1185-3464 quality measures at a glance with key · pdf filehmsa quality measures at a glance...

Pay for Quality

HMSAQuality Measures

at a Glance withKey ICD-10-CM Codes

S U M M A R Y

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HMSA Quality Measures at a Glance with Key ICD-10-CM Codes

This is a summary of the measures in HMSA's Pay-for-Quality program shown generally in the order they're presented on Cozeva. We've also suggested actions and standing orders for the primary care provider (PCP) team to achieve quality goals.

To familiarize PCPs and staff with ICD-10-CM codes that affect our quality program beginning October 1, 2015, we have identified key diagnosis codes below. The information will help you when ordering screening tests and knowing which diagnosis codes may be "triggers," making patients eligible for certain measures.

Be sure to consult the Primary Care Pay-for-Quality guide posted on hmsa.com for full details of each measure. Links will be provided to more detailed information on ICD-10 codes.

Health Screenings Use these ICD-10 diagnosis codes when ordering cancer or chlamydia screenings.

Z12.31 Encounter for screening mammogram for malignant neoplasm of breastZ80.3 Family history of malignant neoplasm of breast Z85.3 Personal history of malignant neoplasm of breast

Cervical Cancer Screenings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findingsZ01.419 Encounter for gynecological examination (general) (routine) without abnormal findingsZ01.42 Encounter for cervical smear to confirm findings of recent normal smear following

initial abnormal smearZ12.4 Encounter for screening for malignant neoplasm of cervix

Colorectal Cancer Screenings

Z12.11 Encounter for screening for malignant neoplasm of colonZ12.12 Encounter for screening for malignant neoplasm of rectumZ80.0 Family history of malignant neoplasm of digestive organsZ83.71 Family history of colonic polyps Z84.81 Family history of carrier of genetic disease

Chlamydia Screenings

Z11.8 Encounter for screening for other infectious and parasitic diseases

HMSA QUALITY MEASURES AT A GLANCECommercial QUEST

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ICD-10 Code Pediatric BMI Percentile Range (BMI pediatric codes are for patients age 2 to 20 years old.)

Z68.1 BMI 19 or less, adultZ68.51 BMI pediatric, less than 5th percentile for ageZ68.52 BMI pediatric, 5th percentile to less than 85th percentile for ageZ68.53 BMI pediatric, 85th percentile to less than 95th percentile for ageZ68.54 BMI pediatric, greater than or equal to 95th percentile for age

Controlling Blood PressureReport compliant blood pressures when hypertension (code below) is addressed in the visit. This ICD-10 code may make a patient eligible for this measure.

ICD-10 Code ICD-10 Name

I10 Essential (primary) hypertension

Avoidance of Antibiotic Treatment in Adults with Acute BronchitisThese ICD-10 diagnosis codes may make a patient eligible for this measure.


J20.0 Acute bronchitis due to Mycoplasma pneumoniae J20.1 Acute bronchitis due to Hemophilus influenzae J20.2 Acute bronchitis due to streptococcus J20.3 Acute bronchitis due to coxsackievirus J20.4 Acute bronchitis due to parainfluenza virus J20.5 Acute bronchitis due to respiratory syncytial virus J20.6 Acute bronchitis due to rhinovirus J20.7 Acute bronchitis due to echovirus J20.8 Acute bronchitis due to other specified organismsJ20.9 Acute bronchitis, unspecified

ICD-10 Code Adult BMI Range

Z68.1 BMI 19 or less, adultZ68.20 BMI 20.0-20.9, adultZ68.21 BMI 21.0-21.9, adultZ68.22 BMI 22.0-22.9, adultZ68.23 BMI 23.0-23.9, adultZ68.24 BMI 24.0-24.9, adultZ68.25 BMI 25.0-25.9, adultZ68.26 BMI 26.0-26.9, adultZ68.27 BMI 27.0-27.9, adultZ68.28 BMI 28.0-28.9, adultZ68.29 BMI 29.0-29.9, adultZ68.30 BMI 30.0-30.9, adultZ68.31 BMI 31.0-31.9, adult

