HEDIS Measures & Billing Codes

HEDIS™ Quick Reference Guide

Updated to reflect NCQA HEDIS 2017 Technical Specifications

California Health & Wellness strives to provide quality healthcare to our membership as measured through HEDIS quality metrics. We created the HEDIS Quick Reference Guide to help you increase your practice’s HEDIS rates. Please always follow the State and/or CMS billing guidance and ensure the HEDIS codes are covered prior to submission.

WHAT IS HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) to objectively measure, report, and compare quality across health plans. NCQA develops HEDIS measures through a committee represented by purchasers, consumers, health plans, health care providers, and policy makers.

WHAT ARE THE SCORES USED FOR?

As state and federal governments move toward a quality-driven healthcare industry, HEDIS rates are becoming more important for both health plans and individual providers. State purchasers of healthcare use aggregated HEDIS rates to evaluate health insurance companies’ efforts to improve preventive health outreach for members.
Physician-specific scores are also used to measure your practice’s preventive care efforts. Your practice’s HEDIS score determines your rates for physician incentive programs that pay you an increased premium — for example Pay For Performance or Quality Bonus Funds.

HOW ARE RATES CALCULATED?

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the need for medical record review. If services are not billed or not billed accurately, they are not included in the calculation.

HOW CAN I IMPROVE MY HEDIS SCORES?

  • Submit claim/encounter data for each and every service rendered
  • Make sure that chart documentation reflects all services billed
  • Bill (or report by encounter submission) for all delivered services, regardless of contract status
  • Ensure that all claim/encounter data is submitted in an accurate and timely manner
  • Consider including CPT II codes to provide additional details and reduce medical record requests

ADULT HEALTH

California Health & Wellness-reported measures are highlighted in blue.

AMBULATORY/PREVENTIVE HEALTH SERVICES

Measure evaluates the percentage of members age 20 years and older who had at least one ambulatory or preventive care visit per year. Services that count include outpatient evaluation and management (E&M) Visits, consultations, assisted living/home care oversight, preventive medicine, and counseling.

Ambulatory Residential/Nursing Facility E&M Visits

CPT ICD-10 HCPCS

OUTPATIENT: 99201-99205, 99211-99215

CONSULTATIONS: 99241-99245

NURSING FACILITY, CUSTODIAL CARE:
-99341-99345, 99347-99350, 99401-99404

PREVENTIVE MEDICINE: 99381-99387, 99391-9937

COUNSELING: 99401-99404, 99411-99412

OTHER: 99420, 99429

Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 G0402, G0438, G0439, G0463, T1015

ALCOHOL AND OTHER DRUG DEPENDENCE TREATMENT

Measure evaluates the percentage of adolescent and adult members with a new episode of alcohol or other drug dependence (AOD) who:

  • Initiated dependence treatment within 14 days of their diagnosis
  • Continued treatment with 2 or more additional services within 30 days of the initiation visit

For the follow up treatments, include an ICD-10 diagnosis for Alcohol or Other Drug Dependence from the Mental, Behavioral and Neurodevelopmental Disorder Section of ICD-10 along with a procedure code for the preventive service, evaluation and management consultation or counseling service (see codes below).

Treatment Codes to Be Used with Diagnosis Codes

CPT HCPCS

Education: 98960-98962, 99078

E&M: 99201-99205, 99211-99215, 99217-99220

Consultation: 99241-99245

Assisted living/Home Care Oversight:

99341-99345, 99347-99350,

Preventive Services: 99384-99387, 99394-99397

Counseling: 99401-99404, 99408, 99409, 99411-99412, 99510

G0155, G0176, G0177, G0396, G0397, G0410, G0463, G0409-G0411,G0443, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

Treatment in Office

Use service codes below with the diagnosis code AND a place of service code:

90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875-90876 03, 05, 07, 09, 11-15, 20, 22, 33, 49, 50, 52-53, 57, 71-72

Treatment in Community Mental Health Center or Psychiatric Facility

Use the service codes below with the diagnosis code and the place of service (POS) code:

CPT POS
99221-99223, 99231-99233, 99238, 99239, 99251-99255 52 and 53

ASTHMA (Medication Management)

Measure evaluates the percentage of patients who were identified as having persistent asthma and were dispensed appropriate medications which they remained on during the treatment period within the past year. For Medicare members, the age range measured is 18 to 85 and for Medicaid recipients, the age is 5 to 64.

