pcp hedis documentation tips: older adults...advance are planning pt: 99497 pt ii: 1123f, 1124f,...

Aetna HEDIS Tip Sheet 2019

PCP HEDIS Documentation Tips: Older Adults

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 the last 2 years.

Educate women regarding the benefit of early detection of breast cancer through routine mammograms

Encourage mammography to all women who are within measure age group.

Submit the appropriate mastectomy code to exclude women from this measure if it is part of their history

* See exclusion note on bottom of page 6

Breast Cancer Screening Codes

CPT Codes: 77055-77057, 77061-77067

HCPCS G0202, G0204, G0206 UB Rev Codes 0401, 0403

Exclusions:

Bilateral Mastectomy

ICD-PCS: 0HTV0ZZ ICD-10CM : Z90.13 (history of)

Unilateral Mastectomy

ICD-10CM Codes: 0HTU0ZZ (Left) 0HTT0ZZ (Right)

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

with LT (left) or RT (Right) modifier

Absence of Breast

ICD-10 CM Codes: Z90.12 (Left) Z90.11 (Right)

MRP - Medication Reconciliation Post-Discharge

The percentage of discharges during the year for members 18 and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days)

Documentation in the medical record must include evidence of medication reconcilia-tion of current and discharge meds and the date it was performed by a prescribing prac-titioner, clinical pharmacist or RN.

Regular medication review is a best practice. Have members bring all of their medications with them to appointments.

CPT Codes: 99495, 99496 CPT II Codes: 1111F

COA—Care for Older Adults

The percentage of adults 66 years and older who had each of the following during the measurement year:

Advance Care Planning

Medication Review

Functional Status Assessment

Pain Assessment

Advance Care Planning - document, dated discussion and/or presence of advance di-rective or living will in the chart

Medication Review - Medication list in chart with a dated notation of medication review annually by a prescribing provider or clinical pharmacist. If not on any medications, this should be noted with a date as well.

Functional Status Assessment - Complete functional assessment must include one of the following: - Notation that Activities of Daily Living (ADL)

were assessed [or at least five of the follow-ing were assessed: bathing, dressing, eating,

transferring, using toilet, walking] - Notation that Instrumental Activities of

Daily Living (IADL) were assessed [or at least four of the following were assessed: shop-ping for groceries, driving or using public transportation, using the telephone, meal preparation, housework, home repair, laun-dry, taking medication, handling finances] - Result of assessment using a standardized

functional status assessment tool - Notation that at least three of the follow-

ing four components were assessed: cogni-tive status; ambulation status; hearing, vision and speech (sensory ability) ; other function-al independence (exercise, ability to perform job)

Pain Assessment—see next column

Advance Care Planning CPT: 99497 CPT II: 1123F, 1124F, 1157F, 1158F HCPCS: S0257 ICD10CM: Z66

Medication Review Both a code from the Medication Review and the Medica-tion List category on the same claim Medication Review Codes CPT: 90863, 99605, 99606, CPT II: 1160F Medication List Codes CPT ll: 1159F HCPCS: G8427 Or a Transitional Care Management Code: CPT: 99494, 99496

Functional Status Assessment CPT II: 1170F HCPCS: G0438, G0439

Pain Assessment CPT II: 1125F, 1126F

Pain Assessment - Notations for pain assessment must in-clude one of the following: - Documentation that the member was assessed for pain (positive or negative finding) - Result of assessment using a standardized assessment tool A pain management/treatment plan alone does not count. Either does screening for chest pain or positive chest pain alone or a pain assessment completed during an acute inpa-tient setting.


HEDIS Measure Definitions

What You Can Do

Coding/Tips

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

adequately controlled BP (<140/90)\

If BP elevated (140/90 or greater) at initial vital sign assessment, alleviate potential factors that might cause temporary eleva-tion and retake BP during exam. Make sure you use the correct size cuff. If using a machine, record the actual number, do NOT round up.

Schedule follow up visits to monitor effec-tiveness of BP medication.

BP readings taken from remote monitoring devices and electronically submitted to the provider can be use

ICD-10 CM Code: I10Blood pressure value CPT II codes are now acceptable to meet compliance

Blood Pressure CPT Codes:

Systolic BP: < 130 3074F, 130-139 3075F ; >/= to 140

3077F

Diastolic BP: 80-89 3079F; < 80 3078F; >/= 90 3080F

Exclusions: End Stage Renal Disease (ESRD) or a kidney transplant on or prior to December 31st of the measure-ment year or a diagnosis of pregnancy during the meas-urement year.


