Gateway to Practitioner Excellence (GPE) Incentive Program Guide - Gateway Health Plan
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Gateway to Practitioner
Excellence (GPE )®
Incentive Program Guide
1
TABLE OF CONTENTS
Medicaid
Program Overview: Medicaid Quality Performance Measures and Requirements....................5
Adolescent Well-Care Visits.........................................................................................................6
Annual Dental Visit.......................................................................................................................7
Controlling High Blood Pressure.................................................................................................8
Comprehensive Diabetes Care: HbA1c Poorly Controlled.........................................................9
Prenatal Care in the First Trimester...........................................................................................10
Postpartum Care........................................................................................................................11
Well-Child Visit in the First 15 Months of Life, 6 or more..........................................................12
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life...........................................13
Medication Management for People with Asthma 75%...........................................................14
Ambulatory care – ED Visits......................................................................................................15
Plan All Cause Readmissions....................................................................................................16
Frequency of Ongoing Prenatal Care........................................................................................17
Electronic Submission...............................................................................................................18
Medicare
Program Overview: Gateway to Practitioner Excellence (GPE®) Incentive...............................20
Prevention and Screening
Annual Wellness Visit (AWV), Annual Physical Exam,
Initial Preventive Physical Exam (IPPE)..................................................................................23
Body Mass Index Adult BMI......................................................................................................25
Breast Cancer Screening...........................................................................................................27
Colorectal Cancer Screening.....................................................................................................28
Care for Older Adults – Medication Review..............................................................................30
Care for Older Adults – Functional Assessment.......................................................................31
Care for Older Adults – Pain Assessment.................................................................................32
Controlling Blood Pressure........................................................................................................33
2
Chronic Conditions
Diabetes Care — Eye Exam (Retinal)........................................................................................35
Diabetes Care — HbA1c Control .............................................................................................37
Diabetes Care — Medical Attention for Nephropathy..............................................................39
Osteoporosis Management.......................................................................................................41
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (DMARD)............43
Care Coordination
Plan All-Cause Readmissions....................................................................................................43
Medication Management
Medication Adherence for Cholesterol......................................................................................49
Medication Adherence for Diabetic Care..................................................................................50
Medication Adherence for Hypertension...................................................................................51
Medication Reconciliation Post-Discharge...............................................................................52
Statin Therapy for Patients with Cardiovascular Disease.........................................................54
Statin Use in Persons with Diabetes ........................................................................................56
Medication Management Resources
Medication Adherence — Helpful Resources...........................................................................59
Medication Adherence Measures — Preferred Generics..........................................................60
General Resources
General Guidelines.....................................................................................................................62
2019 CMS Stars Performance Measures: Accepted Codes....................................................65
Program Evaluation and Scoring...............................................................................................67
Reporting...................................................................................................................................70
Program Education and Questions...........................................................................................71
Refer to this document for information on how to improve clinical quality care and performance on the Medicare
Stars Quality measures.
Examples of potential coding opportunities for metric compliance and/or exclusion are provided in this document.
The examples provided are meant for guidance only. Listing of a code in this document does not equate to coverage
under Gateways’ medical policy.
3
Medicaid
Program Overview
At Gateway Health, we value the important role that practitioners play in serving our members.
Gateway would like to welcome you to the Gateway to Practitioner Excellence® Program (GPE®).
This program supports Gateway’s mission to improve the health and wellness of the individuals
and the communities we serve by providing access to integrated, superior health care.
PROGRAM INTENT
The intent of the provider program is to encourage improvement in the process of care for
Gateway members. We support recognizing and rewarding performance for those practices
committed to providing quality healthcare that is accessible and efficient.
ELIGIBILITY CRITERIA
The GPE® program is open to the following practitioner types:
• Primary Care Practitioners (PCP) (no minimum panel size required)
— Family Practice
— General Practice
— Internal Medicine
— Pediatricians
— Credentialed Primary Care CRNP
— Physician Assistants
• Dentists (no minimum panel size required)
• Obstetrical Care Providers (no minimum panel size required)
OPT IN
In order for providers to participate in the 2019 GPE® program they must acknowledge that
they are opting-in to the program by attesting via Survey Monkey. By opting-in, the provider
acknowledges the intent to participate in the 2019 program. Providers may opt into the program
until September 30, 2019. The 2019 program includes quality performance from dates of service
January 1, 2019 to December 31, 2019.
https://www.surveymonkey.com/r/2019GPE_optin
5Adolescent Well-Care Visits (AWC)
Targeted providers: PCPs
Description of Measure: Percent of members 12-21 years of age who had one comprehensive
well-care visit with a PCP during the measurement year.
Eligible Population: Members ages 12 to 21 years of age by December 31, 2019.
Exclusions: There are no exclusions for this measure.
Adherent Member: Patient who has had a comprehensive well-care visit in 2019.
How to Submit to Gateway Health:
Measure or Component ICD-10-CM Codes CPT Category I HCPCS
Adolescent Z00.00, Z00.01, Z02.1, Z02.2, Z02.3, 99384, 99385, G0438,
Well-Care Visit Z02.4, Z02.5, Z02.6, Z00.82, Z00.121, 99394, 99395 G0439
Z00.129, Z02.0,- Z02.71
Claims submission, medical record information submitted via Gateway’s provider portal, and/or
electronic data feeds.
Scoring: This measure requires a minimum of 10 members in the denominator in order to qualify
to be scored. Payments are made quarterly and are based on the goal level attained. Providers
can earn once per member per year.
Once a goal has been reached, payments are calculated GOLD SILVER BRONZE
based on compliant members within the quarter. 67% 64% 58%
6Annual Dental Visit (ADV)
Description of Measure: Members age 2–20 years of age who had at least one dental visit
during the measurement year.
Targeted Providers: Dentists
Eligible Population:
• Continuous enrollment for 90 days per the DHS Oral Health Initiative.
• Members 6 months – 20 years of age.
Exclusions: There are no exclusions for this measure.
