Download pdf - Helpful HEDIS Documentation Tips for Providers Beer Health of Kentucky HEDIS Tip Sheet Page 1 Helpful HEDIS Documentation Tips for Providers HEDIS Measure Definitions What You Can

Aetna Be�er Health of Kentucky HEDIS Tip Sheet Page 1

Helpful HEDIS Documentation Tips for Providers

HEDIS Measure Definitions

What You Can Do

Coding Tips

BCS Breast Cancer Screening Women 50-74 years of age with one or

more mammograms within last 2

years.

Document member educa+on on the benefits

of early detec+on of breast cancer. Encourage mammography to all women who

are within risk group.

CPT Codes: 77055-77057

HCPCS: G0202

UB Rev Codes: 0403

Mastectomy Codes:

ICD-10CM Code: Z90.13, or Z90.12 and Z90.11

ICD-10PCS Code: 0HTV0ZZ, or 0HTU0ZZ and 0HTT0ZZ

CPT Codes: 19180, 19200, 19220, 19240, 19303-19307 with

a Bilateral Modifier CPT Codes: 50, 09950 or LT and RT

CCS Cervical Cancer Screening Women 21-64 years of age with one or

more cervical cytology tests within the

last 3 years or for women 30-64 years

of age, a cervical cytology and human

papillomavirus (HPV) co-tes+ng with in

the last 5 years.

Women who have had a total hysterectomy

with no residual cervix are excluded. TOTAL or COMPLETE hysterectomy

MUST be documented in history or problem

list. Documenta+on of “hysterectomy” alone

does not count. Nota+on of Pap test located in progress notes

MUST include the lab results in order to meet

NCQA® requirements. Cervical cytology and human papillomavirus

test must be completed four or less days apart

in order to qualify for every 5 years tes+ng. .

Cervical Cytology

CPT Codes: 88141-88143, 88147, 88148, 88150, 88150-

88154, 88164-88167, 88174, 88175

HCPCS: G0123, G0124, G0141, G0143-G0145, G0147,

G0148, P3000, P3001, Q0091

UB Rev Codes : 0923

LOINC Codes: 10524-7, 18500-9, 19762-4,19764-0,

19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

HPV

CPT Codes: 87620-87622, 87624, 87625

LOINC Codes: 21440-3, 30167-1, 38372-9, 49896-4,

59420-0, 59263-4, 59264-2, 69002-4, 75406-9, 75694-0,

71431-1, 77379-6, 77399-4, 77400-0

Hysterectomy Codes:

51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150,

58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267,

58270, 58275, 58280, 58285, 58290-58294, 58548, 58550,

58552-58554, 58570-58573, 58951, 58953, 58954, 58956,

59135 , 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ, Q51.5,

Z90.710, Z90.712

CHL Chlamydia Screening in Women Women 16-24 years of age who are iden+fied as sexually ac+ve with a Chlamydia test annually.

Assist with member educa+on of STD. Perform rou+ne test for Chlamydia, document

and submit +mely. Urine Chlamydia test is the

easiest to perform.

CPT Codes: 87110, 87270, 87320, 87490-87492, 87810

LOINC Codes: 14463-4, 14464-2, 14467-5, 14470-9, 14471-

7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7,

21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6,

31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3,

42931-6, 43304-5, 43404-3, 43406-8, 44806-8, 44807-6,

45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7,

45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1,

45100-5, 47211-8, 47212-6, 49096-1, 4993-2, 50387-0,

53925-4, 53926-2, 557-9, 560-3, 6349-5,6354-5, 6355-2,

6356-0, 6357-8, 80360-1, 80361-9, 80362-7, 80363-5,

80364-3, 80365-0, 80367-6



What You Can Do

Coding Tips

ART Disease-Modifying An+-Rheuma+c Drug Therapy for Rheumatoid Arthri+s Members 18 years of age or older who

were diagnosed with rheumatoid arthri+s

and were prescribed a disease-modifying

an+-rheuma+c drug (DMARD).

Prescribe DMARDs to members with rheu-

matoid arthri+s. Exclusions: A diagnosis of HIV any+me

during the member’s history through

December 31 or a diagnosis of pregnancy

during the year.

Diagnosis Codes: M05.00-M06.9 DMARD HCPCS:

J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262,

J7502, J7515-J7518, J9250, J9260, J9310

CBP Controlling High Blood Pressure Members 18-85 years of age with a diagnosis of hypertension (HTN) and

whose BP is adequately controlled.

If BP elevated (140/90 or greater) at ini+al

vital sign assessment, alleviate poten+al

factors that might cause temporary eleva-

+on and retake BP during exam. If eleva+on persists, treat as necessary

and retake BP. Document all measure-

ments and efforts to obtain BP control. Schedule follow up visits to monitor effec-

+veness of BP medica+on.

Diagnosis Codes: I10

Blood Pressure Procedure Codes :

Systolic BP < 140 3074F, 3075F Diastolic <90 3078F, 30709F

CDC Comprehensive Diabetes Care Members 18-75 years of age with diabetes should have each of the follow-

ing at least annually: HbA1C tes+ng, medi-

cal a�en+on for nephropathy, a re+nal

eye exam and blood pressure monitoring

at each visit.