CDC—Comprehensive Diabetes Care

Members 18-75 years of age with diabe-

tes should have each of the following:

HbA1C testing,

HbA1C control

Medical attention for nephropathy

Retinal eye exam (refer for exam)

Blood pressure control


Order screenings annually or more often as needed and educate member on im-portance of compliance with testing and medications.

Include all current medications on the med-ication list. Be sure to indicate if a member is on an ACE/ARB medication

Refer member to Optometrist or Ophthal-mologist for Dilated Retinal Eye Exam annu-ally. Explain why this is important and that it is different than an eye for glasses or contacts.

Document Stage 4 chronic kidney disease or End State Renal Disease (ESRD) with appro-priate codes:

Stage 4 chronic kidney diseaseICD-10 CM: N18.4

ESRDICD-10 CM: N18.5, N18.6, Z91.15, Z99.2 ICD-10 PCS: 3E1M39Z, 5A1D00Z, 5A1D60Z-5A1D90Z

Diabetes ICD-10 CM Codes: E10.10-E13.9, O24.011-

O24.33, O24.811-O24.83

HbA1c CPT Codes: 83036, 83037 CPT II HbA1c Result CodesHbA1c level less than 7.0: 3044FHbA1c level 7.0-9.0: 3045F HbA1c level greater than 9.0: 3046F

Urine Protein Tests—check annually, especially if not on an ACE/ARB medication

CPT Codes: 81000-81003, 81005 , 82042-82044, 84156

CPT II Codes: 3060F-3062FBlood Pressure CPT Codes:

Systolic BP: < 130 3074F, 130-139 3075F ;

>/= to 140 3077F

Diastolic BP: < 80 3078F; 80-89 3079F; >/= 90 3080F

AAP - Adults’ Access to Preventive/Ambulatory Health Services

Members 20 years and older who had an ambulatory or preventive care visit during the measurement year.

Each adult member should have a routine outpatient visit annually.

Utilize your Gaps in Care report to outreach members that have not had care.

CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99429 UB Rev Codes: 051X, 052X, 0982, 0983 HCPCS: G0402, G0438, G0439, G0463, T1015 ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.3, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9, Z76.1, Z76.2 Other Ambulatory Visits: CPT: 92002, 92004, 92012, 92014, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 UB Rev: 0524, 0525 Any of the above with or without a telehealth modifier: CPT modifier: 95, GT Online Assessments CPT: 98969, 99444 Telephone Visits: 98966-98968, 99441-99443

PSA—Non-Recommended PSA-Based Screening in Older men

Men 70 years and older who were screened unnecessarily for prostate can-cer using prostate-specific antigen (PSA)-based screening.

A lower rate indicates better performance

Total population PSA testing is not currently advised for men 70 years and older.

The exclusions to this measure are men with a prostate cancer diagnosis at any time, dysplasia of the prostate during the measurement year and year prior, anyone that had a PSA test during the year prior to the measurement year with an elevated result (>4.0 ng/mL), or anyone dispensed a prescription for 5-alpha reductase inhibitor during the measurement year.

Prostate CancerICD 10: C61, D07.5, D40.0, Z15.03, Z85.46

Prostate Dysplasia ICD 10: N42.3– N42.32, N42.39

PSA test >4.0 : CPT: 84153 HCPCS: G0103

5-alpha reductase inhibitors: Finasteride; Durasteride



What You Can Do

Coding/Tips

OMW - Osteoporosis Management in

Women Who Had a Fracture

Women 67-85 years of age who suffered a fracture and had either a bone mineral density test or were prescribed a drug to treat osteoporosis in the 6 months after a fracture.

Schedule women age 67-85 years old for a bone mineral density test (BMD) within six months after a fracture if they have not had a BMD test in the prior 24 months.

Prescribe medications to treat osteoporo-sis when indicated.

*See exclusion note on bottom of page 6

Bone Density: CPT Codes :76977, 77078, 77080-77082, 77085-77086 ICD-10 PCS Codes: BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00Z-ZI, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1 HCPCS G0130 Osteoporosis MedicationsJ0630, J0897, J3110, J1740, J3487-J3489, Q2051

SPR -Use of Spirometry Testing in the

Assessment and Diagnosis of COPD

Members age 40years or older with a new diagnose of COPD or newly active COPD, who received appropriate spirometry to confirm the diagnosis.

