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HEDIS/Quality Assurance Reporting
Requirements coding review
Agenda
• What is HEDIS®/Quality Assurance Reporting Review (QARR)?
• Why is coding important for HEDIS/QARR?
• Coding focus topics:
o Adolescent well visits Adult body mass index (BMI)
o Antidepressant medication management
o Breast cancer screening
o Cervical cancer screening
o Childhood and adolescent immunizations: 0 to 2 years of age
o Childhood and adolescent immunizations: 9 to 13 years of age
o Chlamydia screening
o Colorectal screening
o Comprehensive diabetes care: HbA1c testing
o Comprehensive diabetes care: retinal eye exam
o Comprehensive diabetes care: nephropathy screening and urine
microalbumin test
o Comprehensive diabetes care: evidence of treatment for nephropathy
Agenda (cont.)
• Coding focus topics (cont.):
o Controlling high blood pressure
o Diabetes screening for people with schizophrenia or bipolar disorder
o Follow-up after hospitalization for mental illness
o Follow-up care for children prescribed ADHD medication
o Initiation and engagement of alcohol and other drug dependence
treatment
o Medication management for people with asthma
o Prenatal care
o Postpartum care
o Spirometry testing for members with chronic obstructive pulmonary
disease (COPD)
o Viral load suppression
o Weight assessment, counseling for nutrition and counseling for physical
activity
o Well-child visits: 0-15 months
o Well-child visits: 3 to 6 years
What is HEDIS?
Healthcare Effectiveness Data and Information Set:
• HEDIS is a National Committee on Quality Assurance
(NCQA)-developed tool used to measure performance on
important dimensions of care and service.
• More than 90% of America’s health plans use HEDIS.
• HEDIS makes it possible to compare the performance of
health plans on an apples-to-apples basis.
• Measures address a range of health issues and outcomes.
• To ensure the validity of HEDIS results, all of the data is
audited by certified auditors.
• NCQA has a process for evolving the measurement set
each year.
What is QARR?
Quality Assurance Reporting Requirements:
• The New York State Department of Health (NYSDOH)
version of HEDIS
• Set of performance measures that health plans must
report on an annual basis to NYSDOH under
Medicaid Managed Care and Child Health Plus
• Includes performance measures related to many
preventive health services, such as well-care visits,
age-appropriate immunizations, screenings for cancer
and comprehensive diabetes care
• Has many measures in common with HEDIS
Why is coding important for HEDIS and QARR?
• When documented, each measure includes a set of codes that meet the requirements for the measure.
• Codes may be ICD-10, CPT or HCPCS codes.
• Some measures are considered administrative only. This means the data for compliance comes strictly from claim and encounter submission. No medical record review is performed. If services are being performed but the codes are not being submitted on claims or encounters, you will not receive credit.
• In addition, if only some of the services are coded but others are not, you will not have met all the required components of the measure.
Coding focus: Adolescent well visits
Measure description Eligibility for
denominator
Diagnosis coding Procedure
coding
Members ages 12 to 21
years who have had at
least one annual
comprehensive
well-care visit with a
PCP or OB/GYN during
the year
12 to 21 years of
age, must be
enrolled during the
measurement year
Z00.00, Z00.01,
Z00.121, Z00.129
99384, 99385,
99394, 99395,
G0438, G0439
Notes and tips:
• Make sure your medical records reflect all of the following: a health and developmental
history (both physical and mental), a physical exam, health education and anticipatory
guidance.
• Do not include services rendered during an inpatient or emergency department visit, or
that are specific to the assessment or treatment of an acute or chronic condition.
• Sick visits may be missed opportunities for your patient to get health checks; complete
an annual exam during the sick visit.