Adherent Member: The following episodes of care occur and the correct claims are submitted
from the table below:
Examination, Prophylaxis, and a Topical Fluoride Treatment will all need to be submitted for
member’s ages 6 months through 17 years of age. The Topical Fluoride Treatment service is not
required for members over the age of 17 years.
Oral Care Service Codes
Oral Examination Codes D0120, D0145,
and D0150
Dental Prophylaxis D1110 or D1120
Topical Application of Fluoridee D1206 (with varnish)
(with or without varnish) This only D1208 (without varnish)
applies to ages 6 months to 17 years.
Note: PCPs will not be incented for dental visits in the 2019 program
7Controlling High Blood Pressure (CBP)
Targeted Providers: PCPs
Description of Measure: The percent of members 18-85 years of age with a diagnosis of
hypertension whose BP was adequately controlled during the measurement year.
Eligible Population: Members ages 18 to 85 years of age in 2019 with a diagnosis of
hypertension.
Exclusions: The following members will be excluded from this denominator:
• Members that are 66 years of age or older and in an Institutional Special Needs Plans
(I-SNP), members living in a long term institution (LTI) with a LTI flag on the CMS
enrollment file, members 81 years of age or older with a frailty diagnosis, or members
66-80 years old with a frailty diagnosis and advanced illness
• Evidence of end-stage renal disease (ESRD), active dialysis or kidney transplant
• All members with a diagnosis of pregnancy (Pregnancy Value Set) during the
measurement year.
• A non-acute inpatient facility admission during the measurement year before the
submission of the blood pressure measurement
Adherent Member: The member is compliant if the most recent controlled blood pressure
reading on or after the 2nd hypertension diagnosis is less than 140/90 mm Hg during the
measurement year.
How to Submit to Gateway Health: The PCP must submit a CPT II code or other evidence of a
controlled blood pressure reading of less than 140/90 mm Hg.
Acceptable CPT II Systolic Values 3074F:Comprehensive Diabetes Care: HbA1c Poorly Controlled (>9%)
Targeted Providers: PCPs
Description of Measure: The percentage of members with diabetes who received at least one HbA1c
screening during the measurement year and whose last HbA1c test for the measurement year was
≤9.0%
Eligible Members: Members ages 18 to 75 with diabetes (type 1 or type 2)
Exclusions: Members who do not have a diagnosis of diabetes during the measurement year or the
prior year, and have a diagnosis of gestational diabetes or steroid-induced diabetes, in any setting,
during 2018-2019.
Adherent Member: The adherent member is compliant if the most recent HbA1c level is ≤9.0%
during the measurement year.
How to Submit to Gateway Health: The PCP must submit a CPT II code or other evidence of a
controlled HbA1c of less than or equal to 9.
Acceptable CPT II codes for controlled HbA1c are listed in the table below:
CPT II Code HbA1c Level
3044F Value < 7
3045F Values 7 - 9
*Note: This also qualifies for the Electronic Submission measure.
Provider can submit via claims submission, medical record information submitted via Gateway’s
provider portal, and/or electronic data feeds.
Scoring: This measure requires a PCP to have a minimum of 10 members in the denominator
in order to qualify to be scored. Payments are made quarterly and are based on the goal
level attained.
Once a goal has been reached, payments are calculated GOLD SILVER BRONZE
based on compliant members within the quarter. 29% 31% 35%
9Prenatal Care in the First Trimester
Targeted providers: Obstetrical Care Providers and PCPs
Description of Measure: Percent of members with deliveries who have had a prenatal visit
within the first trimester.
Eligible Population: Members with deliveries of live births on or between November 6 of the
year prior to the measurement year and November 5 of the measurement year.
Adherent Member: Member who has had a prenatal visit within the first trimester and have
submitted an ONAF to Gateway’s Mom Matters department within 5 days of the intake visit.
The prenatal visit must occur in the first trimester.
How to Submit to Gateway Health: The provider must submit all codes listed in in the table
below on the same claim form to qualify for the combined incentive. The ONAF can either be
submitted via fax or electronic submission. Members’ claims will establish the data set for
participant performance and incentives based on processed adjudicated claims. A visit on the
day of enrollment is acceptable.
Acceptable codes needed to receive the prenatal incentive are listed in the below table:
Type of Code Code
Initial Visit in First Trimester in Gateway Health 99429-HD
Initial ONAF Submitted T1001-U9
E&M Code and Pregnancy Related 99201-99205-U9
Diagnosis Code 99211-99215-U9
FQHC must also bill T1015
Provider can submit via claims submission, medical record information submitted via
Gateway’s provider portal, and/or electronic data feeds.
10Postpartum Care
Targeted providers: Obstetrical Care Providers and PCPs
Description of Measure: Members with deliveries who have had a postpartum care visit on or
between 21-56 days after delivery.
Eligible Population: Members with deliveries of live births on or between November 6 of the
year prior to the measurement year and November 5 of the measurement year.
Adherent Member: Payments are made to the provider who submits a claim for postpartum
care (as defined by the 2019 HEDIS specifications) on or between 21-56 days after delivery.
How to Submit to Gateway Health: Payments are made to the provider who submits a claim
for postpartum care (as defined by the 2019 HEDIS specifications) on or between 21-56 days
after delivery.
Below is a listing of postpartum codes. Please note the list is not all inclusive.
CPT ICD 10 Diagnosis Code CPT II
58300, 59430 Z39.2, Z39.1, Z01.411, Z01.419, 0503F
Z01.42, Z30.430
Provider can submit via claims submission, medical record information submitted via
Gateway’s provider portal, and/or electronic data feeds.
11Well-Child Visits in the First 15 Months of Life, 6 or more
Targeted providers: PCPs
Description of Measure: Percent of members who turned 15 months old during the
measurement year and who had six or more well-child visits.
Eligible Population: Members who turned 15 months old during the measurement year.
Exclusions: There are no exclusions for this measure.
Adherent Member: Patient must have had 6 comprehensive well-child visits by their
15-month birthday.