Educate members that are newly diag-nosed with COPD or newly active COPD about the importance of spirometry testing

Submit timely claims for spirometry testing performed in your office.

COPD ICD-10 Codes: J44.0, J44.1, J44.9, Chronic Bronchitis ICD-10CM: J41 .0, J41.1, J41.8, J42 Emphysema ICD-10 CM Codes: J43- J43.2, J43.8, J43.9

Spirometry CPT Codes: 94010, 94014-94016, 94060, 94070, 94375, 94620

PCE - Pharmacotherapy Management of COPD Exacerbation

Members age 40 and older who had an acute IP stay or ED visit with a diagnosis of COPD exacerbation and were dispensed appropriate medications.

Two rates are reported:

1. Dispensed a systemic corticosteroid (or evidence of an active prescription within 14 days of the event

2. Dispensed a bronchodilator (or evi-dence of an active prescription) within 30 days of the event.

Schedule follow-up appointments with these members within a few days of their hospital discharge or ED visit

Medication reconciliation is key

Member education to include filling the prescriptions, appropriate use and side effects

Order medications that are on the member’s health plan formulary

Systemic Corticosteroids -

Glucocorticosteroids - Cortisone-acetate, Dexame-thasone, Hydrocortisone, Methylprednisolone, Predniso-lone, Prednisone

Bronchodilators-

Anticholinergic Agents - Albuterol-ipratropium,Ipratropium, Aclidinium-bromide, Tiotropium,Umeclidium

Beta 2-agonists - Albuterol, Levalbuterol, Arformoterol, Mometasone-formoterol, Budesonide-formoterol, Metaproterenol, Fluticasone-salmeterol, Olodaterol-hydrochloride, Olodaterol-tiotropium, Fluticasone-vilanterol, Formoterol, Salmeterol, Indacaterol, Umec-lidinium-vilanterol, Formoterol-glycopyrrolate, In-dacaterol-glycopyrrolate

Antiasthmatic combinations— Dyphylline-guaifenesin

ART - Disease-Modifying Anti-rheumatic Drug Therapy for Rheumatoid Arthritis

Members 18 years of age or older who were diagnosed with rheumatoid arthritis and were prescribed a disease-modifying anti-rheumatic drug (DMARD).

Prescribe DMARDs to members with rheu-

matoid arthritis.

Exclusions: A diagnosis of HIV anytime during the member’s history through the end of them measurement year or a diag-nosis of pregnancy in the measurement year


ICD-10 CM Codes: M05.00-M06.9

DMARD HCPCS: J0129, J0135, J0717, J1438, J1600, J1745,

J3262, J7502, J7515-J7518, J9250, J9260, J9310

ABA - Adult BMI Assessment

Members 18-74 years of age who had their body mass index (BMI) and weight documented at least every other year.

Perform and document Ht/Wt/BMI calcu-lation at each visit or at least annually.

Patients younger than 20 years old need to have a BMI percentile documented

*Pregnant members are excluded from this measure*

ICD-10 CM Codes: BMI—Z68.1, Z68.20-Z68.29, Z68.30-Z68.39, Z68.41- Z68.45 BMI Percentile—Z68.51-Z68.54



What You Can Do

Coding/Tips

AMM - Antidepressant Medication Management

Patients 18 years of age and older who were newly treated with antidepressant medication, had a diagnosis of major de-pression and who remained on antidepres-sant medication treatment. Two rates are reported:

Effective Acute Phase: Percentage of pa-tients who remained on an antidepressant medication for at least 84 days (12 weeks)

Effective Continuation Phase: Percentage of patients who remained on an antide-pressant medication for at least 180 days (6 months)

Educate patients that medication may take several weeks to become effective, they should call with any medication concerns/reactions

Stress that they should not stop medication abruptly or without consulting you first for assistance

Schedule follow up appointments prior to patient leaving your office

Outreach patients that cancel appointments and have not rescheduled

Stress the importance of medication compli-ance. Share tips to help them remember to take their medication.

