GLOBAL P4P Pay for Performance (P4P) Program Guide
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GLOBAL
P4P
Pay for Performance (P4P)
Program Guide
Contact: QualityPrograms@iehp.org
Published: March 28, 2018PROGRAM OVERVIEW
This program guide provides an overview of the 2018 Global Quality Pay for Performance
(GQ P4P) Program for Primary Care Providers (PCPs). In this third year of the program,
IEHP has made enhancements based on feedback from Providers in an effort to continually
improve program effectiveness. The IEHP GQ P4P Program for PCPs is designed to reward
PCPs for high performance and year-over-year improvement in key quality performance
measures. This program overview is designed for Physicians and their staff as an easy guide to
help maximize GQ P4P.
This year’s GQ P4P Program continues to provide financial rewards to PCPs for improving
healthcare quality across multiple domains and measures. The 2018 GQ P4P program focuses on
performance-based incentives to PCPs for services rendered in 2018.
If you would like more information about IEHP’s GQ P4P Program or best practices to help
improve quality scores and outcomes, visit our Secure Provider Portal at www.iehp.org, email
the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team
at (909) 890-2054.
What’s New?
The Program incentive for 2018 PCP performance is now $67 million
- This is an increase of $29 million additional incentive dollars to the annual program budget
Four measures were retired
- Annual Monitoring for Patients on Persistent Medications - Total
- Childhood Immunizations - Combo 3
- Comprehensive Diabetes Care - Eye Exam
- Member Satisfaction Survey – Access to Routine Care
Two measures were moved to reporting-only status
- Encounter Data PCP PMPY - SPD
- Encounter Data PCP PMPY - Non-SPD
Three measures were added to the Clinical Quality Domain
- Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
- Weight Assessment and Counseling for Nutrition and Physical Activity for
Children and Adolescents
- Concurrent Use of Opioids and Benzodiazepines (monitoring only)
New Tier 1 and Tier 2 goal methodology includes a ‘practical significance’ standard
New Quality Per Member Per Month (PMPM) Payments methodology
1Eligibility and Participation
To be eligible for incentive payments in the 2018 GQ P4P Program, PCPs must meet the
following criteria:
• Have at least 200 Medi-Cal Members assigned as of January 2018
• Have at least 30 Members in the denominator as of December 2018 for each quality
measure to qualify for scoring
• Have at least 3 quality measures that meet minimum denominator requirements in order
for a global quality score to be calculated
PCP enrollment into the GQ P4P program is automatic once the above three criteria have been met.
Minimum Data Requirements
Encounter Data
Encounter data is foundational to performance scoring and is essential to success in the GQ
P4P Program. Complete, timely and accurate encounter data should be submitted through
normal reporting channels for all services rendered to IEHP Members. Please use the codes
listed in Appendix 2 to help with proper coding to meet measure requirements.
Lab Results
Data from lab results data is also foundational to Program performance scoring. Providers
should ensure they submit complete lab results data for services rendered to IEHP Members.
Work with your IPA to ensure you are using the appropriate lab vendors for IEHP Members,
and submitting lab results data to IEHP.
Lab results that are performed in the office (e.g., point of care HbA1c testing, urine tests, etc.)
should be coded and submitted through your encounter data.
2Immunizations
To maximize performance in immunization-based measures, IEHP strongly encourages all
Providers to report all immunizations via the California Immunization Registry (CAIR2).
For more information on how to register for CAIR2, please visit http://cairweb.org/. IEHP is
working closely with CAIR in establishing a data sharing arrangement to be used in Global
Quality P4P reporting.
IEHP’s Traditional P4P
Data provided to IEHP as part of Traditional P4P Programs will be used as a data source to
support the performance scoring methodology for measures in the Clinical Quality domain.
P4P Program data are not used in scoring methodology for encounter data performance measures.
P4P Program data are subject to retrospective data validation and must pass all quality assurance
checks prior to inclusion into final Provider performance scores.
Financial Overview
Providers are eligible to receive financial rewards for performance excellence and for
performance improvement. Financial rewards are based on a tiered system, providing
increasing financial rewards for reaching higher tiered level performance. The 2018 GQ P4P
Program incentive pool is $67 million for the PCP Program. Incentive dollars for the 2018
performance period will be distributed monthly via a new monthly per Member per month
(PMPM) Quality Payment beginning in July 2019 and continuing through June 2020.