ICD-10 Code Adult BMI Range

Z68.32 BMI 32.0-32.9, adultZ68.33 BMI 33.0-33.9, adultZ68.34 BMI 34.0-34.9, adultZ68.35 BMI 35.0-35.9, adultZ68.36 BMI 36.0-36.9, adultZ68.37 BMI 37.0-37.9, adultZ68.38 BMI 38.0-38.9, adultZ68.39 BMI 39.0-39.9, adultZ68.41 BMI 40.0-44.9, adultZ68.42 BMI 45.0-49.9, adultZ68.43 BMI 50-59.9 , adultZ68.44 BMI 60.0-69.9, adultZ68.45 BMI 70 or greater, adult

Body Mass Index AssessmentUse these ICD-10 diagnosis codes to report a patient's body mass index on a claim for numerator credit.

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Appropriate Treatment for Children with Upper Respiratory InfectionThese ICD-10 diagnosis codes may make a patient eligible for this measure.


J00 Acute nasopharyngitis [common cold]J06.0 Acute laryngopharyngitisJ06.9 Acute upper respiratory infection, unspecified

Pediatric Services

Use these ICD-10 diagnosis codes with appropriate procedure codes when submitting claims for these services.

Childhood Immunizations

Z23 Encounter for immunization

Well-Child Visits

Z00.00 Encounter for general adult medical examination without abnormal findingsZ00.01 Encounter for general adult medical examination with abnormal findingsZ00.110 Health examination for newborn under 8 days old Z00.111 Health examination for newborn 8 to 28 days old Z00.121 Encounter for routine child health examination with abnormal findingsZ00.129 Encounter for routine child health examination without abnormal findings

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Plans Measure DescriptionPCP and Staff Action/

Standing Orders

Preventive Health Screening Breast Cancer*

Women ages 52–74 who had a mammogram during the measurement year or 15 months prior.

Refer patients for mammogram. Staff follows up.

Preventive Health Screening Cervical Cancer*

Women ages 24–64 screened for cervical cancer with either criteria:

• Women ages 24–64 who had cervical cytology performed every three years.

• Women ages 30–64 who had cervical cytology and HPV co-testing performed every five years.

Refer patients to ob/gyn. Staff follows up.

Preventive Health Screening Colorectal Cancer*

Adults ages 51-75 screened for colorectal cancer with one of the following:

• FOBT during the measurement year.

• Flexible sigmoidoscopy during the measurement year or the four prior measurement years.

• Colonoscopy during the measurement year or the nine prior measurement years.

Provide FOBT kit with instructions. Refer patients for sigmoidoscopy or colonoscopy.

Preventive Health Screening Chlamydia Screening*

Women ages 16-24 identified as sexually active and who had a test for chlamydia during the measurement year.

Order chlamydia test.

Preventive Health Screening Body Mass Index Assessment*

Patients ages 3-74 who had an outpatient visit and whose BMI was documented during the measurement year.

Record height, weight, and BMI in medical record.

Report BMI using appropriate diagnosis code.

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* See ICD-10 coding tips on pages 1-2.


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Standing Orders

Preventive Health Screening Advance Care Planning

Members age 75 and older who had an advance care plan and/or an advance care planning discussion with their PCP documented during the measurement year.

Even if a document was previously included or noted in the patient’s medical record, a documented discussion or review during the measurement year is still required to be included in the numerator.

Document advance care planning document or discussion associated with an office visit. Report via claim procedure codes 1157F, 1158F, or S0257.

Comprehensive Diabetes Care Eye Exam

Patients with diabetes ages 18-75 who received a dilated eye exam, seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist, or imaging validated to match diagnosis from those photos during the measurement year.

A negative dilated eye exam (negative for retinopathy) in the prior measurement year also meets the criteria.

Refer patient to ophthalmologist or optometrist. Staff follows up.

Diabetes Screening HbA1c Testing (display only)

Patients with diabetes ages 18-75 receiving at least one HbA1c test during the measure-ment year. This measure is for display only.

Order HbA1c test. Staff follows up on patients who are overdue.

