2019

Creating Health Care Solutions

HEDIS OVERVIEW and

BEST PRACTICES

P R O V I D E R T R A I N I N G S

Britta Vigurs, BFA Quality Improvement Projects & Communications Specialist

HEDIS Overview

HEDIS Implementation Review

HEDIS Measure Details

HEDIS Reporting & Performance

HEDIS OVERVIEW and BEST PRACTICES

AGENDA

HEDIS Overview

HEDIS Implementation Review

HEDIS Measure Details

HEDIS Reporting & Performance

HEDIS OVERVIEW and BEST PRACTICES

AGENDA

A l l i a n c e V a l u e s

Customer Service

Integrity

Partnership Excellence

Members

H E D I S

HEDIS: HEALTHCARE

EFFECTIVENESS

DATA AND

INFORMATION

SET

20+ year performance measurement assessment

Designed by the National Committee of Quality Assurance (NCQA)

H E D I S

W H Y H E D I S ?

Mandated participation by the state of California.

All Medi-Cal Managed Care Plans must participate.

Annual data collection is required.

W H Y H E D I S ?

WHY HEDIS?

MEASURING QUALITY & IMPROVING HEALTH CARE

HEDIS Illustrates:

• Quality of Care & Services

• Provider Performance

• Health Plan Performance

HEDIS Supports:

• Quality Improvement Initiatives & Projects

HEDIS Overview

HEDIS Implementation Review

HEDIS Measure Details

HEDIS Reporting & Performance

HEDIS OVERVIEW and BEST PRACTICES

AGENDA

H O W I S H E D I S I M P L E M E N T E D ?

January May HEDIS SEASON

H O W I S H E D I S I M P L E M E N T E D ?

Claims, Encounter &

RX Data

Medical Records

Supplemental Data: Labs, Immunizations &

Provider Data

DATA EVALUATION/REVIEW:

MEDICAL RECORDS

Member & Required

Documentation List

Send Records within

5 -7 business Days

Lessen the burden with EMR access

January May

H O W I S H E D I S I M P L E M E N T E D ?

PROVIDER DOCUMENTATION

Complete & Legible

Must Include:

1. Provider Name

2. Member Name

3. Date of Birth

HEDIS Time Frames

(Reference Measure Tip Sheets)

Accurate Coding

(Reference HEDIS Code Set)

K E Y I M P L E M E N T A T I O N R O L E S

Monitoring Measures Clinic Systems

CLINIC SYSTEMS

Provider Portal Reports Care Based Incentives (CBI)

Practice Profiles

Claims Accuracy

EMR Alerts

Incorporate MedImpact into EMR

Chart Scrubbing

Monitor claims for accurate billing HEDIS Code Set

K E Y I M P L E M E N T A T I O N R O L E S

HEDIS Overview

HEDIS Implementation Review

HEDIS Measure Details

HEDIS Reporting & Performance

HEDIS OVERVIEW and BEST PRACTICES

AGENDA

W H A T D O E S H E D I S M E A S U R E ?

5 DOMAINS

OF CARE:

1. Effectiveness of Care 2. Access/Availability of Care 3. Utilization and Relative Resource Use 4. Experience of Care 5. Health Plan Descriptive Information

SUMMARIZED

KEY HEALTH

CARE AREAS:

• Medication Management • Emergency Room Usage • Chronic Conditions & Care Management • Routine Visits & Procedures

H E D I S M E A S U R E T Y P E S

I. Administrative Data: Automated Data

Claims

Immunization registry data

Supplemental data submitted by labs and providers

II. Hybrid Data: Automated Data & Medical Record Review

Combo of administrative data and medical record review

H E D I S 2 0 2 0 M E A S U R E M E N T P E R I O D

HEDIS 2020 looks at the year prior.

Some measures have longer “look backs”: 1. Breast Cancer

Screening 10/1/17 to 12/31/19

2. Prenatal and

Postpartum Care 11/6/18 to 11/5/2019

Do you submit data via the Alliance’s Data Submission Tool? a. Yes b. No

P O L L Q U E S T I O N

D A T A S U B M I S S I O N T O O L

HbA1c Test Results Cervical Cancer

Screening Results

Depression Screening Results

Available Now!