Coding focus: Adult body mass index (BMI)
Measure
description
Eligibility for
denominator
Diagnosis coding
The percentage of
members 18 to 74
years of age who had
an outpatient visit and
whose BMI was
documented during the
measurement year or
the year prior to the
measurement year
Members younger than
21 must have a height,
weight and BMI
percentile documented
and/or plotted on a BMI
chart
The measurement
year and the year
prior to the
measurement year;
anchor date
December 31 of
measurement year
For members 21 and older:
• Z68.1 (BMI of 19 or less)
• Z68.2 (BMI of 20-29)
• Z68.20 (20.0–20.9)
• Z68.21 (21.0–21.9)
• Z68.22 (22.0–22.9)
• Z68.23 (23.0-23.9)
• Z68.24 (24.0-24.9)
• Z68.25 (25.0-25.9)
• Z68.26 (26.0-26.9)
• Z68.27 (27.0-27.9)
• Z68.28 (28.0-28.9)
• Z68.29 (29.0-29.9)
• Z68.3 (BMI of 30-39)
• Z68.30 (30.0-30.9)
• Z68.31 (31.0-31.9)
• Z68.32 (32.0-32.9)
• Z68.33 (33.0-33.9)
• Z68.34 (34.0-34.9)
• Z68.35 (35.0-35.9)
• Z68.36 (36.0-36.9)
• Z68.37 (37.0-37.9)
• Z68.38 (38.0-38.9)
• Z68.39 (39.0-39.9)
• Z68.4 (BMI of 40 or greater)
• Z68.41 (40.0-44.9)
• Z68.42 (45.0-49.9)
• Z68.43 (50.0-59.9)
• Z68.44 (60.0-69.9)
• Z68.45 (BMI of 70 or greater)
For 19- and 20-year-old members
(in percentiles):
• Z68.51 (less than 5th)
• Z68.52 (5th to less than 85th)
• Z68.53 (85th to less than 95th)
• Z68.54 (greater than or equal to
95th)
Notes and tips:
• Document all discussions about BMI in the medical record, including
documentation of any patient nutritional counseling sessions.
Coding focus: Antidepressant medication management
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
Members ages 18
years or older with a
diagnosis of major
depression who were
newly treated with an
antidepressant
medication and
remained on
antidepressant
medication treatment
The measurement year
and the year prior to the
measurement year;
anchor date
December 31 of
measurement year
F32.0-F32.4, F32.9,
F33.0-F33.3, F33.41,
F33.9
Not applicable
Notes and tips:
• Two timelines are required for this measure:
o Effective acute phase treatment — patients newly diagnosed and treated who remained on an
antidepressant medication for at least 84 days (12 weeks)
o Effective continuation phase treatment — members newly diagnosed and treated who remained
on an antidepressant medication for at least 180 days (six months)
• Educate your patients and their caregivers about the importance of complying with long-term medications,
not abruptly stopping medications, contacting you immediately if they experience any unwanted/adverse
reactions.
Coding focus: Breast cancer screening
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
The percentage of
women 50 to 74
years of age who
had a mammogram
to screen for breast
cancer
October 1 two years
prior to the
measurement year
through December
31 of the
measurement year
Not applicable 77065, 77066,
77067,
87.36, 87.37,
G0202,
G0204, G0206
Notes and tips:
• The procedure codes for mammography are most often billed by a radiology center or
outpatient hospital location.
• MRIs do not count as primary breast cancer screening.
• Be sure to follow-up with patients after giving a referral for a mammogram to ensure
they follow through with your plan of care.
• Tell your patients to make sure the radiology center or outpatient hospital location sends
a copy of the screening to your office for your records.
Coding focus: Cervical cancer screening
Measure description Eligibility for
denominator
Diagnosis
coding
Procedure coding
Ages 21 to 64 years:
• At least one cervical
cytology (Pap) test
every three years
Ages 30 to 64:
• Pap test/human
papillomavirus (HPV)
cotesting every five
years
Ages 21 to 64
years and
enrolled during
measurement
year
Z12.4 Pap codes:
88141-88143, 88147, 88148,
88150, 88152-88154,
88164-88167, 88174, 88175,
G0123, G0124, G0141,
G0143-G0145, G0147, G0148
HPV codes:
87623-87625, G0476
Notes and tips:
• Remember to document any history of hysterectomy in your patient’s chart; include details
(complete, total, radical abdominal or vaginal hysterectomy). Also document history of
cervical agenesis or acquired absence of cervix.