Rates HCPS
Medication Compliance 50%: Members who were covered by oneasthma control medication at least 50% of the treatment period

Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Mast cell stabilizers, Methylxanthines

Medication Compliance 75%: Members who were covered by oneasthma control medication at least 75% of the treatment period

Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Mast cell stabilizers, Methylxanthines

BMI ASSESSMENT

This measure demonstrates the percentage of members ages 18 to 74 who had their BMI documented during any outpatient visit in the past two years. Recommendation is for adults to have BMI assessed at least every 2 years.

  1. For patients 20 and over: Code the BMI value on the date of service.
  2. For patients younger than 20, code the BMI percentile value set on the date of service.

Ranges and thresholds do NOT meet criteria; a distinct BMI value or percentile is required.

ICD-10
ICD-10 BMI Value set Z68.1-Z68.45; ICD-10 BMI Percentile Value Set Z68.51-Z85.54

CARE FOR OLDER ADULTS

Measure evaluates four components:

  1. At least one functional status assessment per year. Can be a standard assessment tool or notation of either of the following: Activities of Daily Living (ADLs); Instrumental Activities of Daily Living *(IADL); or at least three of the following: notation of cognitive status, ambulation status, sensory ability (hearing, vision, and speech), and/or other functional independence.
  2. Evidence of advance care planning and the date of the discussion or the presence of a plan
  3. At least annually, a review of the patient’s medications by a prescribing practitioner. Includes the presence of a medication list and review of the medications. Transitional care management services also meet criteria.
  4. At least annually, a pain assessment, either through a standardized pain assessment tool or documentation that pain was assessed.
Description CPT CPT Category II HCPCS
Advance care planning 99497 1157F, 1158F S0257
Medication review 90863, 99605, 99606 1160F
Medication list 1159F G8427
Transitional care management services 99495, 99496
Functional status assessment 1170F
Pain assessment 1125F, 1126F


COLORECTAL CANCER SCREENING

Measure evaluates the percentage of members ages 50-75 who had at least one appropriate screening for Colorectal Cancer in the past year. Appropriate screening is FOBT in 2016, FIT-DNA (Cologuard) in the last 3 years, flexible sigmoidoscopy or CT Colonography (Virtual Colonoscopy) in the last 5 years or colonoscopy in last 10 years. Patients who have a history of colon cancer (Z85.038 or Z85.048) or who have had a total colectomy are exempt from this measure.

FOBT

CPT

HCPCS

82270, 82274

G0328


Flexible Sigmoidoscopy

CPT

HCPCS

45330-45335, 45337-45342, 45345

G0104


Colonoscopy

CPT

HCPCS

44388-44394, 44397, 45355, 45378-45387, 45391, 45392

G0105, G0121


CT Colonography

CPT

74263


FIT-DNA

CPT

HCPCS

81528

G0464

 

COPD EXACERBATION (Pharmacotherapy Management)

Measure evaluates the percentage of COPD exacerbations for members age 40 and older, had an acute inpatient stay or ED visit and who were dispensed appropriate medications.

Intent is to measure compliance with recommended pharmacotherapy management for those with COPD exacerbations.

RATES

DESCRIPTION

Systemic Corticosteroid: Dispensed prescription for systemic corticosteroid within 14 days after the episode.

Glucocorticoids

Bronchodilator: Dispensed prescription for a bronchodilator within 30 days after the episode date.

Anticholinergic agents, Beta 2-agonists, Meth- ylxanthines


COPD (Spirometry Testing in the Assessment and Diagnosis)

Measure evaluates the percentage of members age 40 and older with a new diagnosis of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis. Spirometry testing should be completed within 6 months of the new diagnosis or exacerbation.

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


DIABETES CARE
(Comprehensive)

Measure demonstrates the percentage of members ages 18-75 with diabetes (types 1 & 2) who were compliant in the following submeasures:

HbA1c Test: is completed at least once per year (includes rapid A1c).