Annual Monitoring for Patients on Persistent

Medications (MPM)

Available Now!

Immunizations

Available Now!

2019 2017

H E D I S 2 0 2 0 A D M I N I S T R A T I V E M E A S U R E S

Abbreviation Measure Data Source

PCR Plan All-Cause Readmissions Claims

BCS Breast Cancer Screening Claims

AMB Ambulatory Care Claims and Pharmacy Data

MPM Annual Monitoring for Patients on Persistent Medications

Claims and Pharmacy Data

AAB Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Claims and Pharmacy Data

CAP Children & Adolescents’ Access to Primary Care Practitioners

Claims

AMR Asthma Medication Ratio Claims and Pharmacy Data

LBP Use of Imaging Studies for Low Back Pain Claims

DSF Depression Screening and Follow-Up for Adolescents and Adults

ECDS: EHR, HIE, case management registry, claims

M E D I C A L R E C O R D R E V I E W N O T P E R M I T T E D

H E D I S 2 0 2 0 H Y B R I D M E A S U R E S

Abbreviation Measure Data Source:

CIS Childhood Immunization Status Immunization Registry, Claims, Provider Submission Data

IMA Immunizations for Adolescents Immunization Registry, Claims, Provider Submission Data

W34 Well-Child Visits in the 3 to 6

Years of Life Claims

WCC Weight Assessment & Counseling for Nutrition & Physical Activity

Claims

CCS Cervical Cancer Screening Claims, Lab Data and Provider Submission Data

PPC Prenatal and Postpartum Care Claims

CDC Comprehensive Diabetes Care Claims, Lab and Pharmacy Data, Provider Submission Data

CBP Controlling High Blood Pressure Claims

M E D I C A L R E C O R D R E V I E W

P O L L Q U E S T I O N

Are you currently utilizing the reports available on the Provider Portal? a. Yes b. No

Q U A L I T Y R E P O R T S

Monthly Quality Reports:

Cervical Cancer Screenings Childhood Immunizations (Combo10) Immunizations for Adolescents Well Adolescent Visits (12-21 years) Well Child Visits (3-6 years)

Quarterly Quality Reports:

Annual Monitoring for Patients on Persistent Medications Asthma Medication Ratio Avoidance of Antibiotics in Adults with Acute Bronchitis Breast Cancer Screenings Chlamydia and Gonorrhea Screenings Diabetes Care

A V O I D A N C E O F A N T I B I O T I C S T R E A T M E N T I N A D U L T S W I T H A C U T E B R O N C H I T I S ( A A B )

M E A S U R E D E S C R I P T I O N :

Adults ages 18-64 with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription at initial diagnosis.

H E L P F U L T I P S :

• If patient presents with

another acute condition; code for both (i.e. sinusitis).

• Set appropriate expectations of duration of symptoms.

• Utilize the Provider Portal Report.

• Use the most accurate codes to reflect the correct diagnosis.

I C D - 1 0 C O D E S :

Acute Bronchitis: J20.3-J20.9

A A B E D U C A T I O N A L M A T E R I A L S

A S T H M A M E D I C A T I O N R A T I O ( A M R )

M E A S U R E D E S C R I P T I O N :

• Members 5-64 years of age. • Identified as having

persistent asthma . • Ratio of controller

medication to total asthma medications of 0.50 or greater.

H E L P F U L T I P S :

• Incorporate the Alliance’s

MedImpact software into your EMR.

• Prescribe reliever inhalers for schools at the time of home refill to count as 1 dispensing event.

• For every reliever make sure you prescribe one or more contollers to keep ratio above 0.5.

E L I G I B L E C O D E S :

Persistent Asthma: J45.20-J45.998

U S E O F I M A G I N G S T U D I E S F O R L O W B A C K P A I N ( L B P )

M E A S U R E D E S C R I P T I O N :

• Members 18 to 50 years of age.

