NCQA releases Quality Compassreg results nationwide

Each year NCQA sets a hard deadline in May for health plans to complete HEDIS data collection Providers are encouraged to provide electronic medical records (EMR) data feeds to health plans year-round to reduce office disruption

Quality Compassreg is a registered trademark of NCQA

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

HEDIS data is collected the following waysbull Administrative data obtained from our claims database of received provider

EMR data feeds The use of ICD-10 and CAT II coding is highly recommendedbull Hybrid data obtained from our claims database and medical record reviewsbull Survey data obtained from member and provider surveys

bull New for 2019 HEDIS Electronic Clinical Data System reporting

o Depression Screening and Follow-Up for Adolescents and Adults (DSF)

o Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS)

o Depression Remission or Response for Adolescents and Adults (DRR)

o Unhealthy Alcohol Use Screening and Follow-Up (ASF)

o Adult Immunization Status (AIS)

o Prenatal Immunization Status (PRS)

8

Types of reviews

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull Medical record requests are sent to providers

bull The request includes a member list identifying their assigned measures and the minimum information needed

bull Data collection methods include fax mail onsite visits (for larger requests) remote electronic medical record system access and electronic data interchange via a secure site

9

Medical record requests

Due to the shortened data collection time frame a five- to seven-business day turnaround is appreciated

We recommend uploading records to our secure site to allow for better tracking of submitted information

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

10

Hybrid HEDIS measures

ABA Adult BMI Assessment IMA Immunizations for Adolescents

ADL Adolescent Preventive Care LSC Lead Screening in Children

AWC Adolescent Well-Care Visits MRPMedication Reconciliation Post-Discharge (Medicare only)

CBP Controlling High Blood Pressure PPC Prenatal and Postpartum Care

CCS Cervical Cancer Screening TRC Transitions of Care (Medicare only)

CDC Comprehensive Diabetes Care WCCWeight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

CIS Childhood Immunization Status W15Well-Child Visits in the First 15 Months of Life

COACare of Older Adults (Medicare Special Needs Population SNP and Medicare-Medicaid Plans MMPs)

W34Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

COL Colorectal Cancer Screening

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

11

Administrative HEDIS measures

AABAvoidance of Antibiotic Treatment in Adults With Acute Bronchitis

FUH Follow‐Up After Hospitalization for MentalIllness

ADDFollow-Up Care for Children Prescribed ADHD Medication

IET Initiation and Engagement of Alcohol andOther Drug Abuse or DependenceTreatment

AMMAntidepressant Medication Management LBP Use of Imaging Studies for Low Back Pain

ARTDisease‐Modifying Anti‐RheumaticDrug Therapy for Rheumatoid Arthritis MMA Medication Management for People With

Asthma

OMW Osteoporosis Management in WomenWho Had a Fracture SSD

Diabetes Screening for People with Schizophrenia or Bipolar Disorder WhoAre Using Antipsychotic Medications

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull Should you send the entire record No we ask that you only provide the minimum necessary to meet our request

bull Who do I contact if I have questions about HEDIS requestsEach medical record request includes contact information for a HEDIS Lead in Clinical Quality who is assigned to your office

bull How do I improve scores for HEDIS measures Use correct diagnosis and procedure codes submit claims and encounter data in a timely manner and ensure presence of all components required in medical record documentation

bull How are HEDIS rates communicated to physiciansEducational articles are included in provider newsletters which can be found on our website (httpsprovidersamerigroupcomTN)

bull Where can I get more information about NCQA and HEDISMore information can be found at wwwncqaorg

12

Questions and answers

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

Appendix oneA HEDIS hybrid measures and required documentation

B HEDIS administrative measures

13

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

Appendix one section A

HEDIS hybrid measures and required documentation

14

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

15

ABA mdash Adult BMI Assessment

Members 18-74 years of age who had an outpatient visit with a BMI documented during the measurement year or the prior year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull BMI (body mass index) date and valuebull Weight date and valuebull For members who are 18-19 years of age height

weight and BMI percentile on the date of visit

Common chart deficiencies

bull Height andor weight are documented but there is no calculation of the BMI

bull Ranges and thresholds are not acceptable for this measure a distinct BMI value or percentile is required

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

16

ADL mdash Adolescent Preventive Care

Adolescents 12 to 17 years of age who had at least one outpatient visit with a PCP or OBGYN practitioner and required documentation during the measurement year

Applicable forNew York Quality Assurance Reporting Requirements (QARR)