How to Submit to Gateway Health:
CPT ICD 10 Diagnosis Code CPT II
New Patient Z00.110, Z00.111, Z00.121, Z00.129, ageWell-Child Visits in the Third, Fourth, Fifth and
Sixth Years of Life
Targeted providers: PCPs
Description of Measure: The percent of members 3-6 years of age who had one or more
well-child visits with a PCP during the measurement year.
Eligible Population: Members who turn 3, 4, 5, or 6 in measurement year.
Adherent Member: Patient who has had a comprehensive well-care visit in 2019.
How to Submit to Gateway Health:
Measure or Component ICD-10-CM Codes CPT Category I HCPCS
Well-Child Visits in the Z00.8, Z00.121, New patient: G0438,
Third, Fourth, Fifth and Z00.129, Z02.0, 99382 (age 1-4), 99383 (age 5-11) G0439
Sixth Years of Life Z02.5, Z02.71,
Z02.82 Established patient:
99392 (age 1-4), 99393 (age 5-11)
Provider can submit via claims submission, medical record information submitted via
Gateway’s provider portal, and/or electronic data feeds.
Scoring: This measure requires a minimum of 10 members in the denominator in order
to qualify to be scored. Payments are made quarterly and are based on the goal level
attained. Providers can earn once per member per year.
Once a goal has been reached, payments are
GOLD SILVER BRONZE
calculated based on compliant members within
the quarter. 84.5% 80.5% 75%
13Medication Management for People with Asthma 75%
Targeted providers: PCPs
Description of Measure: The percent of members 5-64 years of age during the measurement
year who were identified as having persistent asthma and were dispensed appropriate
medication that they remained on during the treatment period. The percent of members who
remained on an asthma controller medication for at least 75% or more of the time they are to
be taking this medication.
Eligible Population: Members 5-64 years of old during the measurement year who were
identified as having persistent asthma and dispensed appropriate medications according to
the HEDIS 2019 specifications at any point during the measurement year.
Exclusions: Diagnosis of emphysema, other emphysema, COPD, obstructive chronic
bronchitis, chronic respiratory conditions due to fumes/vapors, cystic fibrosis, acute
respiratory failure.
Adherent Member: Patients who have achieved at least 75% compliance for asthma
medications as defined by HEDIS specifications.
How to Submit to Gateway Health: The data is only captured via a pharmacy claim.
Scoring: This measure requires a minimum of 10 members in the denominator in order to
qualify to be scored. Payments are made quarterly and are based on the goal level attained.
Providers can earn once per member per year.
Once a goal has been reached, payments are calculated GOLD SILVER
based on compliant members within the quarter. 53.5% 46%
14Ambulatory Care – ED Visits
Targeted providers: PCPs
Description of Measure: This measure summarizes utilization of ambulatory care, ED visits.
Eligible Population: Members with an ED visit regardless of diagnosis.
Exclusions: This measure does not include mental health or chemical dependency services.
Adherent Member: The only way for the gap to remain compliant is if the member does not
have an ED visit.
How to Submit to Gateway Health: This measure is captured through claims submission.
Scoring: This measure requires a minimum of
50 members in order to qualify to be scored.
The measure will be paid out at the goal level GOLD SILVER BRONZE
attained in the Final Reconciliation payment 63% 73% 84%
once per member per year for the attributed
Gateway membership.
15Plan All Cause Readmissions
Targeted providers: PCPs
Description of Measure: Percent of members 18 years of age and older, discharged from a
hospital stay who were readmitted to a hospital within 30 days, either for the same condition
as their recent hospital stay or for a different reason. (Patients may have been readmitted back
to the same hospital or to a different one. Rates of readmission take into account how sick
patients were when they went into the hospital the first time. This “risk-adjustment” helps make
the comparisons between plans fair and meaningful).
Eligible Population: Count of index hospital stays (IHS) — For members 18- 64 years of
age, the count of acute inpatient stays with a discharge on or between the first day of the
measurement year and 31 days prior to the last day of the measurement year.
Exclusions: Hospital stays where the index admission date is the same as the index discharge
date. Inpatient stays with discharges for death. Acute inpatient discharges with a principal
diagnosis of pregnancy. Acute inpatient discharge with a principal diagnosis for a condition
originating in the perinatal period. Acute inpatient stays as an IHS if the admission date of the
first planned hospital stay within 30 days of the discharge includes any of the following:
• A principal diagnosis of maintenance chemotherapy
• A principal diagnosis of rehabilitation
• An organ transplant
• A potentially planned procedure without a principal acute diagnosis
Adherent Member: The only way for the gap to remain compliant is if the member does not
have a readmission within 30 days of a discharge date.
How to Submit to Gateway Health: This measure is captured through inpatient claims.
Scoring: This measure requires a minimum of
50 members in order to qualify to be scored.
The measure will be paid out at the goal level GOLD SILVER BRONZE
attained in the Final Reconciliation payment 8% 10% 12%
once per member per year for the attributed
Gateway membership.
16Frequency of Ongoing Prenatal Care:
≥81 Percent of the Expected Number of Prenatal Visits
Targeted providers: Obstetrical Care Providers and PCPs
Description of Measure: This measure looks at the number of prenatal visits during pregnancy.
Eligible Population: Women who delivered a live birth on or between November 6 of the year
prior to the measurement year and November 5 of the measurement year, as defined by the
2019 PAPM Specifications.
Adherent Member: Evidence of ≥81% of expected prenatal visits with a pregnancy-related
diagnosis code during the pregnancy.
How to Submit to Gateway Health:
FQHC T1015, E&M (99201-99205, Pregnancy ICD 10 Code
99211-99215), U9 modifier
(must follow the code in the
first position)
Non-FQHC E&M (99201-99205, 99211-99215), Pregnancy ICD 10 Code
U9 modifier (must follow the code in the
first position)
Provider can submit via claims submission, medical record information submitted via
Gateway’s provider portal, and/or electronic data feeds.
Scoring: Payment made quarterly once compliance with PAPM Specification is confirmed.
17Electronic Submission
Targeted providers: PCPs
Description of Measure: This measure reduces the burden placed on plans and providers to
acquire medical records.