ICD-10 CM Codes for Major Depression: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9

CCS - Cervical Cancer Screening

Women 21-64 years of age with one or more Pap tests within the last 3 years or for women 30-64 years of age, a cervical cytol-ogy and human papillomavirus (HPV) co-testing with in the last 5 years.

Women who have had a total hysterectomy with no residual cervix are excluded. This must be documented in the history or prob-lem list.

Notation of Pap test located in progress notes MUST include the lab results in order to meet NCQA® requirements. Reflex testing: perform-ing HPV test after determining cytology result, does not count.

Cervical cytology and human papillomavirus test must be completed four or less days apart in order to qualify for every 5 year testing.

Cervical Cytology CPT Codes: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143-G0145, G0147,

G0148, P3000, P3001, Q0091 UB Rev Codes : 0923

HPVCPT Codes: 87620-87622, 87624-87625 HCPCS: G0476

COL - Colorectal Cancer Screening

Adults 50-75 years of age with an appropriate screening for colorectal cancer.

Educate members on importance of screening to enable early detection of colon cancer.

A guaiac test in the office during a rectal exam does not count.

Any of the following meet compliance of done in the correct time period:

Colonoscopy: 2009-2018 Flexible sigmoidoscopy: 2014-2018 CT colonography: 2014-2018 FIT-DNA test : 2016-2018 Fecal occult blood test (3 samples): 2018


Colonoscopy

CPT Codes: 44388-44394, 44397, 44401-44408, 45355, 45378-45393, 45398 HCPCS G0105, G0121

Flexible Sigmoidoscopy

CPT Codes: 45330-45335, 45337-45342, 45345-45347, 45349-45350 HCPCS: G0104

CT Colonography CPT Code: 74261-74263

FIT-DNA test CPT Code: 81528 HCPCS: G0464

Fecal Occult Blood Test (FOBT)

CPT Codes: 82270, 82274 HCPCS: G0328

PBH - Persistence of Beta-Blocker Treat-ment After a Heart Attack

Members 18 years of age and older who were hospitalized and discharged with a diagnosis of AMI and received persistent beta-blocker treatment for six months after discharge.

Stress the importance of medication compli-ance and why they need to take a beta blocker at follow-up visits.

Advise member not to stop medication with-out talking with provider first.

Consider ordering a 90 day supply if permitted by member’s benefit.

There are exclusions for intolerance or allergy to beta blockers as well as conditions listed in next column.


ICD-10 Codes to Identify Exclusions:

History of Asthma: J45.20-J45.998 COPD: J44.0, J44.1, J44.9 Chronic Respiratory Conditions due to Fumes/Vapors: J68.4

Hypotension: I95.0-I95.9 Heart Block > 1st degree: l44.1-I44.7, I45.10-I45.3, I45.6, I49.5 Unspecified Bradycardia: R00.1

Adverse effect of Beta-Adrenoreceptor Antagonists: T44.7X5A, T44.7X5D, T44.7X5S



What You Can Do

Coding/Tips

SPC—Statin Therapy for Patients with Cardi-ovascular Disease

Males 21–75 years of age and females 40–75 years of age, who were identified as having clinical atherosclerotic cardiovascular disease(ASCVD) and met the following criteria. The following rates are reported:

Received Statin Therapy. Members who were dispensed at least one high or moder-ate-intensity statin medication during the measurement year.

Statin Adherence 80%. Members who re-mained on a high or moderate-intensity statin medication for at least 80% of the treatment period. (RX date through end of year).

Educate patients about the importance of statin therapy

Educate patients on side effects and im-portance of reporting any side effects to you so their medication can be adjusted/changed if necessary Advise patients not to stop taking without consulting you

Exclusions: ESRD, cirrhosis, myalgia, myopa-thy, myositis, or rhabdomyolysis. Pregnancy during the measurement year, IVF during the measurement year or year prior, or dispensed a prescription for clomiphene during the measurement year or year prior.


High-intensity statin therapyAtorvastatin 40-80 mgRosuvastatin 20-40mgAmlodipine-atorvastatin 40-80 mgSimvastatin 80mgEzetimibe-simvastatin 80 mg

Moderate-intensity statin therapyAtorvastatin 10-20 mgLovastatin 40 mgAmlodipine-atorvastatin 10-20 mgPravastatin 40-80mgEzemtimibe-simvastatin 20-40mgFluvastatin XL 80mgFluvastatin 40 mg BIDPitavastatin 2-4 mgSimvastatin 20-40 mgRosuvastatin 5-10mg

SPD—Statin Therapy for Patients With Dia-betes

Patients 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following crite-ria. Two rates are reported:

Received Statin Therapy. Dispensed at least one statin medication of any intensity during the year

Statin Adherence 80%. Remained on a statin medication of any intensity for at least 80% of the treatment period (Rx date through end of year.