• Primary diagnosis of low back pain.

• Had imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis = non-compliance.

Goal is to avoid imaging studies, unless: • Imaging should be used when

other noninvasive regimens have failed and injections or surgery are being considered.

H E L P F U L T I P S :

Effective treatments for acute low back pain are as followed:

• Nonsteroidal anti-inflammatory drugs,

• Acetaminophen, or • Muscle relaxants

(see tip sheet on the HEDIS web page for more information)

C E R V I C A L C A N C E R S C R E E N I N G ( C C S )

M E A S U R E D E S C R I P T I O N :

Women 21-64 years of age • Cervical cytology performed

1/1/17 - 12/31/19 with result or finding.

Women 30-64 years of age • Cervical cytology and human

papillomavirus (HPV) co-testing performed between 1/1/16 - 12/31/19 with results or findings; or

• Cervical cytology performed 1/1/17 - 12/31/19 with result or finding.

C O D I N G T I P S :

Q0091 Screening papanicolaou smear: obtaining, preparing and conveyance of cervical or vaginal smear to laboratory. To remove women who do not qualify for the measure use: Z90.710 [Z90.710] Acquired absence of both cervix and uterus Z90.712 [Z90.712] Acquired absence of cervix with remaining uterus

2 0 1 9 C A R E B A S E D I N C E N T I V E ( C B I ) M E A S U R E S

C E R V I C A L C A N C E R S C R E E N I N G ( C C S ) C O N T .

M E D I C A L R E C O R D

D O C U M E N TAT I O N :

• Indicate date of cytology and result/finding in the medical record.

• Cytology and HPV test must be performed on same DOS.

• Women without a cervix are excluded from the measure. See the CCS tip sheet for what documentation is required.

• Refer to tip sheet for additional medical record requirements.

H E L P F U L T I P S :

• Use Provider Portal to track non-compliant members.

• Order screenings when they are due.

• EMR alert when Paps are due.

M E A S U R E D E S C R I P T I O N : • Members 18 – 85 years of

age who had diagnosis of hypertension (HTN) and their BP was adequately controlled (<140/90)

E L I G I B L E C O D E S : Outpatient E/M codes: 99201-99205; 99211- 99215, 99241-99245, 99341-99350, 99385- 99387, 99395-99397, 99429 HTN ICD-10 code: I10

M E A S U R E C H A N G E S : • Removed different

threshold for members ages 60-85 without diagnosis of diabetes

• No BP recorded after last diagnosis of HTN = Non-compliant.

• BP readings from remote monitoring devices accepted

(see tip sheet on the HEDIS web page for more information)

C O N T R O L L I N G H I G H B L O O D P R E S S U R E ( C B P )

C O M P R E H E N S I V E D I A B E T E S C A R E ( C D C )

Required Tests Required Results

HbA1c Test HbA1c Good Control <8.0% (2019 CBI Measure)

HbA1c Poor Control >9.0% Nephropathy Test

Retinal Exam (2018 CBI Measure) BP Control <140/90

M E A S U R E D E S C R I P T I O N :

• 18 to 75 years old

• Diagnosis of Diabetes (type 1 or 2)

The following are reported separately:

C D C - H b A 1 c T E S T I N G & C O N T R O L < 8 . 0 %

M E A S U R E D E S C R I P T I O N :

• HbA1c test performed.

• Most recent HbA1c test result <8.0%.

H E L P F U L T I P S :

• HbA1c Data Submission Tool

• Point of Service (POS) in-house testing.

• Perform A1C tests at least two times a year.

E L I G I B L E C O D E S :

CPT Codes: 83036, 83037 CPT-II: 30344F, 30345F, 30346F

2 0 1 9 C A R E B A S E D I N C E N T I V E ( C B I ) M E A S U R E

C D C – R E T I N A L E X A M

M E A S U R E D E S C R I P T I O N :

• Dilated eye exam by optometrist or ophthalmologist in 2019, or

• Negative retinal or dilated eye exam (negative for retinopathy) in 2018.

• Bilateral eye enucleation anytime during the member’s history through December 31 of the measurement year.