Documentation needed

bull Assessment counseling or education on risk behaviors associated with sexual activity and preventative actions

bull Assessment for depressionbull Risks of tobacco usebull Risk of substance abuse (including alcohol)

Common chart deficiencies

bull No documentation in chartbull Not all items addressed during the visit

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

17

AWC mdash Adolescent Well-Care Visits

Members 12-21 years of age in the measurement year who had at least one well-care visit with a PCP or OBGYN (school physical Pap or postpartum visit) during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health historybull Physical and mental developmental historybull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Adolescents being seen for sick visits and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

18

CBP mdash Controlling High Blood Pressure

Members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled(lt14090 Hg) during the measurement year (2018)

Applicable forMedicareMedicaidCommercial

Documentation needed

1 At least two outpatient visits on different dates of service with a diagnosis of HTN during the measurement year (2018) or the year prior (2017)

2 The BP reading must occur on or after the date when the second diagnosis of hypertension occurs

Common chart deficiencies

bull Rechecked elevated pressures during the same visit

not documented

bull Diagnosis date of hypertension is not clearly

documented

Special notes

bull Diagnosis can be from progress note problem list

consult note hospital admission or discharge

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

19

CCS mdash Cervical Cancer Screening

Female members 24-64 years of age who had cervical cancer screening during the measurement time frame ORFemale members 30-64 years of age during the measurement time frame who had cervical cancer screening and HPV test

Applicable forMedicaid Commercial

Documentation needed (one of the following)

bull Date and result of cervical cancer screening testbull Date and result of cervical cancer screening test

and date of HPV test on the same date of servicebull Evidence of hysterectomy with no residual cervix

Common chart deficiencies

bull Lack of documentation related to womenrsquos health in PCP charts

bull Incomplete documentation related to hysterectomy

bull HPVs ordered due to positive Pap tests do not count

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

20

CDC mdash Comprehensive Diabetes Care

Members 18-75 years of age with type I or II diabetes who received proper testing and care for diabetes during the measurement year

Applicable forMedicareMedicaidCommercial

Documentation needed

bull Hemoglobin A1Cbull Blood pressurebull Nephropathy urine tests ACEARB prescription

or visits to nephrologists during the measurement year

bull Dilated retinal eye exam (during the measurement year or year prior)

Date and result of last screening in the measurement year

Common chart deficiencies

bull Incomplete information from consultants in the PCP charts

bull Incomplete information related to yearly lab testing and results

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

21

CIS ndash Childhood Immunization Status

Required immunizations

4 each Diphtheria tetanus pertussis (DTP) pneumococcal conjugate vaccine (PCV)

3 each Hepatitis B Haemophilus influenza type B (HIB) inactivated polio vaccine (IPV)

2 or 3 RotavirusRV

Rotavirus (RV) available in Rotarix (two dose) or Rota Teq (three dose)

2 each Influenza

1 each Hepatitis A measles mumps and rubella (MMR) varicella zoster virus (VZV) or had chickenpox

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Documentation needed

Please include the following if any immunizations are missing bull Parental refusalbull Request for delayed immunization schedulesbull Immunizations given at health departmentsbull Immunizations given in the hospital at birthbull Contraindications or allergies

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

22

CIS mdash Childhood Immunization Status (cont)

Percentage of children two years of age who had all of the required immunizations

Applicable forMedicaidCommercial

Common chart deficiencies

bull Immunizations received after the second birthday

bull Incomplete number of vaccines administered according to the recommended vaccine series

bull PCP charts do not contain immunization records if received elsewhere such aso Health Departmentso Immunizations that are given in the hospital

at birthbull No documentation of contraindicationsallergies

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

23

COA mdash Care of Older Adults

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Advance care planning bull Includes a discussion about preferences for

resuscitation life sustaining treatment and end of life care Examples include o Advance directiveso Actionable medical orderso Living willo Surrogate decision maker

Medication reviewbull Includes at least one medication review

conducted by a prescribing practitioner or clinical pharmacist in the measurement year and the presence of a medication list or includes notation that the member is not taking any medication

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

24

COA mdash Care of Older Adults (cont)

Percentage of adults over 66 years of age who had each of the following during the measurement yearbull Advance care planningbull Medication reviewbull Functional status

assessmentbull Pain assessment

Applicable forMedicare SNPMMP

Documentation needed

Functional status assessmentbull Includes evidence of at least one functional

status assessment and the date it was performed as documented by o Instrumental Activity of Daily Living o Activities of Daily Livingo Results of a standardized functional status

assessment toolo Notation that at least three of the four

following were assessed notation of functional independence sensory ability cognitive status and ambulatory status