Educate patients about the importance of statin therapy in patients with diabetes

Educate patients on side effects and im-portance of reporting any side effects to you so medication can be adjusted/changed

Advise patients not to stop taking without consulting you

Exclusions: During the year prior to the measurement year (MY): MI, CABG, PCI, other revascular procedure During the MY or year prior: Preg-nancy, IVF, one Rx for Clomiphene, ESRD, Cirrhosis. During both the MY & year prior: IVD. During the MY: Myalgia, Myositis, Myo-pathy or Rhabdomyolysis.

In addition to the high and moderate intensity statins listed above, the following low-intensity statins per-tain to this measure:

Simvastatin 10 mgLovastatin 20 mgEzemtimibe-simvastatin 10 mg Fluvastatin 20-40 mg Pravastatin 10-20 mg Pitavastatin 1 mg


DDE—Potentially Harmful Drug-Disease Interactions in the Elderly

The percentage of Medicare members 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambula-tory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Four rates reported:

1. A history of falls and a prescription for anticonvulsants, SSRIs, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics or tricyclic antidepressants.

2. Dementia and a prescription for anti-psychotics, benzodiazepines, nonbenzo-diazepine hypnotics, tricyclic antide-pressants, H2 receptor antagonists or anticholinergic agents.

3. Chronic kidney disease and prescription for Cox-2 selective NSAIDs or nonaspirin NSAIDs

4. Total Rate

1. Carefully review patient’s history before prescribing anticonvulsants, SSRIs, antipsy-chotics, benzodiazepines, non-benzodiazepine hypnotics or tricyclic antidepressants. Patients with an accidental fall or hip fracture in the

past 2 years are at an increased risk if taking these medications. There are exclusions for this measure: patients with a diagnosis of psychosis, schizophrenia, schizoaffective disorder, bipolar disorder, or seizure disorder during the 2 year period.

2. Carefully review patient’s history before prescribing any antipsychotics, benzodiaze-pines, non-benzodiazepine hypnotics, tricyclic antidepressants, H2 receptor antagonists or anticholinergic agents. Patients with a diagno-sis of dementia in the past two years have increased risk. There are exclusions for this measure: patients with a diagnosis of psychosis, schizophrenia, schizoaffective disorder or bipolar disorder during the 2 year period.

3. Review patient history for CKD, ESRD or kidney transplant before ordering any Cox-2 selective NSAIDs or nonaspirin NSAIDs

Refer to the list of medications attached

Falls and Hip Fracture: Any fall or Hip Fracture ICD10 or CPT code is pulled into the denominator

Dementia: ICD 10: F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F04, F10.27, F10.97, F13.27, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.83

Chronic Kidney Disease Stage 4 ICD 10: N18.4

ESRD CPT: 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90951-90970, 90989, 90993, 90997, 90999, 99512 HCPCS: G0257, S9339 ICD 10 CM: N18.5, N18.6, Z91.15, Z99.2 ICD10 PCS : 3E1M39Z, 5A1D00Z, 5A1D60Z-5A1D90Z

Kidney Transplant CPT: 50300, 50320, 50340, 50360, 50365, 50370, 50380 HCPCS: S2065 ICD10CM: Z94.0 ICD10PCS: 0TY00Z0—0TY00Z2, 0TY10Z0—0TY10Z2 UBREV 367



What You Can Do

Coding/Tips

DAE—Use of High-Risk Medication in the Elderly

The percentage of Medicare members 66 years of age and older who had at least one dispensing event for a high-risk medication.

The percentage of Medicare members 66 years of age and older who had at least two dispensing events for the same high-risk medication.

For both rates, a lower rate represents better performance.

Always complete a thorough medication re-view and re-evaluate the use of high risk drugs at each visit.

Monitor adverse side effects and possibility of it being misinterpreted as a new diagnosis or symptom.