• Be sure to keep a copy of the lab results on file.
Coding focus: Childhood and adolescent immunizations: 0 to 2 years of age
DescriptionEligibility for
denominatorImmunization Doses Procedure coding CVX
Members ages
2 years and
younger who
received these
specific
vaccinations by
their 2nd
birthday
Ages 2 years
and younger
and enrolled on
the date of their
2nd birthday
Diphtheria, tetanus and
acellular pertussis (Dtap)4 90698, 90700, 90723
20, 50, 106,
110, 120
Polio (IPV) 3 90698, 90713, 90723 10, 110, 112
Measles, mumps and
rubella (MMR)1 90707, 90710 03, 94
Haemophilus influenza
type B (Hib)3 90647, 90648, 90698, 90748
46-51, 120,
148
Hepatitis B (Hep B) 390723, 90740, 90744, 90747,
9074808, 44, 51, 110
Varicella Zoster (VZV) 1 90710, 90716 21, 94
Pneumococcal Conjugate
(PCV)4 90670 100, 133
Hepatitis A (Hep A) 1 90633 83
Rotavirus 3Two dose = 90681
Three dose = 90680119, 116
Influenza 290655, 90657, 90661, 90662,
90673, 90685, 90687
135, 140, 141,
153, 155, 161,
166
Notes and tips:
• Document any parental refusal, history of anaphylactic reaction or seropositive test
result.
Coding focus: Childhood and adolescent immunizations: 9 to 13 years of age
DescriptionEligibility for
denominatorImmunization Doses Specific age
Procedure
codingCVX
Members ages
9 to 13 who
received these
specific
immunizations
by their 13th
birthday
Ages 9 to 13,
males and
females
Meningococcal 1 11 to 13 90644, 90734 136, 138
Tdap 1 10 to 13 90715 115
HPV 3 9 to 1390649,90650,
9065162, 118, 165
Notes and tips:
• Be sure to document:
o A note indicating the name of the specific antigen and the date of the immunization.
o The certificate of immunization prepared by an authorized health care provider or agency.
o Any parental refusal, history of anaphylactic reaction or seropositive test result.
o The date of the first hepatitis B vaccine given at the hospital and name of the hospital if
available.
Coding focus: Chlamydia screening
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
Members who as of
December 31, 2017, are
16 to 24 years of age,
identified as sexually
active and who had at
least one test for
chlamydia in 2015
Must be eligible during
the measurement year
Not applicable 87110, 87270, 87320,
87490, 87491, 87492,
87810
Notes and tips:
• Remember to document any history of hysterectomy in your patient’s chart; include details
(complete, total, radical abdominal or vaginal hysterectomy). Also document history of cervical
agenesis or acquired absence of cervix.
• Be sure to keep a copy of the lab results on file.
Coding focus: Colorectal screening
Measure description Eligibility for
denominator
Diagnosis
coding
Procedure coding
The percentage of members 51 to 75
years of age who had one of the
appropriate screenings for colorectal
cancer:
• Fecal occult blood test (FOBT) during
the measurement year
• Flexible sigmoidoscopy during the
measurement year or during the prior
four years
• Colonoscopy during the measurement
year or during the prior nine years
51 to 75 years of age
by
December 31, 2017,
and enrolled in the
measurement year
Not
applicable
Colonoscopy:
44388-44392, 44401-
44408,
45378-45393, 45398,
45399, G0105, G0121
Flex sigmoidoscopy:
45330-45347,45349,
45350, G0104
FOBT:
82270, 82274, G0328
Notes and tips:
• Be sure to follow up with patients after giving a referral for colonoscopy to ensure they follow through
with your plan of care.
• Tell your patients to make sure the service location sends a copy of the screening to your office for your
records.