Pain assessmentbull Includes evidence of a pain assessment using a

standardized pain assessment tool and the date it was performed

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

25

COL mdash Colorectal Cancer Screening

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Documentation needed

Date and result of one of these screeningsbull Colonoscopy (within last 10 years)bull Fecal occult blood testing FOBT (in

measurement year) o FOBT tests performed in an office setting or

on a digital rectal exam do not countbull Flexible Sigmoidoscopy (within last 5 years)bull CT Colonography (within last 5 years)bull Fecal immunochemical DNA test (FIT-DNA)(aka

Cologuardreg) test (within last 3 years)

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

26

COL mdash Colorectal Cancer Screening (cont)

Members 50-75 years of age who had appropriate screening for colorectal cancer

Applicable forMedicareCommercial

Common chart deficiencies

bull Colorectal screenings are not consistently documented in health histories

bull Typically this information is included on health history forms however this information is not always provided as part of the record submissions

Special notes

bull Patient reported data noted on a medical record is sufficient evidence with date and resultsnoted

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

27

IMA mdash Immunizations for Adolescents

Adolescent members turning 13 years of age in the measurement year who had these immunizations

Applicable forMedicaid Commercial

Documentation needed

bull Meningococcal one dose on or between 11th and 13th birthdays

bull Tdap one dose on or between 10th and 13th

birthdaysbull HPV 2-dose or 3-dose vaccine series

administered between 9th and 13th birthdaysbull If immunizations are missing please include

o Documentation of parental refusalo Health Department recordso Patient contraindicationsallergies

Common chart deficiencies

bull Immunizations not administered during appropriate timeframes

bull PCP charts do not contain immunization records if received elsewhere (ie Health Departments)

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

28

LSC mdash Lead Screening in Children

Percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Applicable forMedicaidNew York QARR

Documentation needed

bull A note indicating the date the test was performed

bull Result or finding

Common chart deficiencies

bull Lead assessment does not constitute a lead screening

bull Testing conducted outside of time framebull Provider assumes that there is no exposure due

to environment

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

29

MRP mdash Medication Reconciliation Post-Discharge

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

bull Medication reconciliation completed by the prescribing practitioner clinical pharmacist or registered nurse on or within 30 days of discharge

bull Need documentation that it was completed and the date that it was done

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

30

MRP mdash Medication Reconciliation Post-Discharge (cont)

Percentage of discharges from January 1st to December 1st of the measurement year for members over 18 years of age for whom medications were reconciled on or within 30 days of discharge

Applicable forMedicare

Documentation needed

Any of the following evidence meets criteria bull Notation that the medications prescribed upon

discharge were reconciled with the current medications in the outpatient record

bull A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications

bull Notation that no medications were prescribed or ordered upon dischargeo Evidence that the member was seen for

post-discharge hospital follow-up with evidence of medication reconciliation or review

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

31

PPC mdash Prenatal and Postpartum Care

Female members who had a live birth between November 6 of the year prior and November 5 of the measurement year

Applicable forMedicaid Commercial

Documentation needed

bull Prenatal care Prenatal visit within 42 days of enrollment or during the first trimester

bull Postpartum care Postpartum visit within 21-56 days of delivery

Common chart deficiencies

bull Incision check for post C-section alone does not constitute a postpartum visit

bull Office visit outside of time frame

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

32

TRC mdash Transitions of Care

Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year

Four rates are reportedbull Notification of Inpatient

Admissionbull Receipt of Discharge

Informationbull Patient Engagement after

Inpatient Dischargebull Medication Reconciliation

Post-Discharge

Applicable forMedicare (new for 2018)

Documentation needed

bull Documentation of receipt of notification of inpatient admission on the day of admission or the following day

bull Documentation of receipt of discharge information on the day of discharge or the following day

bull Documentation of patient engagement after inpatient discharge (eg office visits home visits telehealth) provided within 30 days after discharge

bull Documentation of medication reconciliation conducted by a prescribing practitioner clinical pharmacist or registered nurse within 31 days after discharge

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

33

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Documentation needed

BMI (body mass index) percentile bull BMI percentile and date

o Note BMI values ranges and thresholds do not meet the criteria for this measure

bull Weight and datebull Height and date

Counseling for nutrition bull Discussion on diet and nutrition anticipatory

guidance or counseling on nutrition

Counseling for physical activity bull Discussion of current physical activities

counseling for increased activity or anticipatory guidance on physical activity

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

34

WCC mdash Weight Assessment and Counseling for Nutrition and Physical Activity for ChildrenAdolescents (cont)