Diabetes Screening LDL-C Screening (display only)

Patients with diabetes ages 18-75 receiving at least one lipid profile (or all component tests) during the measurement year. This measure is for display only.

Order lipid test. Staff follows up on patients who are overdue.

Comprehensive Diabetes Care Nephropathy

Patients ages 18-75 who had a test for microalbumin during the current measurement year or evidence of medical attention for existing nephropathy (diagnosis of nephro-pathy or documentation of microalbuminuria or albuminuria). Evidence of ACE inhibitor/ARB therapy from pharmacy claims data will also count for numerator inclusion.

Order microalbumin test.

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Standing Orders

Heart DiseaseAnnual Monitoring–ACE/ARB

Patients age 18 and older who received at least 180 treatment days of ACE inhibitors or ARBs and at least one monitoring event for the therapeutic agent during the measurement year. Patients must meet one of these two criteria to satisfy the measure:

• Lab panel test during the measurement year.

• One serum potassium and one serum creatinine during the measurement year.

Order lab test.

Heart Disease Annual Monitoring–Diuretics

Patients ages 18 and older who received at least 180 treatment days of diuretics during the measurement period and at least one therapeutic monitoring event during the measurement year. Patients must meet one of these two criteria to satisfy the measure:

• Lab panel test during the measurement year.

• One serum potassium and one serum creatinine test during the measurement year.

Order lab test.

Appropriate Respiratory Care Medication Management for People With Asthma

Patients ages 5–64 identified as having persistent asthma, filled prescriptions for appropriate medications, and adhered to their medication during the treatment period (filling 75 percent of the time for their controller medication).

Monitor Cozeva prescription dashboard to understand fill pattern for asthma medications. Encourage patients to fill prescriptions.

Appropriate Respiratory Care Spirometry testing for COPD (display only)

Patients ages 42 years and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. The testing should have been completed between two years before to six months after the COPD diagnosis. See the patient’s Diagnosis Date on Cozeva. This measure is for display only.

Order spirometry test.

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Standing Orders

Appropriate Respiratory Care Avoidance of Antibiotic Treatment with Acute Bronchitis*

Patients ages 18-64 years with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.

Evaluate appropriateness of antibiotic prescription when diagnosis is only acute bronchitis.

Comprehensive Diabetes Care BP Control < 140/90

Patients with diabetes ages 18-75 whose blood pressure was adequately controlled (less than 140/90) based on the most recent blood pressure reading during the measurement year.

Both the systolic and diastolic blood pressure must be less than 140/90.

Take blood pressure correctly and record in medical record. If value is compliant and below 140/90, report systolic and diastolic on claim, using 3074F, 3075F, 3078F, or 3079F. Each value (systolic and diastolic) must be reported separately.

Comprehensive Diabetes Care HbA1c Poor Control

Patients with diabetes ages 18-75 whose most recent HbA1c level during the measurement year was greater than 9.0 percent or whose HbA1c wasn’t measured during the measurement period.

Order HbA1c test. Counsel on results. Staff follows up on patients who are overdue.

Comprehensive Diabetes CareHbA1c Control <8.0%

Patients with diabetes ages 18–75 whose most recent HbA1c level was less than 8.0 percent (in control).

Order HbA1c test. Counsel on results. Staff follows up on patients who are overdue.

Chronic Care BP Control*

Patients ages 18-85 who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year based on the following criteria:

• Patients ages 18–59 years whose BP was less than 140/90 mm Hg.

• Patients ages 60–85 years whose BP was less than 150/90 mm Hg.

Because there are no procedure codes to describe a systolic pressure of 140 to 149 mm Hg, controlled blood pressure for patients ages 60 - 85 (i.e., one with a systolic pressure of 140 to 149 mm Hg and a diastolic pressure of <90 mm Hg), must be reported using Cozeva supplemental data.

Take blood pressure correctly, record in medical record, and report if value is compliant and below 140/90 on claim, using 3074F, 3075F, 3078F, or 3079F. Each value (systolic and diastolic) must be reported separately. Report values when office visit includes diagnosis for hypertension.