• Exclusions for this measure include: Evidence of a diagnosis of colorectal cancer on or before
December 31, 2017, or documentation of a total colectomy on or before December 31, 2017.
Coding focus: Comprehensive diabetes care:HbA1c testing
Measure
description
Eligibility for
denominator
Diagnosis coding Procedure coding
Members ages
18 to 75 years with
type 1 or type 2
diabetes with a
HbA1c test once per
year
Must be eligible
during the
measurement year
Not applicable 83036, 83037,
3044F, 3045F, 3046F
Notes and tips:
• For the recommended frequency of testing and screening, refer to the Clinical Practice Guidelines for
diabetes mellitus.
• Educate your patients about the multiple tests needed to properly manage their diabetes.
• Be sure to keep a copy of the lab results on file.
• Try scheduling your patients to come in for all diabetes care services on the same day.
Coding focus: Comprehensive diabetes care:retinal eye exam
Measure
description
Eligibility for
denominator
Procedure coding
Members ages 18 to
75 years with type 1
or type 2 diabetes
with a dilated eye
exam in current year
or negative exam in
previous year
Must be eligible
during the
measurement year
67028, 67030, 67031, 67036, 67039-67043,
67101, 67105, 67107, 67108, 67110, 67113,
67121, 67141, 67145, 67208, 67210, 67218,
67220, 67221, 67227, 67228, 92002, 92004,
92012, 92014, 92018, 92019, 92134, 92225-
92228, 92230, 92235, 92240, 92250, 92260,
99203-99205, 92213-99215, 99242-99245
Notes and tips:
• Tell your patients to make sure the service location sends a copy of the screening to
your office for your records.
Coding focus: Comprehensive diabetes care:nephropathy screening and urine microalbumin test
Measure
description
Eligibility for
denominator
Diagnosis
coding
Procedure coding
Members ages 18 to
75 years with type 1
or type 2 diabetes
with a nephropathy
screening at least
once per year
Must be eligible
during the
measurement year
Not applicable 82042, 82043, 82044,
84156
Urine microalbumin
codes:
81000-81003, 81005,
3060F-3062F
Notes and tips:
• Be sure to follow up with patients after giving referral for a nephrologist visit to ensure
they follow through with your plan of care.
• Tell your patient to ask the nephrologist to send a visit summary to your office and be
sure to keep a copy on file.
Coding focus: Comprehensive diabetes care: evidence of treatment for nephropathy
Notes and tips:
• Be sure to follow up with patients after giving referral for a nephrologist visit to ensure
they follow through with your plan of care.
• Tell your patient to ask the nephrologist to send a visit summary to your office and be
sure to keep a copy on file.
Measure
description
Eligibility for
denominator
Procedure coding
Members ages
18 to 75 years with
type 1 or type 2
diabetes with
evidence of
treatment for
nephropathy
Must be eligible
during the
measurement year
36800, 36810, 36815, 36818-36821,
36831-36833, 36901-36906, 50300, 50320,
50340, 50360, 50365, 50370, 50380, 90935,
90937, 90940, 90945, 90947,90957-90962,
90965, 90966, 90969, 90970, 90989, 90993,
90997, 90999, 99512
Coding focus: Controlling high blood pressure
Notes and tips:
• Both systolic and diastolic must be below stated value to be considered controlled.
• Most recent BP measurement during the year counts towards compliance.
• Retake BPs over 140/90 during the same visit and document the second reading.
Measure description Eligibility for
denominator
Diagnosis
coding
Procedure coding
Members ages
18 to 75 years who
have had a diagnosis of
hypertension and whose
blood pressure (BP) is
regularly monitored and
controlled
18 to 85 years and
eligible during the
measurement year
I10 3074F: systolic BP <130
3075F: systolic BP 130-139
3077F: systolic BP > 140
3078F: diastolic BP <80
3079F: diastolic BP 80-89
3080F: > 90
Member age range Blood pressure
18 to 59 years <140/90 mm Hg
60 to 85 years with diabetes <140/90 mm Hg
60 to 85 years without diabetes <150/90 mm Hg
Members whose BP is adequately controlled include:
Coding focus: Diabetes screening for people with schizophrenia or bipolar disorder
Notes and tips:
• Be sure to follow up with patients after giving referral for a psychologist visit to ensure they follow
through with your plan of care.