CPT

CPT II

HCPCS

83036, 83037

3044 (HbA1c <7%)

3045 (HbA1c 7%-9%)

3046 (HbA1c >9%)


Eye Exam:
a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) is completed every year OR a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior. CPT II code 3072F reflects a dilated retinal exam negative for retinopathy.

CPT

CPT II

HCPCS

67028, 67030, 67031, 67036, 67039- 67043, 67101, 67105, 67107, 67108, 67110, 67112, 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, 99213-99215, 99242-99245

2022F, 2024F, 2026F,

3072F

S0620, S0621, S0625, S3000


Diabetic Retinal Screening with Eye Care Professional

CPT

CPT II

HCPCS

2022F, 2024F, 2026F, 3072F

S0625 (retinal telescreening)


Nephropathy Screening Test:
a urine protein test to screen for nephropathy performed at least once a year. A member who is being treated for nephrophathy (on ACE/ARB), has evidence of ESRD, stage 5 chronic kidney disease, a history of a kidney transplant or is being seen by a nephrologist is compliant for this submeasure.

CPT

CPT II

HCPCS

81000-81003, 81005, 82042-82044, 84156

3060F-3062F, 3066F, 4010F


MEDICATION RECONCILIATION POST-DISCHARGE

Measure evaluates the percentage of discharges for members age 18 and older for whom medications at discharge were reconciled against the outpatient medical record on or within 30 days of discharge.

CPT

CPT CATEGORY II

99495, 99496

1111F


MONITORING FOR PATIENTS ON PERSISTENT MEDICATIONS (Annual)

ACE Inhibitors or ARBs: Members who are 18 years of age and older who received at least 180 treatment days of ACE inhibitors or ARBs within the past year should have at least one:

  • Serum postassium and one serum creatinine test annually

Digoxin (NOT a California Health & Wellness-reported measure): Members who are 18 years of age and older who received at least 180 treatment days of digoxin within the past year should have at least one:

  • Serum potassium, one serum creatinine test, and one serum digoxin test annually

Diuretics: Members who are 18 years of age and older who have received at least 180 treatment days of a diuretic within the past year should have at least one.

  • One serum potassium and one serum creatinine test annually

DESCRIPTION

CPT

Lab panel

80047, 80048, 80050, 80053, 80069

Serum potassium (K+)

80051, 84132

Serum creatinine (SCr)

82565, 82575

Digoxin level

80162

PERSISTENCE OF BETA-BLOCKER TREATMENT AFTER A HEART ATTACK

Measure evaluates the percentage of members age 18 and older who were hospitalized and discharged with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.

DESCRIPTION

CPT

Non-cardioselective beta-blockers

Carvedilol, Labetalol, Nadolol, Penbutolol, Pindolol, Propranolol, Timolol, Sotalol

Cardioselective beta-blockers

Acebutolol, Atenolol, Betaxolol, Bisoprolol, Metoprolol, Nebivolol

Antihypertensive combinations

Atenolol-chlorthalidone, Bendroflumethiazide- nadolol, Bisoprolol-hydrochlorothiazide, Hydrochlorothizide-metoprolol, Hydrochlorothizide-propranolol

WOMEN’S HEALTH

California Health & Wellness-reported measures are highlighted in blue.

BREAST CANCER SCREENING

Measure evaluates the percentage of women ages 50–74 who had a mammogram at least once in the past 27 months. Women who have had a bilateral mastectomy are exempt from this measure. Diagnostic screenings are not compliant.

Mammography Screening:

CPT

HCPCS

77055-77057

G0202


History of Bilateral Mastectomy

ICD10
Z90.13

CERVICAL CANCER SCREENING

Measure evaluates the percentage of women ages 21–64 who were screened for cervical cancer using either of the following criteria:

  1. Cervical cytology performed every 3 years for women ages 21–64
  2. Cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years (must occur within 4 days of each other) for women ages 30–64. **HPV testing in response to a positive cervical cytology test is not compliant.
  3. Women who have had a hysterectomy without a residual cervix are exempt from this measure.