Eligible Population: Members who fall in the eligible population for the following two measures:
• Comprehensive Diabetes Care: HbA1c Poorly Controlled (>9%)
• Controlling High Blood Pressure
Adherent Member: All PCPs who submit an electronic HbA1c and/or blood pressure,
regardless of value, will be eligible for this additional incentive.
How to Submit to Gateway Health: Provider can submit via claims submission.
Scoring: Electronic submission is defined as a CPT II on a claim from a PCP. Payments
quarterly for all those compliant within the quarter. Providers can earn one payment per
quarter per member.
18Medicare
Gateway to Practitioner Excellence (GPE®) Incentive
Program Overview
At Gateway Health, we value the important role practitioners that play in serving our members.
Gateway would like to welcome you to the Gateway to Practitioners Excellence (GPE®) Program.
This program supports Gateway’s mission to improve the health and wellness of the individuals
and the communities we serve by providing access to integrated, superior health care.
PROGRAM INTENT
The intent of the provider program is to encourage improvement in the process of care for
Gateway members. We support recognizing and rewarding performance for those practices
committed to providing quality healthcare that is accessible and efficient. Our new incentive
structure provides larger payments to providers actively achieving outcomes through a tiered
payment structure with bonus potentials. No minimum membership levels are required for
participation.
Gateway wants to ensure consistent quality of care to their membership based on CMS
standards for each measure as well as where Gateway has historically performed. We will
provide monthly reports during the 3rd week of each month. The majority of measurement
payments will be paid on a quarterly basis. Exceptions include the measures for Comprehensive
Diabetic Care: HbA1c control, Diabetes Adherence, Hypertension Adherence and Cholesterol
(Statin) Adherence, which will be paid out at the end of the year after final results.
The Low Target payments are to incentivize providers to ensure that these standards are met,
and you will start earning incentive payments. At this point, you will be eligible for the kicker
payment. The High Target payments are designed to maximize the provider’s incentive for
providing the highest possible quality of care to our membership.
Providers are eligible for bonus payments if they receive an overall Stars score of 3.75 or above.
Providers must be scored on at least three measures to receive a Stars score. There must be ten
eligible member care gaps in a measure to be scored for that measure.
QUARTER 5 BONUS PAYMENT
Overall Star Rating ≥3.75 ≥4.00 ≥4.25 ≥4.50 ≥4.75
Bonus 5% 10% 15% 20% 25%
20ELIGIBLE PROVIDERS
• Primary Care Physicians (PCPs) • Non-Physician Practitioners
— General Practice (01) — Clinical Nurse Specialist (89)
— Family Practice (08) — Nurse Practitioner (50)
— Internal Medicine (11) — Physician Assistant (97)
— Geriatric Medicine (38)
• Specialists
— Cardiology (Cardiovascular Disease, Adolescent, Advanced Heart Failure)
— Certified Nurse – Midwife
— Certified Registered Nurse Practitioner (CRNP)*
— Developmental Pediatrics
— Adolescent Medicine
— OB-GYN
— Endocrinology (Metabolism)
— Oncology (Gynecologic, Hematology, Medical)
— Pediatrics (Cardiology, Endocrinology, Metabolism)
— Physician Assistant*
*Associated to a Specialist Practice
OPT IN
In order to participate in the 2019 GPE® provider incentive program, you must opt-in to the
program by completing the acknowledgement form online at https://www.surveymonkey.com/
r/2019GPE_optin. Providers must opt into the program by September 30, 2019. When you opt-
in, you will be enrolled for the 2019 program. The 2019 program includes quality performance
from dates of service January 1, 2019 to December 31, 2019. If you need assistance in opting
into Gateway’s program please contact your Clinical Transformation Consultant or Provider
Account Liaison.
PROVIDER ATTRIBUTION AND GPE® REPORTS
Gateway is redesigning its attribution logic to align with industry and CMS standards starting
at the end of first quarter 2019. A member is attributed to a PCP if they have received more
PCP services than another provider (i.e. Specialist) if two providers have the same number of
claims, for a member, then that member is attributed to the provider with the most recent claim.
If a member did not receive a service from a PCP in the rolling 18 month period, they can be
attributed to a specialist that provides preventative medicine. The new GPE® reports will be
available on your provider portal on NaviNet. If you need assistance in locating your reports on
Gateway’s NaviNet portal please contact your Clinical Transformation Consultant or Provider
Account Liaison for assistance. Attribution does freeze at the end of the third quarter 2019 to
allow proper amount of time to address any new attributed patients.
21PREVENTION & SCREENING
22Annual Wellness Visit (AWV), Annual Physical Exam,
Initial Preventive Physical Exam (IPPE)
Measure Type: Static (Not a CMS Star Measure)
Description of Measure: Percentage of Medicare members who had the Annual Wellness
Visit (AWV) during the measurement year or Initial Preventive Physical Exam (IPPE) or Annual
Physical Exam within the first 12 months of enrollment in the Medicare product.
Eligible Population: All Medicare members age 65 years and older.
Exclusions: There are no exclusions for this measure.
Adherent Member: Patients who completed the Annual Wellness Visit or the IPPE during the
measurement year.
How to Submit to Gateway Health: Submit the appropriate HCPCS for the AWV/IPPE visit:
Service Codes
Initial AWV G0438
Subsequent AWV G0439
Initial Preventive Physical Exam G0402
(Welcome to Medicare)
Annual Physical Exam Z00.00
CPT codes for physical exams are also accepted as adherent for this measure.
23Best Practices:
• Schedule early in year to maximize benefit.
• Maximize member encounter — this may be the only visit of the year.
• Develop template (EHR or paper) to capture all components.
• Have patient complete his or her portion of components (self-report).
• Utilize medical assistant to capture applicable components of visit.
• Redeploy office personnel and space to accommodate visit.
• Prepare by capturing information in advance of visit-chart prep.
• Allow enough time to complete the visit.
• Know that CMS requires the provider to, at a minimum, collect and document the
patient’s medical and surgical and procedural history, including experiences with
illnesses, hospital stays, operations, allergies, injuries, and treatment.