• Tell your patient to ask the psychiatrist to send a visit summary to your office and be sure to keep a
copy on file.
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
The percentage of
members 18 to 64
years of age with
schizophrenia or
bipolar disorder, who
were dispensed an
antipsychotic
medication and had a
diabetes screening
test during the
measurement year
Must be eligible during
the measurement year
Not applicable 80047, 80048, 80050
80053, 80069, 82947
82950, 82951, 83036
83037
3044F, 3045F, 3046F
Coding focus: Follow-up after hospitalization for mental illness
Notes and tips:
• Two timelines are required:
o An outpatient visit, intensive outpatient encounter or partial hospitalization within seven days
of discharge
o An outpatient visit, intensive outpatient encounter or partial hospitalization within 30 days of
discharge
• The date of service on the claim is the date of the face-to-face visit
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
Members ages 6 years and
older who were hospitalized
for treatment of select
mental health disorders and
who had an outpatient visit,
intensive outpatient
encounter or partial
hospitalization with a mental
health practitioner
6 years and older and
enrolled for the
measurement year
F03.90, F03.91,
F20.0 – F99
Not applicable
Coding focus: Initiation and engagement of alcohol and other drug dependence treatment
Notes and tips:
• Initiation of treatment refers to the percentage of members diagnosed with alcohol
or other drug dependence and who have initiated treatment within 14 days of being
diagnosed.
• Engagement of treatment refers to the percentage of members who had two
additional alcohol or other drug dependence treatment sessions within 30 days
after initiating treatment.
Measure
description
Eligibility for
denominator
CPT and HCPCS coding
Members ages
13 years and
older for two
indicators
related to
alcohol and
other drug
dependence
treatment
13 years and
older and
enrolled in the
measurement
year
IET visits group 1:
90791, 90792, 90832-90840,
90845, 90847, 90849, 90853,
90875, 90876
IET stand-alone outpatient
visits:
98960-98962, 99078,
99201-99205, 99211-99215,
99217-99220, 99241-99245,
99341-99345, 99344-99350,
99384-99837, 99394-99397,
99401-99404, 99408, 99409,
99411, 99412, 99510
IET visits group 2:
99221-99223, 99231-99233,
99238, 99239, 99251-99255,
G0155, G0176, G0177, G0396,
G0397, G0409, G0443, G0463
H0001, H0002, H0004, H0005,
H0007, H0016, H0020, H0022,
H0031, H0034, H0037, H0039,
H0040, H2000, H2010, H2020,
H2035, H2036, S9475, T1006,
T1012, T1015
Coding focus: Medication management for people with asthma
Measure description Eligibility for
denominator
Asthma controller medications
Members ages 5 to 64
years old who were
identified as having
persistent asthma, were
dispensed appropriate
medications and
remained on asthma
controller medication
during the treatment
period
5 to 64 years and enrolled
during the measurement
year
Anti-asthmatic
combinations
Dyphylline-guaifenesin
Antibody inhibitors Omalizumab
Inhaled steroid
combinations
Budesonide-formoterol
Fluticasone-formoterol
Mometasone-formterol
Inhaled corticosteroids Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone CFC-free
Mometasone
Triamcinolone
Leukotriene modifiers Montelukast
Zafirlukast
Zileuton
Mast cell stabilizers Cromolyn
Methylxanthines Aminophylline
Dyphylline
Theophylline
Coding focus: Medication management for people with asthma (cont.)
Notes and Tips:
For patients with asthma, you should:
• Prescribe controller medication.
• Educate patients in identifying asthma triggers and proper use of controller medications.
• Create an asthma action plan.