Cervical Cytology Codes (ages 21-64):

CPT

HCPCS

88141-88143, 88147, 88148, 88150, 88152- 88154, 88164-88167,88174, 88175 

G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

Ages 30-64 years old, Code from Cervical Cytology plus one

CPT

HCPCS

87620-87622, 87624, 87625

G0476

HPV code:

HPV Test

CPT

ICD-10

HCPCS

87620-87622, 87624, 87625


Absence of Cervix

ICD10
Q51.5, Z90.710, Z90.712


CHLAMYDIA SCREENING

Measure evaluates the percentage of women ages 16 to 24 who are sexually active who had at least one test for Chlamydia during the year. Chlamydia tests can be completed using any method, including a urine test. “Sexually active” is defined as a woman who has had a pregnancy test; testing or diagnosis of any other sexually transmitted disease; is pregnant or has been prescribed birth control.

ICD10
87110, 87270, 87320, 87490-87492, 87810PRENATAL VISITS

PRENATAL VISITS 
TIMELINESS OF FIRST VISIT AND FREQUENCY OF VISITS

Measure evaluates the percentage of pregnant women who had their first prenatal visit in the first trimester or within 42 days of enrollment with the plan. Also, the frequency of prenatal visits is assessed.

If a bundled service code is used, submit any prenatal visits as encounters to count

  • For OB or PCP provider types, choose to submit Stand Alone Prenatal Visit codes
  • OB provider types may also submit any Prenatal Visit code in conjunction with any code for Other Prenatal Services
  • PCP provider types can also submit any Stand Alone Prenatal Visit code and any code for Other Prenatal Services along with a pregnancy diagnosis.
  • Other Prenatal Services (any one listed): Obstetric Panel, Prenatal Ultrasound, Cytomegalovirus and Antibody Levels for Toxoplasma, Rubella, and Herpes Simplex, Rubella antibody and ABO, Rubella and Rh, Rubella and ABO/Rh

Stand Alone Prenatal Visit Codes

CPT

HCPCS

99500, 0500F, 0501F, 0502F

H1000-H1004

Prenatal Visit Codes (to Use with Pregnancy Diagnosis or Other Prenatal Services)

CPT

HCPCS

99201-99205, 99211-99215, 99241-99245

G0463, T1015, Z1032, Z1034

POSTPARTUM VISITS

Measure evaluates the percentage of women who delivered a baby and who had their postpartum visit on or between 21 and 56 days after delivery (3 and 8 weeks). If a bundled service code is used, submit the encounter for the postpartum service using a code below.

Any Postpartum Visit:

CPT

ICD-10

HCPCS

57170, 58300, 59430, 99501,

0503F

Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2, Z1038

G0101

Any Cervical Cytology Procedure:

CPT

HCPCS

88141-88143, 88147, 88148, 88150, 88152-

88154, 88164-88167, 88174, 88175

G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091


OSTEOPOROSIS MANAGEMENT IN WOMEN WHO HAD A FRACTURE

Measure evaluates the percentage of women age 67–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the 6 months after the fracture.

Bone Density Tests

CPT

HCPCS

ICD-10

PRESCRIPTION

76977, 77078, 77080-

77082, 77085, 77086

G0130

BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ3ZZ1, BQ04ZZ1, BR00ZZ1,  BR07ZZ1, BR09ZZ1,  BR0GZZ1

— Biphosphonates: (Alendronate, Risedronate, Ibandronate, Zoledronic acid, Alendronate- cholecalciferol), Other agents: Calcitonin, Denosumab, Raloxifene, Teriparatide

PEDIATRIC HEALTH

California Health & Wellness-reported measures are highlighted in blue.

ACCESS TO PRIMARY CARE PRACTITIONERS

Measure evaluates the percent of children ages 12 months–19 years who had an outpatient visit within the year with a Primary Care Physician.

Office or Other Outpatient Services

CPT
99201-99205, 99211-99215, 99241-99245

Home Services

CPT
99341-99345, 99347-99350

Flexible Sigmoidoscopy

CPT

HCPCS

ICD-10

99381-99385,

99391-99395,

99401-99404,

99411

99412, 99420,

99429

G0402, G0438, G0439, G0463, T1015

Z00.110-Z00.129 Z00.00- Z02.9

General Medical Examination

CPT
Z00.129, Z00.00, Z00.01, Z00.121, Z00.5, Z00.8, Z02.0 - Z02.9

ADHD MEDICATION FOLLOW-UP CARE

Measure demonstrates the percent of children ages 6–12 newly prescribed an ADHD medication that had at least three follow-up care visits within a 10 month period, one of  which was within 30 days of when the first ADHD medication was dispensed. The intent of the measure is to assess medication impact and side effects and therefore, visits with a counselor does not count. The visit should be with a practitioner with prescribing authority. Two rates:

Initiation Phase: one face-to-face outpatient follow-up visit with a prescribing practitioner within 30 days after the date the ADHD medication was newly prescribed.