Members 3-17 years of age who had an outpatient visit with the following components in the measurement year

Applicable forMedicaidCommercial

Common chart deficiencies

bull BMI documented as number not percentile based on height weight age and gender

bull BMI growth chart not included in records submitted

bull Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate

bull Notation of anticipatory guidance related solely to safety (eg wears helmet or water safety) without specific mention of physical activity recommendations

bull Developmental milestones do not constitute anticipatory guidance or education for physical activity

bull Preprinted forms do not always address nutrition and physical activity

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

35

W15 mdash Well-Child Visits in the First 15 Months of Life

Children who turned 15 months of age during the measurement year who had 0-6 well-child visits

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

36

W34 mdash Well-Child Visits in the 3rd 4th 5th and 6th Years of Life

Children 3-6 years of age in the measurement year that have had at least one well-care visit with a PCP during the measurement year

Applicable forMedicaidCommercial

Documentation needed

bull Health history bull Physical and mental developmental historybull Physical exambull Health educationanticipatory guidance

Common chart deficiencies

bull Lack of documentation of education and anticipatory guidance

bull Children being seen for sick visits only and no documentation related to well-child visits

Special notes

bull Preventive services may be rendered on visits other than well-child visits

bull Services specific to the assessment or treatment of an acute or chronic condition do not count toward the measure

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

Appendix one section B

HEDIS administrative measures

37

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

38

AAB mdash Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Applicable forMedicaidCommercial

Details

Dispensed prescription for antibiotic medications (listed in the HEDIS 2018 Medication List) on or three days after the index episode start date bull Intake period (January 1ndashDecember 24 of the

measurement year) the intake period captures eligible episodes of treatment

bull Episode date the date of service for any outpatient or ED visit during the intake period with a diagnosis of acute bronchitis

This measure is reported as an inverted rate A higher rate indicates appropriate treatment of adults with acute bronchitis (ie the proportion for whom antibiotics were not prescribed)

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

39

AMM mdash Antidepressant Medication Management

Percentage of members 18 years of age and older who were treated with antidepressant medication had a diagnosis of major depression and who remained on an antidepressant medication treatment

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull Effective Acute Phase Treatment the percentage

of members who remained on an antidepressant medication for at least 84 days (12 weeks)

bull Effective Continuation Phase Treatment the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

40

ADD mdash Follow-Up Care for Children Prescribed ADHD Medication

Percentage of children 6-12 years of age who received an initial prescription for ADHD medication and had at least two follow up visits within 270 days (nine months)

Applicable forMedicaidCommercial

Details

Two rates are reportedbull Initiation phase received at least one follow-up

visit with a practitioner with prescribing authority within 30 days of prescription

bull Continuation and maintenance phase remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least two follow-up visits within 270 days after the initiation phase ended with a practitioner with prescribing authority

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

41

ART mdash Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

The percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for adisease-modifying anti-rheumatic drug (DMARD)

Applicable forCommercial Medicaid Medicare

Details

Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year

There are two ways to identify members who received a DMARD1 Claimencounter data2 Pharmacy data

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

42

FUH mdash Follow-Up After Hospitalization for Mental Illness

Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner

Applicable forMedicareMedicaidCommercial

Details

Two rates are reportedbull The percentage of discharges for which the

member received follow-up within 30 days of discharge

bull The percentage of discharges for which the member received follow-up within 7 days of discharge

Do not include visits that occur on the date of discharge

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

43

IET mdash Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year

Applicable forMedicareMedicaidCommercial

Details

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence who received the followingbull Initiation of AOD Treatment the percentage of

members who initiate treatment through an inpatient AOD admission outpatient visit intensive outpatient encounter partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis

bull Engagement of AOD Treatment the percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

44

LBP mdash Use of Imaging Studies for Low Back Pain

Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray MRI or CT scan) within 28 days of the diagnosis

Applicable forMedicaidCommercial

Details

bull Intake period (January 1-December 3 of the measurement year) the intake period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain

bull Index episode start date the earliest date of service for an outpatient or ED encounter during the intake period with a principal diagnosis of low back pain

bull This measure is reported as an inverted rate A higher score indicates appropriate treatment of low back pain (ie the proportion for whom imaging studies did not occur)