• Be aware of what medications are on formulary as well as require prior authorization and/or step
therapy prior to prescribing. Advise your patients to use mail order whenever possible; this will assist
with compliance.
• Remind your patients to get their controller medications filled regularly and to continue taking them
even if they are feeling better and are symptom-free.
Measure description Eligibility for denominator Asthma reliever Medications
Members ages 5 to 64 years
old who were identified as
having persistent asthma,
were dispensed appropriate
medications and remained on
asthma controller medication
during the treatment period
5 to 64 years and enrolled
during the measurement year
Short-acting
inhaled beta-2
agonists
Albuterol,
Levalbuterol,
Pirbuterol,
Coding focus: Prenatal care
Notes and tips:
• The patient must have at least 14 visits for a 40-week pregnancy.
• Make sure your records accurately reflect all prenatal visit dates
• When seeing a PCP for monitoring of a pregnancy, the diagnosis of pregnancy
must be present and a basic physical obstetrical examination or a standard prenatal
care visit must be documented.
Measure
description
Eligibility for
denominator
Diagnosis coding Procedure coding
The percentage of
pregnant members
who received at
least one prenatal
care visit on the
enrollment start
date or within 42
days of enrollment
or within the first
trimester of
pregnancy
Enrolled
during the
measurement
year
• O00-O08 pregnancy with
abortive outcome
• O09 supervision of a
high-risk pregnancy
• O10-O16 edema, proteinuria
and hypertensive disorders
in pregnancy, childbirth and
the puerperium
• O20-O29 other maternal
disorders
• O30-O48 maternal care
related to the fetus
• O94-O9A other obstetric
conditions
Prenatal visits:
59400, 59425, 59426, 59510,
59610, 59618, 99201-99205,
99211-99215 or 99241-99245
with one of the following CPT
II codes: 0500F, 0501F,
0502F, G0463, H1002-H1004,
H1005, T1015
Prenatal ultrasound:
76801, 76805, 76811, 76813,
76815-76821, 76825-76828
Coding focus: Postpartum care
Notes and tips:
• Be sure to document the exact date of the postpartum visit.
• A visit for post cesarean staple removal or incision check does not satisfy the postpartum
requirement. At the time of the visit, remind your patient to return for a postpartum visit within
21-56 days post delivery; if possible, schedule the appointment before the patient leaves your office.
• If you use a global billing code, make sure the postpartum visit date is on the claim.
Measure
description
Eligibility for
denominator
Diagnosis coding Procedure coding
The percentage of
members who had a
postpartum visit on or
between 21 and 56
days after delivery
Enrolled during the
measurement year
Z01.411, Z01.419,
Z01.42, Z30.430,
Z39.1, Z39.2
57170, 58300,
59400, 59410,
59430, 59510,
59515, 59610,
59614, 59618, 59622
99201 with CPT II
code 0503F
G0101
Coding focus: Spirometry testing for members with COPD
Notes and tips:
• Perform a spirometry test for patients who present with dyspnea, chronic cough, increased sputum
production or wheezing.
• To support a COPD diagnosis, perform and document a spirometry test prior to initiating
pharmacotherapy treatment.
• Educate patients about the use of and compliance with both long-term and quick-relief medications,
the proper use of metered inhalers and avoiding elements that trigger attacks.
Measure description Eligibility for
denominator
Diagnosis coding Procedure coding
Members ages 40
years and older with a
new diagnosis of
COPD or newly active
COPD who received
appropriate spirometry
testing to confirm the
diagnosis
Enrolled during the
measurement year
Chronic bronchitis:
J41.0, J41.1, J41.8,
J42
Emphysema:
J43.0, J43.1, J43.2,
J43.8, J43.9
COPD:
J44.0, J44.1, J44.9
94010,
94014-94016,
94070, 94375, 94620
Coding focus: Viral load suppression
Notes and tips:
• Preschedule the next follow-up appointment while the patient is still in your office and make a
reminder call prior to the appointment.
• Be sure to keep a copy of the lab results on file.