Whenever possible, avoid prescribing these medications for patients over age 66

Refer to attached list of medications considered high risk in the elderly.

MPM– Annual Monitoring for Patients on Persistent Medications

Members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitor-ing event for the therapeutic agent in the measurement year.

Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB).—at least one serum K+ and serum Cr during the year

Annual monitoring for members on diuretics—at least one serum K+ and serum Cr during the year

Total rate (the sum of the three nu-merators divided by the sum of the three denominators

Educate patients on the importance of lab work when taking certain medications

Check each visit to see if lab work has been completed, if not re-educate and reorder

CPT Codes Lab panels that include K+ and Cr 80047, 80048, 80050, 80053, 80069

Serum K+ 80051, 84132

Serum Cr 82565, 82575

FMC– Follow-Up After Emergency Depart-ment Visit for People With High-Risk Mul-tiple Chronic Conditions

The percentage of emergency department (ED) visits for patients 18 and older who have high-risk multiple chronic conditions and had a follow-up service within 7 days of the ED visit

An ED visit that changes to a IP stay is not in-cluded in this measure.

To be included in the measure, prior to the ED visit , the patient must have 2 or more of the chronic conditions listed during the measure-ment year or the year prior - identified by 2 OP visits or 1 IP stay :

COPD and asthma, Alzheimer’s disease and related disorders, chronic kidney disease, De-pression, Heart failure, Acute MI, Atrial fibrilla-tion, Stroke and TIA.

In addition to an Outpatient Visit or BH visit code,

the following are compliant codes for a follow-up

visit within 7 days:

Telephone Visit:: CPT Code: 98966-98968, 99441-

99443

Transitional Care Management: CPT Code: 99495,

99496

Case Management Visit/Encounter: CPT code:

99366 HCPCS: T1016, T1017, T1022, T1023

Complex Case Management Services: HCPCS: G0506

CPT Code: 99487, 99489, 99490

*Exclusion note: The exclusions in the mid-

dle column apply to these measures: ART,

BCS, CDC, COL, OMW, PBH, SPC and SPD if

the member was 66 years old by 12/31 of

the measurement year. One exception -

OMW exception starts at age 67.

If enrolled in an institutional SNP or living

in a long-term institution any time during

the measurement year OR

If at least one claim for frailty AND spe-

cific claims for advanced illness or dis-

pensed dementia medication.

*Additional exception for ART, CBP, OMW, and PBH:

Exclude members age 81 and older as of 12/31 of the measurement year that had at least one frailty claim.


DDE Measure Medications for Rates 1 and 2

Potentially Harmful Drugs - Rate 1

Description Prescription

Anticonvulsants

·

Carbamazepine

· Clobazam

· Divalproex sodium

· Ethosuximide

· Ethotoin

· Ezogabine

· Felbamate

· Fosphenytoin

· Gabapentin

· Lacosamide

· Lamotrigine

· Levetiracetam

· Methsuximide

· Oxcarbazepine

· Phenytoin

· Pregabalin

· Primidone

· Rufinamide

· Tiagabine HCL

· Topiramate

· Valproate sodium

· Valproic acid

· Vigabatrin

· Zonisamide

SSRIs · Citalopram

· Escitalopram

· Fluoxetine

· Fluvoxamine

· Paroxetine

· Sertraline

Potentially Harmful Drugs - Rates 1 & 2


Antipsychotics

·

Aripiprazole

· Asenapine

· Brexpiprazole

· Cariprazine

· Chlorpromazine

· Clozapine

· Fluphenazine

· Haloperidol

· Iloperidone

· Loxapine

· Lurasidone

· Molindone

· Olanzapine

· Paliperidone

· Perphenazine

· Pimozide

· Quetiapine

· Risperidone

· Thioridazine

· Thiothixene

· Trifluoperazine

· Ziprasidone

Benzodiazepines

· Alprazolam

· Chlordiazepoxide products

· Clonazepam

· Clorazepate-dipotassium

· Diazepam

· Estazolam

· Flurazepam HCL

· Lorazepam

· Midazolam HCL

· Oxazepam

· Quazepam

· Temazepam

· Triazolam

Nonbenzodiazepine hyp-notics

· Eszopiclone · Zaleplon · Zolpidem

Tricyclic antidepressants

· Amitriptyline

· Amoxapine

· Clomipramine

· Desipramine

· Doxepin (>6 mg)