CPT

HCPCS

Health/Behavior Assessment:

96150-96154

Education: 98960-98962, 99078

Office or Outpatient Visit: 99201-99205, 99211-99215, 99217-99220, 99241-99245

Assisted Living/Home Care Oversight:

99341-99345;  99347-99350

Preventive Medicine: 99382-99384,

99391-99394

Counseling: 99401-99404, 99411-99412

G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015

 

CPT

 

POS

90791, 90792, 90832-90834, 90836-

90840, 90845, 90847, 90849, 90853,

90857, 90862, 90875, 90876

WITH

3, 5, 7, 9, 11-20, 22, 33, 49, 50, 52, 53,

71, 72

99221-99223, 99231-99233, 99238, 99239,

99251-99255

WITH

52, 53


Continuation and Maintenance Phase:
Two more follow-up visits from 31 to 210 days after the first ADHD medication was newly prescribed. One of the two visits may be a telephone visit with the prescribing practitioner.

CODES TO IDENTIFY VISITS

CPT CODES TO IDENTIFY TELEPHONE VISITS

Any code noted above in the initiation phase.

9896-98968, 99441-99443


ASTHMA (MEDICATION MANAGEMENT)

Measure evaluates the percentage of members ages 5–85 who were identified as having persistent asthma and were dispensed appropriate medications which they remained on during the treatment period within the past year.

RATES

APPROPRIATE  MEDICATIONS

Medication Compliance 50%:

Members who were covered by one asthma control medication at least 50% of the treatment period

Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Mast cell stabilizers, Methylxanthines and Short-acting, inhaled beta-2

Medication Compliance 75%: Members who were covered by one asthma control medication at least 75% of the treatment period

agonists


DENTAL VISIT (ANNUAL)

Measure evaluates the percentage of members ages 2–20 who had at least one dental exam with a dental practitioner in the past year.

IMMUNIZATIONS

Childhood Immunizations: percentage of 2 year olds that have all of the required immunizations listed below by age 2.

Note: Parent refusal for any reason is not a valid exclusion.

IMMUNIZATION

DETAILS

CPT

HCPCS

CVX

DTaP

At least 4 doses

< age 2

90698, 90700,

90721, 90723

20, 50, 106, 110, 120

IPV

At least 3 doses

< age 2

90698, 90713,

90723

10, 110, 120

MMR

At least 1 dose

< age 2

90707, 90710

Measles/ Rubella-90708

Mumps-90704, Measles-90705, Rubella-90706

 

03, 94

04

Mumps-07, Measles-05, Rubella-0

Hib

At least 3 doses < age 2

90645-90648,

90698, 90721,

90748

46-51, 120,

148

Hepatitis B

At least 3 doses < age 2

90723, 90740,

90744, 90747,

90748 ICD10:

99.55, ICD10PCS:

3E0234Z

G0010

08, 44, 51,

110

VZV

At least 1 doses < age 2

90710, 90716

21, 94

Pneumococcal

At least 4 doses < age 2

90669, 90670

G0009

100, 133

Hepatitis A

At least 1 doses < age 2

90633

83

Rotavirus1

Before age 2:

2 doses of 2-dose vaccine; 1 dose of the 2 dose vaccine and 2 doses of the 3 dose vaccine or 3 doses of the 3 dose vaccine

2  dose schedule-90681 schedule-90681

 

 

 

3  dose

schedule-90680

119

 

 

 

 

116

Influenza

At least 2 doses < age 2

90655, 90657,

90661, 90662,

90673,

90685, 90687

G0008

135, 140-

141, 153,

155, 161,

166

1 Record must document if Rotavirus is 2 or 3 dose vaccine.

Adolescent Immunizations: percentage of adolescents turning 13 who had all the required immunizations listed below.