• Know that CMS requires the provider to prepare and provide the patient with a
personalized plan for preventive care.
• Schedule a “wellness day” to focus on AWVs.
Other:
• AWV is not a CMS Star Measure and is not included in the Star rating.
• AWV is included in Gateway Health’s Value-Based Reimbursement and Quality
Incentive Programs.
• AWV can be completed any time during the calendar year.
• There is no copay when performing an AWV by itself.
• AWV can be performed in any setting/location.
• AWV can be performed with problem office visit (use modifier 25) when services
performed do not duplicate components already included in code G0438, G0439,
or G0402. Documentation must clearly reflect the services reported as significant
and separately identifiable. A copay may apply.
24Body Mass Index
Adult BMI
Measure Type: Static Star Measure
Description of Measure: Percentage of members 18–74 years of age who had an outpatient
visit and who’s BMI was documented during the measurement year or the year prior to the
measurement year.
Eligible Population: Attributed members 18–74 years of age as of the last date of the
measurement year who had an outpatient visit.
Exclusions: Diagnosis of pregnancy during the measurement year or the year prior.
Adherent Member:
• The appropriate documentation of BMI during the measurement year or the year
prior is dependent on age of the member.
• For members who are 19 years of age and younger on the date of service,
the documentation must indicate the height, weight, and BMI percentile for the
date of service.
• For members 20 years of age and older, the documentation must indicate the weight and
specific BMI value for the date of service.
How to Submit to Gateway Health: Range Codes Range Codes
ICD-10 Code
≤19.9 Z68.1 32-32.9 Z68.32
20.0-20.9 Z68.2 33-33.9 Z68.33
21.0-21.9 Z68.21 34-34.9 Z68.34
22.00-22.9 Z68.22 35-35.9 Z68.35
23.0-23.9 Z68.23 36-36.9 Z68.36
24.0-24.9 Z68.24 37-37.9 Z68.37
25-25.9 Z68.25 38-38.9 Z68.38
26-26.9 Z68.26 39-39.9 Z68.39
27-27.9 Z68.27 40-44.9 Z68.41
28-28.9 Z68.28 45-49.9 Z68.42
29-29.9 Z68.29 50-59.9 Z68.43
30-30.9 Z68.30 60-69.9 Z68.44
31-31.9 Z68.31 ≥70 Z68.45
25ICD-10 Code Range Codes
(continued) For the younger than 20 year of age on the date of service:
Less than 5th percentile for age Z68.51
5th to less than 85th percentile for age Z68.52
85th to less than 95th percentile for age Z68.53
95th percentile or greater for age Z68.54
• When submitting BMI 1500 zero charge claim via Clearing House, use Current
Procedural Terminology (CPT®) II code 3008F (Body Mass Index, documented),
along with the appropriate ICD-10 Z code.
• Documentation in the medical record must indicate the height/weight and specific
BMI value (20 years and older) or BMI percentile (19 years and younger), dated during
the measurement year or the year prior.
Best Practices:
• Identify patients who are listed as non-adherent.
• Ensure that height/weight and BMI value are obtained on every patient.
• Ensure that BMI value is properly documented in patient charts.
• If patient cannot or r efuses to be weighed, provider can approximate and document
BMI value; medical record must indicate that this is an approximate value and why actual
cannot be obtained.
• Ensure that BMI diagnosis is submitted to Gateway Health.
Other: BMI can be obtained for either calendar year 2019 or 2018
• Both years will close the gap.
• Gap closure incentives, when applicable, are paid only on 2019 gap closures.
26Breast Cancer Screening
Measure Type: Static Star Measure
Description of Measure: Percentage of female members 50–74 years of age who had a
mammogram to screen for breast cancer.
Eligible Population: Attributed female members 52–74 years of age as of the last date of the
measurement year. This measure has a two-year look-back period.
Exclusions: Those who had two unilateral or bilateral mastectomy any time during the
member’s history through the last day of the measurement year.
Adherent Member: One or more mammograms any time on or between October 1 two years
prior to the measurement year and December 31 of the measurement year (27-month period).
How to Submit to Gateway Health:
• Codes to identify breast cancer screening: 77055, 77056, 77057, G0202,
G0204, G0206 (as of Jan . 1, 2019, CPT codes 77067, 77066, and 77065 replace
HCPCS codes G0202, G0204, and G0206)
• Submit screening via claim.
Best Practices:
• Identify non-adherent patients.
• Create alerts to inform providers of needed mammography.
• Prep chart to ensure that provider orders mammography in next office visit.
• If no upcoming visit, schedule an office visit to order mammography.
• Create a standing order to mail to patient for mammography.
• Create process to identify mammography ordered compared to results received.
• Provide ongoing member outreach to encourage mammography screening.
• Use Gateway Health patient education material.
Other: Gateway Health provides coverage for 3-D digital breast tomosynthesis, effective for
dates of service on or after Jan. 1, 2015. 2019 HEDIS® specifications accept 3-D digital breast
tomosynthesis to meet breast cancer screening compliance.
27Colorectal Cancer Screening
Measure Type: Static Star Measure
Description of Measure: Percentage of members 50–75 years of age who had appropriate
screening for colorectal cancer.
Eligible Population: Members 50–75 years of age as of the last date of the measurement year.
Exclusions: Diagnosis of colorectal cancer or evidence of a total colectomy.
• Codes to identify exclusions:
— Colorectal Cancer - HCPCS: G0213-G0215, G0231
ICD-10: Z85 .038, Z85 .048
— Total Colectomy - CPT®: 44150-44153, 44155-44158, 44210-44212
Adherent Member: One or more of the following screenings for colorectal cancer:
• Fecal occult blood test (FOBT) performed during the measurement year. The following
meet screening criteria:
— Guaiac (gFOBT)
— Immunochemical (iFOBT, also referred to as fecal immunochemical test, or FIT)
• Flexible sigmoidoscopy performed during the measurement year or the 4 years prior to
the measurement year.
• Colonoscopy performed during the measurement year or the 9 years prior to the
measurement year.