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* See ICD-10 coding tips on page 2.

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Standing Orders

Medication Adherence Oral Diabetes Medications

Patients age 18 and older with diabetes who adhered to their prescribed drug therapy across these classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DPP-IV inhibitors.

Monitor Cozeva prescription dashboard to understand fill pattern for diabetes medications. Encourage patients to fill prescriptions.

Medication Adherence Comprehensive Diabetes Treatment

Patients age 18 and older who were dispensed appropriate medication for diabetes, medication for hypertension, and an ACEI or ARB medication recommended for people with diabetes.

Monitor Cozeva prescription dashboard to understand fill pattern for comprehensive diabetes medications. Encourage patients to fill prescriptions.

Medication Adherence Hypertension (RAS Antagonist)

Patients age 18 and older who adhered to their prescribed drug therapy for RAS antagonists during the measurement year for at least 80 percent of the time based on pharmacy claims data.

Monitor Cozeva prescription dashboard to understand fill pattern for hypertension medications. Encourage patients to fill prescriptions.

Medication Adherence Cholesterol (Statins)

Patients age 18 and older who adhered to their prescribed drug therapy for statin cholesterol medications during the measurement period at least 80 percent of the time based on pharmacy claims data.

Monitor Cozeva prescription dashboard to understand fill pattern for cholesterol medications. Encourage patients to fill prescriptions.

Chronic Disease Review Review of Chronic Conditions

The review of chronic conditions measure encourages PCPs to review each patients’ persistent conditions. The measure groups all patient diagnoses identified over two calendar years prior to the measurement year into groupings called Hierarchical Condition Categories (HCC). You must review and confirm the persistence of each clinical condition every calendar year. In the final performance scoring, HMSA will remove all numerator-negative conditions that were exclusively coded by ED physicians, the hospital, and hospitalists during the two-year look-back period.

Staff prints out or communicates chronic condition diagnoses on RCC measure. PCP reviews condition with patient in 2015 office visit and documents M.E.A.T. (manage/monitor, evaluate, assess, or treat) for each condition in medical record. Biller reports diagnosis code on claim.

RCC measure closes on September 30, 2015.

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Standing Orders

Access to Care Well-child 15 months*

Children turning 15 months old during the measurement year who had six or more well-child visits with a PCP during their first 15 months of life.

Staff monitors Cozeva and tracks children due for six visits before age 15 months. Staff follows up.

Access to Care Well-child 3-6 years*

Children ages 3-6 who received one or more well-child visits with a PCP during the current measurement year.

Staff monitors Cozeva and tracks children due for annual visit. Staff follows up.

Appropriate Respiratory Care Tests for Pharyngitis*

Patients ages 2-18 who were diagnosed with pharyngitis, prescribed an antibiotic, and received a group A streptococcus test for the episode from three days prior through three days after the first eligible episode.

Evaluate appropriateness of antibiotic prescription. Order strep test before antibiotics are prescribed.

Appropriate Respiratory Care Treatment for URI*

Children ages 3 months to 18 years who were given a URI diagnosis and weren’t dispensed an antibiotic prescription on or three days after the episode.

Evaluate appropriateness of antibiotic prescription.

Immunizations Childhood Immunization Status*

Children who had four DTaP, three IPV, one MMR, three HiB, two HepB, one VZV, and four PCV by their second birthday. DTaP, HiB, IPV, or PCV given before baby is 42 days old can't be counted.

Staff monitors Cozeva and tracks children due for immunizations in current and upcoming quarters. Staff follows up.

Immunizations Immunizations for Adolescents*

Adolescents who had one meningococcal vaccine and one Tdap or one Td by their 13th birthday. Timing: One meningococcal vaccine on or between the adolescent's 7th and 13th birthday, and one Tdap or one TD between the adolescent's 10th and 13th birthday.

Staff monitors Cozeva and tracks adolescents due for immunizations in coming quarters. Staff follows up.

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* See ICD-10 coding tips on page 3.

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1186-3464 08:15 JR

1185-3464 quality measures at a glance with key · pdf filehmsa quality measures at a glance...

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