3Performance Measures Appendix 1 provides a list of the 22 measures included in the 2018 GQ P4P Program and includes thresholds and benchmarks associated with respective tier goals. These measures have been categorized into four domains: Clinical Quality, Behavioral Health Integration; Patient Experience; Encounter Data. Most measures included in the Clinical Quality Domain primarily use standard Healthcare Effectiveness Data and Information Set (HEDIS®) process and outcomes measures that are based on the specifications published by the National Committee for Quality Assurance (NCQA). Non-HEDIS® measures that are included in the Clinical Quality Domain come from the California Department of Health Care Services (DHCS) Medi-Cal Managed Care Quality Program and the Pharmacy Quality Alliance (PQA). Clinical Quality Domain Measures: • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (New) • Breast Cancer Screening • Cervical Cancer Screening • Childhood Immunizations – Combo 10 • Comprehensive Diabetes Care – HbA1c Control < 8 • Concurrent Use of Opioids and Benzodiazepines (New) • Immunizations for Adolescents – Combo 2 • Initial Health Assessment • Medication Management for People with Asthma – 75% rate • Timely Postpartum Care • Timely Prenatal Care • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (New) - Counseling for Physical Activity - Counseling for Nutrition - BMI Percentile • Well-Child 3-6 Years of Life IEHP’s HEDIS® 2019 data set (measurement year 2018) will be used to evaluate Providers’ year-end performance. This measure set undergoes an independent audit review prior to rate finalization. The Initial Health Assessment (IHA) measure follows IEHP’s IHA internal compliance monitoring methodology and is not a HEDIS® measure. 4
The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and
maintained by the PQA. This measure will not be used for incentive calculations but will be
collected to establish a baseline rate for 2018. See Appendix 2 for measure details.
Behavioral Health Integration Domain Measures:
The Behavioral Health Integration Domain includes two measures derived from the Centers for
Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) measure set.1
• Screening for Clinical Depression in Primary Care
• Positive Depression Screening with Follow-Up Plan
Patient Experience Domain Measures:
Patient Experience Domain measures include Member Satisfaction Survey questions from the
Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey that is published
by the Agency for Healthcare Research and Quality (AHRQ). IEHP conducts a Member
Satisfaction Survey that is a modified CAHPS survey and is the sole data source supporting the
performance scoring methodology for this measure domain. The IEHP Member Satisfaction
Survey is conducted between June and December of each year. Surveys received from the 2018
Member Satisfaction Survey will be used to calculate the Patient Experience Domain measures.
A copy of the current Member Satisfaction Survey is included in Appendix 4.
• Access to Care Needed Right Away
• Coordination of Care
• Rating of Personal Doctor
Encounter Data Domain Measures:
The fourth measure domain is Encounter Data. The measures in this domain will not be used for
incentive calculations but will be produced for monitoring purposes only. Since encounter data is
critical to capturing the services provided in primary care settings, encounter data monitoring is
essential in performance measurement improvement efforts. PCPs are encouraged to work with
their IPA throughout the year to monitor encounter data completeness and reporting to IEHP.
1 For information on the PQRS measure set: https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
5Scoring Methodology Payment will be awarded to PCPs based on individual performance in reaching established Quality Goals (e.g., Tier Goals for each measure). In the Clinical Quality Domain, HEDIS® measure results are based on each measure’s total eligible population assigned to the PCP. The eligible population is defined as the set of Members who meet the denominator criteria specified in the current year’s HEDIS® Technical Specifications (Volume 2) published by NCQA. Members in the eligible population are attributed to the assigned PCP on each measure’s anchor date, as defined within the HEDIS® measure. Members contribute to a PCP’s HEDIS® measure denominator if continuous enrollment criteria are met at the health plan level. For each measure, the HEDIS® score reflects the proportion of the eligible population that is in compliance with the numerator criteria as defined in the current HEDIS® technical specifications (Volume 2). In the Clinical Quality Domain, Non-HEDIS® measure (i.e., Initial Health Assessment) results are based on new health plan Members who are assigned to the PCP during the measurement year and who remain enrolled with IEHP and the PCP through the 120 day post-enrollment period. See Appendix 2 for measure details. In the Patient Experience Domain, monthly Member Satisfaction Survey measures are based on Members who meet eligibility criteria to receive a mailed survey between June and December of the measurement year. Members eligible to receive a Member Satisfaction Survey must have been continuously enrolled with IEHP for at least six months in the measurement year (2018) and must have had an office visit in the prior six months based on encounter data submitted to IEHP. Members who meet the survey eligibility criteria are randomly sampled to receive a survey. Survey measure results are attributed to the Member’s assigned PCP based on the most recent encounter that qualified the Member to be eligible for the survey. A Member is eligible to receive only one survey per calendar year. For PCPs, the Encounter Data Domain measures assess the volume of PCP encounters received for all assigned PCP Members. The denominator is all assigned Medi-Cal Members each month of the measurement year (2018). All monthly assigned Members are summed to create the denominator (i.e., Member months). The numerator is the sum of all unique encounters (e.g., unique Member, Provider, date of service) in the measurement year for all assigned Members in the denominator. A Per Member Per Year (PMPY) rate is calculated following this formula: (Total Unique Encounters / Total Member Months) x 12 = PMPY 6
Payment Methodology
PCP performance for each quality measure will be given a point value (i.e., a Quality Score).
Points are assigned based on the Tier Goal achieved (i.e. Tier 1 = one point, Tier 2 = two points,
Tier 3 = three points) for each measure.