• CT colonography performed during the measurement year or the 4 years prior to the
measurement year.
• FIT-DNA testing during the measurement year or 2 years prior to the measurement year.
How to Submit to Gateway Health:
• Colonoscopy or Flexible Sigmoidoscopy:
— Screening completed during the measurement year will be captured by Gateway
Health claims.
— Appropriate documentation must include a note indicating the date the screening
was performed AND the result or finding.
— If the completion of the screening is noted in the member’s medical history,
documentation of a result is not required, but the date (at minimum, the year) must
be provided.
28How to Submit to Gateway Health: (continued)
• FOBT:
— Submit claim for resulting FOBT
• gFOBT — CPT code 82270
• iFOBT — CPT code 82274, HCPCS code G0328
• Digital Rectal Exam:
— FOBT tests performed in an office setting on a sample collected via digital rectal
exam are not an acceptable form of screening for this measure.
• CT Colonography:
— Submit screening via claim.
• CT Colonography — CPT code 74263
• FIT-DNA testing
• FIT-DNA-CPT code 81528
Additional codes to identify screening: Labs will submit services directly to Gateway Health.
Best Practices:
• Identify non-adherent patients.
• Prep chart to order and discuss with patient at next office visit.
• If patient refuses a colonoscopy, order FOBT/FIT-DNA as an alternative.
• Submit completed FOBT claims in a timely manner.
• Provide ongoing outreach and education to non-adherent patients.
• Clearly document patients with ileostomies and colostomies, which imply colon removal
(exclusion), and patients with a history of colon cancer.
• Provide at-home FOBT colorectal cancer screening kits for use in patients’ homes
(via direct distribution or mail).
• Update patient history annually regarding colorectal cancer screening (test completion
and corresponding date).
• Use standing orders for colonoscopy and FOBT.
FIT-DNA testing CPT code 81528 is accepted by HEDIS as numerator-compliant.
• Cologuard™ is a stool DNA test manufactured by Exact Sciences®. A stool DNA test is a
noninvasive laboratory test that identifies DNA changes in the cells of a stool sample. The
stool DNA test specifically looks for DNA changes that indicate the presence of colon
cancer or precancerous polyps in the colon.
• Gateway Health covers the Cologuard™ test for Medicare members age 50–85, effective
for dates of service on or after October 9, 2014.
29Care for Older Adults – Medication Review
Measure Type: Static Star Measure
Description of Measure: Percent of plan members whose physician or clinical pharmacist
reviewed a list of everything they take (prescription and non-prescription drugs, vitamins, herbal
remedies, other supplements) at least once a year.
(Medicare does not collect this information from all plans. Medicare collects it only for
Special Needs Plans. These plans are a type of Medicare plan designed for certain people
with Medicare. Some Special Needs Plans are for people with certain chronic diseases and
conditions, some are for people who have both Medicare and Medicaid, and some are for
people who live in an institution such as a nursing home.)
Eligible Population/Adherent Member: The percentage of Medicare Special Needs Plan
enrollees 66 years and older (denominator) who received at least one medication review
(Medication Review Value Set) conducted by a prescribing practitioner or clinical pharmacist
during the measurement year and the presence of a medication list in the medical record
(Medication List Value Set) (numerator).
How to Submit to Gateway Health:
• 1159F- Medications List documented in medical record.
• 1160F- Review of all medications by a prescribing practitioner or clinical pharmacist
(such as, prescriptions, OTCs, herbal therapies and supplements) documented in the
medical record.
Best Practices:
• Provider completes an Annual Wellness Visit.
• Create a checklist to ensure that you are capturing assessment criteria.
• Keep a list of all patients medications in their chart & update after every visit.
30Care for Older Adults – Functional Assessment
Measure Type: Static Star Measure
Description of Measure: Percent of plan members whose physician has completed a
functional status assessment to see how well they are able to do Activities of Daily Living such
as dressing, eating, and bathing.
(Medicare does not collect this information from all plans. Medicare collects it only for
Special Needs Plans. These plans are a type of Medicare plan designed for certain people
with Medicare. Some Special Needs Plans are for people with certain chronic diseases and
conditions, some are for people who have both Medicare and Medicaid, and some are for
people who live in an institution such as a nursing home.)
Eligible Population/Adherent Member: The percentage of Medicare Special Needs Plan
enrollees 66 years and older (denominator) who received at least one functional status
assessment (Functional Status Assessment Value Set) during the measurement year
(numerator).
How to Submit to Gateway Health:
• 1170F- Functional Status assessed.
Best Practices:
• Provider completes an Annual Wellness Visit.
• Create a checklist to ensure that you are capturing assessment criteria.
31Care for Older Adults – Pain Assessment
Measure Type: Static Star Measure
Description of Measure: Percent of plan members who had a pain screening at least once
during the year.
(Medicare does not collect this information from all plans. Medicare collects it only for
Special Needs Plans. These plans are a type of Medicare plan designed for certain people
with Medicare. Some Special Needs Plans are for people with certain chronic diseases and
conditions, some are for people who have both Medicare and Medicaid, and some are for
people who live in an institution such as a nursing home.)
Eligible Population/Adherent Member: The percentage of Medicare Special Needs Plan
enrollees 66 years and older (denominator) who received at least one pain assessment (Pain
Assessment Value Set) plan during the measurement year (numerator).
How to Submit to Gateway Health:
• 1125F- Pain severity quantified, pain present.
• 1126F- Pain severity quantified, no pain present.
Best Practices:
• Provider completes an Annual Wellness Visit.
• Create a checklist to ensure that you are capturing assessment criteria.
• Provider must provide a numerical pain severity, if any, pain is present.
32Controlling Blood Pressure Measure Type: Profile Measure (Gateway and CMS not scoring in 2019) Description of Measure: Percent of plan members with high blood pressure who received treatment and were able to maintain a healthy pressure. Eligible Population: The percentage of Medicare members 18–85 years of age who had a diagnosis of hypertension (HTN) (denominator) and whose BP was adequately controlled (
CHRONIC CONDITIONS
34Diabetic Care – Eye Exam (Retinal)
Measure Type: Static Star Measure
Description of Measure: Members with a diabetic diagnosis who have received an eye
screening for diabetic retinal disease.