Meningococcal

1 on or between 11th – 13th birthdays

90644, 90734

136, 148

Tdap

1 on or between 10th – 13th birthdays

Tdap-90715

115

Human Papillomavirus (HPV)

Three doses by 13th birthday

90649-90651

62, 118, 165

Exclusions for Immunizations

Vaccine Reason
Any vaccine Anaphylactic reaction
DtaP Encephalopathy with a vaccine adverse-effect
MMR, VZV and influenza

Immunodeficiency

HIV

Lymphoreticular cancer, multiple myeloma or leukemia

Anaphylactic reaction to neomycin

Rotavirus

Severe combined immunodeficiency

History of intussusception

IPV Anaphylactic reaction to streptomycin, polymyxin B or neomycin
Hepatitis B

 

Anaphylactic reaction to common baker’s yeast

 

LEAD SCREENING IN CHILDREN

Measure evaluates the percentage of children who had a screening test for lead poisoning at least once prior to their second birthday. A lead screening completed in the practitioner office is also allowable.

CPT
83655
Z00.129, Z00.00, Z00.01, Z00.121, Z00.5, Z00.8, Z02.0 - Z02.

PHARYNGITIS (APPROPRIATE TESTING)

Measure evaluates the percentage of children age 3-18 diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Ensure any secondary diagnoses indicating the need for an antibiotic are submitted on the claim. Rapid strep tests in the office are acceptable and should be billed.

CPT
87070, 87071, 87081, 87430, 87650-87652, 87880


UPPER RESPIRATORY INFECTION (APPROPRIATE TREATMENT)

Measure evaluates the percentage of children age 3 months–18 years who were given  a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Ensure any secondary diagnoses indicating the need for an antibiotic are submitted on the claim.

WEIGHT ASSESSMENT AND COUNSELING FOR NUTRITION AND PHYSICAL ACTIVITY

Measure demonstrates the percentage of members ages 3–17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following completed at least annually: 1) BMI percentile documentation1; 2) counseling for nutrition; 3) counseling for physical activity.

DESCRIPTION

CPT

ICD-10 DIAGNOSIS

HCPCS

Counseling for Nutrition

97802-97804

Z71.3

G0270, G0271, G0447, S9449, S9452, S9470

Counseling for Physical Activity

Z02.5

G0447, S9451

Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile   is assessed rather than an absolute BMI value. The percentile ranking is based on the Centers for Disease Control and Prevention’s (CDC) BMI-for-age growth charts.

Pregnant members excluded.

WELL CHILD AND ADOLESCENT WELL CARE VISITS

Components of a comprehensive well visit include:

  1. a health history
  2. a physical developmental history
  3. a mental developmental history;
  4. a physical exam
  5. health education/anticipatory guidance.

Visits must be with a primary care practitioner (pediatrician, family practice, OB/GYN), even though the PCP does not have to be the practitioner assigned to the child. Assessment or treatment of an acute or chronic condition do not count toward the measure. Use age- appropriate codes when submitting well child visits.

Well Child Visits in the First 15 Months of Life

Measure evaluates the percentage of infants who had 6 comprehensive well care visits within the first 15 months of life. Initial hospital care for evaluation and management of normal newborn infant counts toward the measure (99461).

CPT

ICD-10 DIAGNOSIS

HCPCS

99381, 99382, 99391, 99392,

99461

Z00.110, Z00.111, Z00.121, Z00.129, Z00.8, Z02.0, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9

G0438, G0439


Well Child Visits, Ages 3–6 Years Old

Measure evaluates the percentage of children ages 3, 4, 5 or 6 years old who had at least one comprehensive well care visit per year.

CPT

ICD-10 DIAGNOSIS

HCPCS

99382, 99383, 99392, 99393

Z00.121, Z00.129, Z00.8, Z02.0, Z02.2, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9

G0438, G0439


Adolescent Well Care Visits

Measure evaluates the percentage of adolescents age 12–21 years old who had at least one comprehensive well care visit per year.

CPT

ICD-10 DIAGNOSIS

HCPCS

99384, 99385, 99394, 99395

Z00.00, Z00.01, Z00.121, Z00.129, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4,

Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9

G0438, G0439