E L I G I B L E C O D E S :

New & Established Eye exam codes:

CPT: 92002 – 92014

E/M: 99203 – 99205, 99213 – 99215, 99243 – 99245

H E L P F U L T I P S :

• Provider Portal Reports • Diabetes Prevention and

Self-Management Education Benefit

2 0 1 9 C B I M E A S U R E

C H I L D H O O D I M M U N I Z A T I O N S T A T U S C O M B O 3

64.74%

68.68% 67.88% 68.03% 66.67%

65.25%

83.84% 82.48%

77.62% 78.72%

79.86%

79.93%

63.07%

79.32%

50%

55%

60%

65%

70%

75%

80%

85%

90%

2013 2014 2015 2016 2017 2018

Merced Santa Cruz/Monterey MPL HPL

C H I L D H O O D I M M U N I Z A T I O N S ( C I S )

M E A S U R E D E S C R I P T I O N :

Children had the following vaccines by their 2nd birthday: 4 diphtheria, tetanus, and acellular pertussis (DTaP) 3 polio (IPV) 1 measles, mumps, and rubella (MMR) 3 haemophilus influenza type B (HiB) 3 hepatitis B (HepB) 1 chicken pox (VZV) 4 pneumococcal conjugate (PCV)

H E L P F U L T I P S :

• Provider Portal Report

• CAIR Immunization Registry

• RIDE (Healthy Futures) Immunization Registry

• CDC Vaccine Schedule

E L I G I B L E C O D E S :

(see tip sheet for full list of codes)

2 0 1 9 C B I M E A S U R E

I M M U N I Z A T I O N S F O R A D O L E S C E N T S ( I M A )

M E A S U R E D E S C R I P T I O N :

Received the following vaccines between 11th and 13th birthday: 1 meningococcal conjugate 1 tetanus, diphtheria toxoids and acellular pertussis (Tdap) 2 doses of human papillomavirus (HPV)

H E L P F U L T I P S :

• Meningococcal – one dose between 11th and 13th birthday

• Tdap – one dose between 10th and 13th birthday

• HPV – two doses between 9th and 13th birthday

• Provider Portal Report

E L I G I B L E C O D E S :

(see tip sheet for full list of codes)

2 0 1 9 C B I M E A S U R E

W E L L - C H I L D V I S I T S 3 - 6 Y E A R S O F L I F E ( W 3 4 )

M E A S U R E D E S C R I P T I O N :

• 3–6 years of age.

• One or more well-child visits with a PCP.

H E L P F U L T I P S :

• Create a checklist to document health history, physical development, mental development history, physical exam, and health education/anticipatory guidance.

• Use the Provider Portal reports as an office tracking tool, and reach out to non-compliant members.

E L I G I B L E C O D E S :

CPT codes: 99381-99385, 99391-99395, 99461

ICD-10 codes: Z00.00-Z00.01, Z00.110-Z00.111, Z00.121-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9

2 0 1 8 C B I M E A S U R E 2 0 1 9 C B I M E A S U R E

WEIGHT ASSESSMENT & COUNSELING FOR NUTRITION & ACTIVITY FOR CHILDREN & ADOLESCENT (WCC)

M E A S U R E D E S C R I P T I O N :

• 3-17 years of age.

• Visit with their PCP or OB/GYN.

• Evidence of physician counseling for nutrition and physical activity.

H E L P F U L T I P S :

Counseling for Nutrition: document current nutrition behaviors, weight or obesity counseling or referral for nutrition. Counseling for Physical activity: document current physical activity behaviors, referral for physical activity education, guidance for physical activity.

E L I G I B L E C O D E S :

(see tip sheet for full list of codes)

D E P R E S S I O N S C R E E N I N G A N D F O L L O W - U P F O R A D O L E S C E N T S A N D A D U L T S ( D S F )

M E A S U R E D E S C R I P T I O N :

• 12 years and older. • Screened for depression

using standardized tool and appropriate code.

• Positive screening with follow up care within 30 days.