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

45

MMA mdash Medication Management for People With Asthma

Percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period

Applicable forMedicaidCommercial

Details

Two rates are reportedbull The percentage of members who remained on an

asthma controller medication for at least 50 of their treatment period

bull The percentage of members who remained on an asthma controller medication for at least 75 of their treatment period

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

46

OMW mdash Osteoporosis Management in Women Who Had a Fracture

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD)test or prescription for a drug to treat osteoporosis in the six months after the fracture

Applicable forMedicare

Details

Intake period mdash A 12‐month (one year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year The intake period is used to capture the first fracture

Index episode start date (IESD) mdash The earliest date of service for any encounter during the intake period with a diagnosis of fracture For an outpatient or emergencydepartment visit the IESD is the date of service For inpatient encounters the IESD is the date of discharge

Negative DX history mdash A period of 60 days (two months) prior to the IESD when the member had nodiagnosis of fracture

For direct transfers the first admission date should be used when determining the number of days prior to the IESD

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

47

SSD mdash Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

Percentage of members 18-64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a glucose or HbA1c test performed during the measurement year

Applicable forMedicaid

Details

bull Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding

bull Count notation of the followingo A1co HbA1co HgbA1co Hemoglobin A1co Glycohemoglobin A1co Glycohemoglobino Glycoated hemoglobino Glycosylated hemoglobin

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

Appendix two

HEDIS Physician Documentation Guidelines and Administrative Codes

48

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull This document is located on our provider website (httpsprovidersamerigroupcomTN)

bull This reference document includes HEDIS measures and the criteria including ICD-10 CPT and HCPCS codes required for our memberrsquos chart or claims review to be considered valid towards HEDIS measurements

49

HEDIS Measure 2019 Physician Documentation Guidelines and Administrative Codes

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

Appendix three

Survey data

50

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

The following are used to collect data

bull CAHPSreg Health Plan Survey 50H Adult Version This survey provides information on the experiences of our members and indicates how well the organization meets their expectations for Commercial and Medicaid populations

o Note Medicare Advantage members are surveyed by each health plan using the Medicare Advantage CAHPS Survey developed by CMS

bull CAHPSreg Health Plan Survey for Children with Chronic Conditions Version This survey provides information on the experiences of our membersrsquo parentsguardians and indicates how well the organization meets their expectations for Medicaid populations

bull Medicare Health Outcomes Survey This survey provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period

51

Survey data

CAHPSreg is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

bull CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans

bull The surveys assess our membersrsquo experience with us over the past six months for Medicaid and Medicare plans

bull Health plans report survey results to NCQA which uses the results to

o Make accreditation decisions

o Rate health plans

o Create national benchmarks for care and service

bull Health plans also use CAHPS survey data for internal quality improvement purposes

52

CAHPS surveys

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

53

CAHPS Health Plan Survey 50 H mdashAdult Version

Results reflect members rating the plan 8 9 or 10 on a scale of 0 to 10 in the following areas 1 Rating of all health

care2 Rating of health plan

overall3 Rating of personal

doctor4 Rating of specialist

seen most often

Composite scores also summarize responses for these key areas

1 Claims processing (Commercial only)2 Customer service3 Getting care quickly4 Getting needed care5 How well doctors communicate6 Shared decision making7 Plan information on costs (Commercial only)

There are two areas that are reported individually

bull Health promotion and educationbull Coordination of care

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

The survey for children with chronic conditions produces the following measures for this population

bull Access to prescription medicines

bull Access to specialized services

bull Family-centered care

bull Having a personal doctor or nurse who knows the child

bull Shared decision making

bull Getting needed information

bull Coordination of care and services

54

CAHPSreg Health Plan Survey for Children with Chronic Conditions Version

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

55

Medicare Health Outcomes Survey

Scores are categorized and percentages reported as bull Better than expectedbull Same as expectedbull Worse than expected

The Medicare Health Outcomes Survey provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance

56

Thank you

The codes and measure tips listed are informational only not clinical guidelines or standards of medical care and do not guarantee reimbursement All member care and related decisions of treatment are the sole responsibility of the provider This information does not dictate or control your clinical decisions regarding the appropriate care of members Your stateprovider contract(s) Medicaid member benefits and several other guidelines determine reimbursement for the applicable codes Proper coding and providing appropriate care decrease the need for a high volume of medical record review requests and provider audits It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members Please note The information provided is based on HEDIS 2019 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA) the Centers for Medicare amp Medicaid Services (CMS) and state recommendations Please refer to the appropriate agency for additional guidance