Document results of HbA1C and Microal-

bumin exams annually or more oJen as

needed. A current medica+on list indica+ng that a

member is on an ACE/ARB medica+on

such as Lisinopril or Losartan is appropri-

ate for nephropathy a�en+on. Refer member to Optometrist for Dilated

Re+nal Eye Exam annually. Obtain the

results from the eye provider and place a

copy in the member’s medical record.

Diagnosis Codes: E10.10-E13.9, O24.011-O24.33, O24.811-O24.83 HbA1c Procedure Codes: 83036, 83037

HbA1c level 7.0-9.0: 3045F

HbA1c level less than 7.0: 3044F

HbA1c level greater than 9.0: 3046

Nephropathy Screen

Procedure Codes: 82042 - 82044, 84156, 3060F, 3061F Blood Pressure Procedure Codes:

Systolic BP < 140 3074F, 3075F Diastolic <90 3078F, 30709F

SPR Use of Spirometry Tes+ng in the Assess-

ment and Diagnosis of COPD. Members age 40 years or older with a

new diagnosis of COPD or newly ac+ve

COPD, who received appropriate spirome-

try to confirm the diagnosis.

Encourage members that are diagnosed

with COPD to have a spirometry test per-

formed. Members who have been diagnosed by

another physician should be encouraged

to have the tes+ng to confirm the diagno-

sis.

COPD ICD-10 Codes: J44.0, J44.1, J44.9

Chronic Bronchi0s ICD-10CM : J41 .0, J41.1, J41.8, J42

Emphysema ICD-10 CM Codes: J43.0, J43.1, J43.2, J43.8,

J43.9

Spirometry CPT Codes:

94010, 94014-94016, 94060, 94070, 94375, 94620

ABA Adult BMI Assessment Members 18-74 years of age with body

mass index (BMI) and weight documented annually.

Perform and document criteria of Ht/Wt/

BMI calcula+on at each visit. *Pregnant members are excluded from

this measure* Use correct diagnosis and procedure

codes and submit claims +mely.

Diagnosis Codes: Z68.1, Z68.20-Z68.29, Z68.30-Z68.39, Z68.41-Z68.45,

Z68.51-Z68.54



What You Can Do

Coding Tips

W15 Well Child 15 months Members 0-15 months of age with 6 com-

prehensive well child visits. Minimum of 6 well visits required before 15

months old

Never miss an opportunity! Exam re-

quirements can be performed during a

sick visit or a well-child exam. Documenta+on MUST include ALL three

criteria: health educa+on/guidance, physical exam, developmental health

and history. An0cipatory guidance must be docu-

mented.

Diagnosis Codes: Z00.110-Z00.129, Z00.5, Z00.8, Z02.1-Z02.9

Procedure Codes: 99381– 99382, 99391– 99392, 99461

HCPCS:

G0438, G0439

W34 Well Child 3-6 years Members 3-6 years of age with at least 1

comprehensive well child visits annually. Minimum of 1 visit required annually



sick visit or a well-child exam. Documenta+on MUST include ALL three

criteria: health and developmental his-

tory, physical exam, health educa+on/

guidance. An0cipatory guidance must be docu-

mented.

Diagnosis Codes: Z00.110 -Z00.129, Z00.5, Z00.8, Z02.1-Z02.9

Procedure Codes: 99382-99383, 99392-99393

HCPCS:

G0438, G0439

WCC Weight Assessment and Counseling for Nutri-

+on and Physical Ac+vity for Children/

Adolescents Children age 3-17 years of age who had a

visit with a PCP or OB/GYN and who had

BMI percen+le documenta+on, and counsel-

ing for nutri+on and physical ac+vity

Document height, weight and BMI per-

cen+le. Discussion and documenta0on of nutri-

0on and physical ac0vity during at least

one office visit annually. *This may be done during a sick visit or

well child exam.*

BMI ICD-10 CM Codes: Z68.51-Z68.54

Nutri0on Counseling Diagnosis Code: Z71.3 Procedure Codes: 97802-97804 HCPCS: G0447, G0270, G0271, S9449, S9452, S9470 Physical Ac0vity Counseling HCPCS: G0447, S9451

AWC Adolescent Well Care Visits Members 12-21 years of age with at least

one comprehensive well care visit with a

primary care prac++oner or an OB/GYN

prac++oner annually.

Minimum of 1 Required

Make certain to notate physical and

mental health development, physical

exam and health educa+on.



sick visit or a well visit exam.

Documenta+on must include ALL 3 crite-

ria. An0cipatory guidance must be docu-

mented.

Diagnosis Codes: Z00.00-Z00.01, Z00.121-Z00.129, Z00.5, Z00.8, Z02.0-

Z02.9

HCPCS: G0438, G0439

Procedure Codes: 99384-99385, 99394-99395, 99461

IMA Immuniza+ons in Adolescents The percentage of adolescents 13 years of

age who had one dose of meningococcal

conjugate vaccine, one tetanus, diphtheria

toxoids and acellular pertussis (Tdap) vaccine

and three doses of the human papilloma-

virus (HPV) vaccine by their 13th birthday.