This measure is unique in that health plans do not report the data; instead the AIDS
Institute and the Office of Quality and Patient Safety will calculate the performance in
this measure using the laboratory testing data captured in the NYSDOH HIV
Surveillance System.
• It is important to make sure patients with HIV keep their follow-up appointments and
complete a viral load screening at least every six months or twice in one calendar
year.
• Regular testing helps identify any needs for changes in a patient’s medication
regimen or helps determine if he or she is complying with treatment plans.
• Reaching viral load suppression can help your patients to live healthier, longer lives
and reduce the risk of transmitting the virus to others.
• For more information on viral load suppression and HIV treatment guidelines, please
visit the NYSDOH AIDS Institute website at https://www.hivtrainingny.org
Coding focus: Weight assessment, counseling for nutrition and counseling for physical activity
Notes and tips:
• Remember a nutritional evaluation and anticipatory guidance are required as
part of the routine health check visit.
• Document any advice you give the patient and/or their caregivers.
Measure description Eligibility for
denominator
Diagnosis coding Procedure
coding
Nutrition The percentage of members 3 to 17
years of age who had an outpatient
visit with a PCP or OB/GYN and who
had counseling for nutrition during the
measurement year
Must be eligible
during the
measurement
year
Z71.3 97802,
97803,
97804
BMI The percentage of members 3 to 17
years of age who had an outpatient
visit with a PCP or OB/GYN and who
had a BMI percentile documented
during the measurement year
Must be eligible
during the
measurement
year
Z68.51, Z68.52, Z68.53,
Z68.54
Not
applicable
Physical
activity
The percentage of members 3 to 17
years of age who had an outpatient
visit with a PCP or OB/GYN and who
had counseling for physical activity
during the measurement year
Must be eligible
during the
measurement
year
Z71.9
This is a miscellaneous
code; therefore, you must
document counseling
specific to physical
activity. Do not document
solely for sports activity
Not
applicable
Coding focus: Well-child visits: 0 to 15 months
Notes and tips:
• The PCP of record will be the PCP as of the date the child turns 15 months old.
• If the dates of service are less than 14 days apart, only one will count for this measure.
• Confirm that your medical record reflects all of the following: five or more visits with a PCP completed
at least two weeks apart, a medical history, physical and mental developmental histories, a physical
exam, health education, and anticipatory guidance.
• Sick visits may be missed opportunities for your patient to get health checks; complete an annual
exam during the sick visit and code with appropriate ICD-10 codes.
Measure description Eligibility for
denominator
Diagnosis
coding
Procedure
coding
Children turning 15 months
old in 2017 who have five
visits with one of the listed
CPT codes or one of the
listed ICD-10 codes during
their first 15 months of life
with a PCP
31 days to 15
months of age;
enrolled at 15
months
Z00.110,
Z00.111, Z00.121, Z00.129
99381, 99382,
99391, 99392,
99461
G0438, G0439
Coding focus: Well-child visits 3 to 6 years
Notes and tips:
• Make sure your medical records reflect all of the following: a note indicating a visit to a
PCP, the date the well-child visit occurred, physical and mental developmental histories,
a physical exam, health education, and anticipatory guidance.
• Sick visits may be missed opportunities for your patient to get health checks; complete
an annual exam during the sick visit.
Measure
description
Eligibility for
denominator
Diagnosis coding Procedure coding
Members ages 3 to 6
years who had one
or more
comprehensive
well-child visits with a
PCP during the year
3 to 6 years of age,
enrolled during the
measurement year
Z00.121, Z00.129,
Z00.8, Z02.0
99382, 99383, 99384,
99392, 99393, 99394,
G0438, G0439
Legal notice
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 state/provider 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 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 2017 technical specifications and
is subject to change based on guidance given by the National Committee for
Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services
(CMS) and state recommendations. Please refer to the appropriate agency for
additional guidance.
Thank you
www.empireblue.com/nymedicaiddocEmpire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue
Cross and Blue Shield Association.
NYEPEC-1125-17 September 2017
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