Eligible Population: Diabetic members age 18-75 years who met any of the following
criteria during the measurement year and who were enrolled in the plan at the end of the
measurement year.
• Pharmacy data — Members who were dispensed insulin or hypoglycemic/
anti-hyperglycemic during the measurement year or prior to the measurement year
on an ambulatory basis.
OR
• Claim encounter data — Patients who had:
— At least two encounters in an outpatient setting, observation, emergency
department or non-acute inpatient setting on different dates of service, with a
diagnosis of diabetes, during the measurement year or prior to the measurement
year. Visit type need not be the same for the two visits.
— At least one encounter in an acute inpatient setting, with diagnosis of diabetes,
during the measurement year or the year prior to the measurement year.
Exclusions:
• Glucophage/metformin is not included because it is used to treat conditions other than
diabetes.
• Patients who did not have a diagnosis of diabetes, in any setting, and who had a
diagnosis of gestational or steroid-induced diabetes, in any setting, during measurement
year or the year prior to the measurement year.
• Members are identified as diabetic by claims data. If you believe a member may be
erroneously identified as a diabetic, document in the member’s medical record that
the member is not diabetic. They will remain in the eligible population until claims data
identifying them as diabetic is not received in the measurement year or the year prior to
the measurement year.
35Adherent Member: An eye screening for diabetic retinal disease as identified by administrative
data or medical record review. This includes diabetics who had one of the following:
• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist)
in the measurement year.
OR
• A negative retinal or dilated eye exam (negative for retinopathy performed by an
ophthalmologist) in the year prior to the measurement year.
How to Submit to Gateway Health:
• Submit eye screening via claim - Codes: 92014 - billed by eye care professional.
• CPT II codes — 2022F, 2024F, 2026F, and 3072F (2018 negative result).
• A CPT II code submitted by primary care physician to indicate the test was not only
completed but reviewed in measurement year.
• An optometrist or ophthalmologist claim submitted to and processed by Gateway Health
in the measurement year.
• Documentation in the medical record must include the following:
— A note or letter from an optometrist, ophthalmologist, PCP, or other health care
professional indicating that an ophthalmoscopic exam was completed by an eye care
professional, with the date the procedure was performed and the results of the exam.
OR
— A chart or photograph of retinal abnormalities. If fundus photography was used
in the exam, there must be documentation in the medical record indicating the
date of the procedure and evidence that an eye care professional read the results.
Alternatively, results may be read by a qualified reading center that operates under
the direction of a medical director who is a retinal specialist.
OR
— Documentation of normal findings for a retinal or dilated eye exam performed by an
eye care professional in the year prior to the measurement year (to support 3072F).
Best Practices:
• Review chart notes to find evidence of retinal eye exam.
• Review chart note to find evidence for exclusion.
• Prepare standing referral to ophthalmologist.
• Assist patient in making appointment with eye specialist.
• Educate patient regarding importance of retinal eye exam.
• Reach out to ophthalmologist to obtain documentation of retinal exam.
36Diabetes Care – HbA1c Control
Measure Type: Static Star Measure
Description of Measure: The percentage of members with diabetes who received at least one
HbA1c screening during the measurement year and whose last HbA1c test for the measurement
year was ≤9.0%.
Eligible Population: Diabetic members age 18-75 years who met any of the following criteria during
the measurement year and who were enrolled in the plan at the end of the measurement year.
• Pharmacy data — Members who were dispensed insulin or hypoglycemic/anti-hyperglycemic
during the measurement year or prior to the measurement year on an ambulatory basis.
OR
• Claim encounter data — Patients who had:
— At least two encounters in an outpatient setting, observation, emergency
department or non-acute inpatient setting on different dates of service, with a
diagnosis of diabetes, during the measurement year or prior to the measurement
year. Visit type need not be the same for the two visits.
— At least one encounter in an acute inpatient setting, with diagnosis of diabetes,
during the measurement year or the year prior to the measurement year.
Exclusions:
• Glucophage/metformin is not included because it is used to treat conditions other
than diabetes.
• Patients who did not have a diagnosis of diabetes, in any setting, and who had
a diagnosis of gestational or steroid-induced diabetes, in any setting, during
measurement year or the year prior to the measurement year.
• Members are identified as diabetic by claims data. If you believe a member may
be erroneously identified as a diabetic, document in the member’s medical record
that the member is not diabetic. They will remain in the eligible population until
claims data identifying them as diabetic is not received in the measurement year
or the year prior to the measurement year.
Adherent Member: The adherent member is compliant if the most recent HbA1c level is ≤9.0%
(during the measurement year).
37How to Submit to Gateway Health:
• Submit a zero charge claim (CPT® II code):
HbA1c Level CPT II Code
9.0%
— Ensure that lab was ordered
— Lab was ordered but not drawn
• Review chart note for exclusion.
• Review chart note to locate value — submit CPT II code via claim.
• Assure HbA1c result and date of testing are recorded within the patient’s EMR.
• Be aware that labs can be ordered by other providers (specialists, ED, Urgent Care,
Veterans Administration, community screenings). The value of the last HbA1c test
completed in the measurement year is required for this measure. Establish a process
for obtaining lab results from other providers participating in the patient’s care.
• Ensure that practice receives results of labs drawn.
• Ensure that practice submits the appropriate CPT II code to Gateway Health.
• Implement care coordination to manage patients with > 9.0% levels.
• Provide ongoing outreach to non-adherent members.
• Schedule HbA1c lab testing before patient leaves the office.
38Diabetes Care – Medical Attention for Nephropathy
Measure Type: Static Star Measure
Description of Measure: The percentage of type 1 and type 2 adult diabetic members who had
medical attention for nephropathy in the measurement year.
Eligible Population: Diabetic members age 18-75 years who met any of the following criteria during
the measurement year and who were enrolled in the plan at the end of the measurement year.