Educate staff to schedule PRIOR to 13th

birthday. Document and submit +mely with cor-

rect code.

Offer HPV Vaccine to members age 9 to

age 13. Three doses should be complet-

ed prior to age 13.

Tdap Procedure Codes: 90715

Meningococcal Procedure Codes: 90734

HPV procedure Codes: 90649, 90650, 90651



What You Can Do

Coding Tips

CIS/LCS Childhood Immuniza+on Status Lead Screening in Children Children who received recommended vaccina+ons prior to second birthday. Children who had one or more lead blood

test for lead poisoning by their second

birthday. *Document parental refusal. *

Educate office staff to schedule appoint-

ments PRIOR to 2nd birthday. Perform

Outreach to members to obtain appoint-

ment. Educate parents/guardians regarding the

importance of having their child immun-

ized and keeping appointments. Immuniza+ons recommended: 4 DTaP/DT,

3 IPV, 1 MMR , 3 Hib, 3 Hep B, 1 VZV, 4

PCV, 1 Hep A, 2 or 3 Rotavirus and 2 Influenza vaccines. Documenta+on in medical record if mem-

ber has evidence of the disease for which

immuniza+on is intended or contraindica+on due to anaphylac+c reac-

+on.

DTaP Procedure Codes: 90698, 90700, 90721, 90723

IPV Procedure Codes: 90698, 90713, 90723

Hib Procedure Codes: 90645-90648, 90698, 90721, 90748

HepB Procedure Codes: 90723, 90740, 90744, 90747,

90748

HCPCS: G0010 Diagnosis Codes: B16.0-B16.9, B17.0, B18.0, B18.1,

B19.10, B19.11, Z22.5

Pneumococal Procedure Codes: 90669, 90670

HCPCS: G0009

MMR Procedure Codes: 90707, 90710

Measles Procedure Code: 90705 Diagnosis Code: B05.0-B05.4, B05.81-B05.9

Measles/Rubella Procedure Code: 90708

Mumps Procedure Code: 90704 Diagnosis Code: B26.0-B26.3, B26.81-B26.9

Rubella Procedure Code: 90706 Diagnosis Code: B06.00-B06.09, B06.81-B06.9

Rubella An0body Procedure Code: 86762

VZV Procedure Code: 90710, 90716 Diagnosis Code: B01.0, B01.11-B01.2, B01.81-B01.9,

B02.0, B02.1, B02.21-B02.29, B02.30-B02.39, B02.7-B02.9

Rotavirus 2 dose Procedure Code: 90681

Rotavirus 3 dose Procedure Code: 90680

HepA Procedure Code: 90633 Diagnosis Code: B15.0, B15.9

Flu Procedure Code: 90655, 90657, 90661, 90662, 90673,

90685, 90687 HCPCS: G0008 Lead Screening Procedure Code: 83655

FPC Frequency of Prenatal Care

Pregnant members that had the following

number of expected prenatal visits:

<21% of expected visits

21% - 40% of expected visits



≥81% of expected visits

RN visits for educa�on do not count in

HEDIS. They must see a prescribing pro-

vider.

Encourage members to a�end to all pre-

natal visits.

Prenatal Procedure Codes: 99201-99205, 99211-99215, 99241-

99245

Stand Alone Prenatal Visits: 99500, 0500F, 0501F, 0502F

Bundled Prenatal Service Codes: 59400, 59425, 59426,

59510, 59610, 59618 HCPCS: G0463, T1015 UB Rev Code: 0514

PPC Prenatal and Postpartum Care Pregnant members with prenatal care

during 1st trimester and Postpartum Care

between 21-56 days aJer delivery.

Educate staff to schedule first appoint-

ment with the MD, DO, NP or PA in the

first trimester. RN visits for educa�on do not count in

HEDIS. They must see a prescribing pro-

vider. Encourage a�endance for postpartum

visit.

Please Note: a C-sec+on incision check is

not a postpartum visit, the member must

return for the full postpartum checkup

between 21 and 56 days aJer delivery.

Prenatal

CPT Codes : 99500, 0500F, 0501F, 0502F

HCPCS: H1000-H1004 Procedure Codes: 99201-99205, 99211-99215, 99241-

99245

Stand Alone Prenatal Visits: 99500, 0500F, 0501F, 0502F

HCPCS T1015, G0463 Bundled Prenatal Service Codes: 59400, 59425, 59426,

59510, 59610, 59618 HCPCS: H1005 UB Rev Code: 0514 Postpartum

Postpartum Bundled Services: 59400, 59410, 59510,

59515, 59610, 59614, 59618, 59622

Procedure Codes: 57170, 58300, 59430, 99501, 0503F Diagnosis Codes: Z01.411-Z01.42, Z30.430, Z39.1, Z39.2