H E L P F U L T I P S :

• Commonly used screening tools: PHQ-2 and PHQ-9.

• Create clear roles and responsibilities of who will screen.

• Behavioral Health Information

E L I G I B L E C O D E S :

(see tip sheet for full list of codes)

2 0 1 9 C B I M E A S U R E

HEDIS Overview

HEDIS Implementation Review

HEDIS Measure Details

HEDIS Reporting & Performance

HEDIS OVERVIEW and BEST PRACTICES

AGENDA

H E D I S R E P O R T I N G

HEDIS RESULT SUMMARY:

By County PLAN RATED PERFORMANCE:

High Performance Level (HPL) – at or above the 90th percentile Minimum Performance Level (MPL) – at or below the 25th percentile Provider Performance – Are you an award winner?

Merced

Santa Cruz/ Monterey

H E D I S O U T C O M E S – S A N T A C R U Z / M O N T E R E Y

10 DHCS High Performance Levels achieved (90th percentile)

• Comprehensive Diabetes Care - Eye

• Childhood Immunization Status - Combo 3

• Immunizations for Adolescents

• Post-Partum Care

• Well Child Visits 3-4 year old

• Weight Assessment & Counseling for Nutrition

• Weight Assessment & Counseling for Physical Activity

• Avoidance of Antibiotics for Acute Bronchitis

• Asthma Medication Ratio

• Low Back Pain

SANTA CRUZ/MONTEREY

MERCED • Avoidance of Antibiotics for Acute Bronchitis above the

90th percentile • Improvement from 2017 in 17 measures

H E D I S O U T C O M E S – M E R C E D

2 0 1 8 A L L I A N C E H E D I S P E R F O R M A N C E

H E D I S Q U A L I T Y A W A R D

A L L I A N C E Q U A L I T Y A W A R D W I N N E R S – S A N T A C R U Z C O U N T Y

100 – 1000 Eligible Members

Gold Josepha Simkin, MD

Silver Palo Alto Medical Foundation – Aptos

Bronze Robert Weber, MD

1000+ Eligible Members

Gold Plazita Medical Group

Silver Salud Para La Gente

Bronze Watsonville Health Center

90th Percentile Award, Pediatric Clinics

Plazita Medical Group

Salud Para La Gente

City of Santa Cruz Watsonville Health Center

A L L I A N C E Q U A L I T Y A W A R D W I N N E R S – M O N T E R E Y C O U N T Y

100 – 1000 Eligible Members

Gold Acacia Family Medical Group - Prunedale

Silver Acacia Family Medical Group - Salinas

Bronze Robert Tongson, MD

1000+ Eligible Members

Gold Alisal Health Center

Silver Seaside Family Health Center

Bronze Santa Lucia Medical Group

90th Percentile Award, Pediatric Clinics

Salinas Pediatric Medical Group

Laurel Pediatrics

A L L I A N C E Q U A L I T Y A W A R D W I N N E R S – M E R C E D C O U N T Y

100 – 1000 Eligible Members

Gold Golden Valley Health Center - Newman

Silver Newman Medical Clinic - Newman

Bronze Merced Faculty Associates – El Portal

1000+ Eligible Members

Gold Merced Faculty Associates - Delhi

Silver Long Thao, MD

Bronze Livingston Community Health

N E X T S T E P S

Next Steps?

HEDIS 2019 is here now!

New HEDIS Vendor – Inovalon

Member lists distributed

Medical Record Turnaround Time:

5-7 business days

EMR Access: will assist your medical records departments

No longer need to pull records

No copying records

No mailing or faxing records

THANK YOU!

Collaborative effort.

Excellence in member care.

Commitment for success.

2019

Creating Health Care Solutions

HEDIS RESOURCE INFORMATION

Britta Vigurs QI Projects & Communications Specialist 831-430-2620 bvigurs@ccah-alliance.org

HEDIS Resources http://www.ccah-alliance.org/hedis.html

Health Education and Disease Management Programs http://www.ccah-alliance.org/healthed_dm.html

P R O V I D E R T R A I N I N G S

QUESTIONS?