• Pharmacy data — Members who were dispensed insulin or hypoglycemic/anti-hyperglycemic
during the measurement year or prior to the measurement year on an ambulatory basis.
OR
• Claim encounter data — Patients who had:
— At least two encounters in an outpatient setting, observation, emergency
department or non-acute inpatient setting on different dates of service, with a
diagnosis of diabetes, during the measurement year or prior to the measurement
year. Visit type need not be the same for the two visits.
— At least one encounter in an acute inpatient setting, with diagnosis of diabetes,
during the measurement year or the year prior to the measurement year.
Exclusions:
• Glucophage/metformin is not included because it is used to treat conditions
other than diabetes.
• Patients who did not have a diagnosis of diabetes, in any setting, and who had
a diagnosis of gestational or steroid-induced diabetes, in any setting, during
measurement year or the year prior to the measurement year.
Members are identified as diabetic by claims data. If you believe a member may be erroneously
identified as a diabetic, document in the member’s medical record that the member is not
diabetic. They will remain in the eligible population until claims data identifying them as
diabetic is not received in the measurement year or the year prior to the measurement year.
39Adherent Member: Diabetic members are considered to be compliant with this measure if there is:
• Evidence of nephropathy in the measurement year:
— A claim/encounter with a code to indicate evidence of treatment for nephropathy.
— A nephrologist visit during the measurement year identified by Gateway Health
specialty provider codes (no restriction on the diagnosis or procedure code submitted).
— Evidence of end-stage renal disease.
— Evidence of renal transplant.
OR
• Evidence of ACE inhibitor or ARB therapy in the measurement year:
— Pharmacy claim as evidence of a dispensed ambulatory prescription for
ACE or ARB therapy.
— Documentation in medical record of ACE or ARB therapy during the
measurement year.
OR
• A nephropathy screening or monitoring test during the measurement year.
How to Submit to Gateway Health:
• Submit lab claim for a urinalysis (CPT® code: 81000, 81001, 81002, 81003 and 81005,
82042, 82043, 82044).
OR
• Submit CPT II codes to identify nephropathy screening tests or therapy:
— 3060F - Positive microalbumin test result (30–300).
— 3061F - Negative microalbumin test documented and reviewed (< 30).
— 3062F - Positive macroalbumin test result documented and reviewed.
— 3066F - Receiving dialysis, treatment for ESRD, CRF, ARF, or renal insufficiency, and
any visit to a nephrologist.
— 4010F - ACE inhibitor/ARB therapy.
Best Practices:
• Identify non-adherent patients.
• Evidence of compliance — documentation of medical attention for any of the following:
diabetic nephropathy, ESRD, CRF, renal insufficiency, proteinuria, albuminuria, renal
dysfunction, ARF chronic kidney disease, dialysis, hemodialysis, or peritoneal dialysis.
• Obtain urine specimen in office (can be sent to lab for analysis).
• Refer patient to a nephrologist.
• Provide ongoing outreach to non-adherent patients.
40Osteoporosis Management
Measure Type: Static Star Measure
Description of Measure: Women ages 67–85 who have suffered a fracture and who had
either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the
six months after the fracture.
Eligible Population: Female members 67–85 years of age by the end of the measurement
year, who were enrolled in the plan at the end of the measurement year and suffered a fracture*
identified by an outpatient, observation, ED, non-acute inpatient, or acute inpatient encounter
for a fracture during the intake period. Further, members with no diagnosis of a fracture for
a period of 60 days prior to the index episode start date (IESD). For fractures requiring an
inpatient stay, use the admission date to determine negative diagnosis history.
*Fractures of finger, toe, face, and skull are not included.
Exclusions: Members who meet any of the following criteria: Members who had a BMD
test during the 730 days (24 months) prior to IESD. Members who had a claim/encounter for
osteoporosis therapy (medication) during the 365 days (12 months) prior to IESD. Members
who received a dispensed prescription or had an active prescription to treat osteoporosis
during the 365 days (12 months) prior to IESD.
Optional Exclusions:
• Members age 66 and older as of December 31 of the measurement year who are
enrolled in an Institutional SNP (I-SNP) or living long-term in an institution during the
measurement year.
• Members age 81 and older as of December 31 of the measurement year with frailty.
• Members age 66 and older as of December 31 of the measurement year with advanced
illness and frailty.
— At least two outpatient visits, observation visits, ED visits or non-acute inpatient
encounters on different dates of service, with an advanced illness diagnosis.
— At least one acute inpatient encounter with an advanced illness diagnosis.
— A dispensed dementia medication (Donepezil, Galantamie, Rivastigmine,
Memantine).
41Adherent Member: Appropriate testing or treatment for osteoporosis after the fracture
defined by any of the following criteria:
• BMD test on the index episode start date (IESD) or in the 180-day period after
the IESD.
• BMD test during the inpatient stay for the fracture.
• Osteoporosis therapy on the IESD or in the 180-day period after the IESD.
• Dispensed prescription to treat osteoporosis on the IESD or in the 180-day period
after the IESD.
How to Submit to Gateway Health:
• Submit a claim for either bone mineral density test or prescription claim for approved
osteoporosis medication. The following are approved therapies:
— Bisphosphonates: Alendronate, Alendronate-Cholecaliferol, Ibandronate,
Risedronate, Zoledronic Acid
— Other agents: Abaloparatide, Calcitonin, Denosumab, Raloxifene, Teriparatide
Best Practices:
• Identify non-adherent patients.
• Prep chart to address with patient next office visit.
• Encourage hospital to perform bone mineral density test prior to discharging patient.
• Provide ongoing outreach efforts to non-adherent patients.
• Ensure proper coding. When fracture has not just occurred and is healed, then
coding should indicate a history of a fracture.
• Utilize Gateway Health’s vendor for patients requiring or requesting the convenience
of in-home testing.
For more information call Gateway Health provider service at 1-800-685-5209
Other:
• Once six months have elapsed following fracture and the proper treatment or
testing has not occurred, the patient is beyond remediation and the opportunity
to close the gap is lost.
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