· Imipramine

· Nortriptyline

· Protriptyline

· Trimipramine

Potentially Harmful Drugs - Rate 2


H2 receptor antagonists ·

Cimetidine · Famotidine · Nizatidine · Ranitidine

Anticholinergic agents, antiemetics

· Prochlorperazine Promethazine

Anticholinergic agents, antihistamines

· Carbinoxamine

· Chlorpheniramine

· Hydroxyzine

· Brompheniramine

· Clemastine

· Triprolidine

· Cyproheptadine

· Dimenhydrinate

· Diphenhydramine

· Meclizine

· Dexbrompheniramine

· Dexchlorpheniramine

· Doxylamine

Anticholinergic agents, antispasmodics

· Atropine

· Homatropine

· Belladonna alka-loids

· Dicyclomine

· Hyoscyamine

· Propantheline

· Scopolamine

· Clidinium-chlordiazepoxide

Anticholinergic agents, antimuscarinics (oral)

· Darifenacin

· Fesoterodine

· Trospium

· Flavoxate

· Oxybutynin

· Tolterodine

· Solifenacin

Anticholinergic agents, anti-Parkinson agents

· Benztropine · Trihexyphenidyl

Anticholinergic agents, skeletal muscle relaxants

· Cyclobenzaprine · Orphenadrine

Anticholinergic agents, SSRIs

· Paroxetine

Anticholinergic agents, antiarrhythmic

· Disopyramide

DAE Measure Medications

High-Risk Medications Prescriptions

Anticholinergics, first-generation antihistamines

· Brompheniramine

· Carbinoxamine

· Chlorpheniramine

· Clemastine

· Cyproheptadine

· Dexbrompheniramine

· Dexchlorpheniramine

· Diphenhydramine (oral)

· Dimenhydrinate

· Doxylamine

· Hydroxyzine

· Meclizine

· Promethazine

· Triprolidine

Anticholinergics, anti-Parkinson agents · Benztropine (oral) · Trihexyphenidyl

Antispasmodics

· Atropine (exclude ophthalmic)

· Belladonna alkaloids

· Clidinium-chlordiazepoxide

· Dicyclomine

· Hyoscyamine

· Propantheline

· Scopolamine

Antithrombotics

· Dipyridamole, oral short-acting

(does not apply to the extended-

release combination with aspirin)

· Ticlopidine

Cardiovascular, alpha agonists, central · Guanfacine · Methyldopa

Cardiovascular, other · Disopyramide · Nifedipine, immediate release

Central nervous system, antidepressants

· Amitriptyline

· Clomipramine

· Amoxapine

· Desipramine

· Imipramine

· Trimipramine

· Nortriptyline

· Paroxetine

· Protriptyline

Central nervous system, barbiturates

· Amobarbital

· Butabarbital

· Butalbital

· Pentobarbital

· Phenobarbital

· Secobarbital

Central nervous system, vasodilators · Ergot mesylates · Isoxsuprine

Central nervous system, other · Meprobamate

Endocrine system, estrogens with or without progestins; include

only oral and topical patch products

· Conjugated estrogen

· Esterified estrogen

· Estradiol

· Estropipate

Endocrine system, sulfonylureas, long-duration · Chlorpropamide · Glyburide

Endocrine system, other · Desiccated thyroid · Megestrol

Pain medications, skeletal muscle relaxants

· Carisoprodol

· Chlorzoxazone

· Cyclobenzaprine

· Metaxalone

· Methocarbamol

· Orphenadrine

Pain medications, other · Indomethacin

· Ketorolac, includes parenteral

· Meperidine

· Pentazocine

High-Risk Medications With Days Supply Criteria Prescriptions Days Supply Criteria

Anti-Infectives, other

· Nitrofurantoin

· Nitrofurantoin macrocrystals

· Nitrofurantoin macrocrystals-

monohydrate

> 90 days

Nonbenzodiazepine hypnotics

· Eszopiclone

· Zaleplon

· Zolpidem

> 90 days

High-Risk Medications With Average Daily Dose Criteria Prescriptions Average Daily Dose Criteria

Alpha agonists, central · Reserpine >0.1 mg/day

Cardiovascular, other · Digoxin >0.125 mg/day

Tertiary TCAs (as single agent or as part of combination prod-

ucts) · Doxepin >6 mg/day


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