Providers who have at least three quality measures that meet the minimum denominator size
(n = 30) will be considered for payment calculations. An average of all eligible Quality Scores
will determine the overall GQ Performance Score. GQ P4P Program payments will be awarded
according to the following formula:
[Global Quality Performance Score] x [# Medi-Cal Average Member Months] = Member Points
[Member Points] x [Payment Amount per Member Point] = Incentive Payout Total
The payment amount per Member point is dependent on the total incentive money available
for PCPs.
PCP PMPM Quality Payment Methodology
From July 2019 – June 2020, PCPs will receive a monthly PMPM (per Member per month) quality
payment based on 2018 GQ P4P performance using the following formula:
2018 Global Quality P4P Payments
Quality PMPM
Payment Amount
Total Medi-Cal Member Months
PCP payment example: PCP with monthly average of 2,500 Members (30,000 Member Months)
and 2.0 GQ Quality Score
(A) Global P4P Payments: $247,200 Quality PMPM Payment
Amount: $8.24
~ $20,600 monthly payment*
Total Member Months: 30,000 ~$247,200 annual payment*
*Assuming stable membership volume
7Quality Incentive Payout Timeline:
Provider Communication Timeline
Interim 2017 GQ P4P payment (PCP & IPA) Final 2017 GQ P4P payment (PCP & IPA)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018
End of Traditional PCP P4P Program Monthly Quality PMPM payments based on 2017
GQ P4P Performance year results (PCP only)
Monthly Quality PMPM payments based on 2017
GQ P4P Performance year results (PCP only)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2019 2019 2019 2019 2019 2019 2019 2019 2019 2019 2019 2019
Monthly Quality PMPM payments based on 2018
GQ P4P Performance year results (PCP & IPA)
Getting Help
Please direct questions and/or comments related to this program to IEHP’s Provider Call
Center at 909-890-2054 or to IEHP’s Quality Department at QualityPrograms@iehp.org.
Program Terms and Conditions
• Participation in IEHP’s GQ P4P Program, as well as acceptance of incentive payments,
does not in any way modify or supersede any terms or conditions of any agreement between
IEHP and Providers or IPAs, whether that agreement is entered into, prior to or subsequent
to, the date of this communication.
• There is no guarantee of future funding for, or payment under, any IEHP Provider incentive
program. The IEHP GQ P4P Program and/or its terms and conditions may be modified or
terminated at any time, with or without notice, at IEHP’s sole discretion.
• Criteria for calculating incentive payments are subject to change at any time, with or without
notice, at IEHP’s sole discretion.
• In consideration of IEHP’s offering of the IEHP GQ P4P Program, participants agree to fully
and forever release and discharge IEHP from any and all claims, demands, causes of action,
and suits, of any nature, pertaining to or arising from the offering by IEHP of the IEHP GQ
P4P Program.
• The determination of IEHP regarding performance scoring and payments under the IEHP
GQ P4P Program is final.
• As a condition of receiving payment under the IEHP GQ P4P Program, Providers and IPAs must
be active and contracted with IEHP and have active assigned Members at the time of payment.
8APPENDIX 1: 2018 PCP Global Quality P4P Program Measures
2018 GQ P4P PROGRAM MEASURE LIST
Domain Measure Name Population Tier 1 Tier 2 Tier 32
Avoidance of Antibiotic Treatment
Clinical Quality Adult Improvement Improvement 39.0%
in Adults with Acute Bronchitis 1
demonstrated demonstrated
Comprehensive Diabetes Care - by meeting by meeting
Clinical Quality Adult 58.0%
HbA1c ControlAPPENDIX 2: Measures Overview
Population: Adult
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB)
Methodology: HEDIS®
Measure Description: The percentage of adults 18-64 years of age (with a diagnosis of acute
bronchitis) who were not dispensed an antibiotic prescription on or three days after the Index
Episode Start Date (IESD).
• Episode Date is the date of service for any outpatient or emergency department (ED)
visit during the Intake Period (January 1, 2018-December 24, 2018) with a diagnosis of
acute bronchitis
• IESD: the earliest Episode Date during the Intake Period with a diagnosis of acute
bronchitis that meets all of the following criteria:
1. Episode Date is the date of service for any outpatient or ED visit during the
Intake Period with a diagnosis of acute bronchitis.
2. A 30-day Negative Medication History prior to the Episode Date.
3. A 12-month Negative Comorbid Condition History prior to and including the
Episode Date.
4. A Negative Competing Diagnosis during the 38-day period from 30 days prior to
the Episode Date through seven days after the Episode Date.
5. The member was continuously enrolled one year prior to the Episode Date through
seven days after the Episode Date.
• The measure is reported as an inverted rate [1 – (numerator/eligible population)].
A higher rate indicates appropriate treatment of adults with acute bronchitis
(i.e., the proportion for whom antibiotics were not prescribed).
• Members in hospice are excluded from the eligible population.
• Exclude denied claims when assessing numerator criteria.
• Do not include ED visits or observation visits that result in an inpatient stay. When an
ED or observation visit and an inpatient stay are billed on separate claims, the visit results
in an inpatient stay when the admission date for the inpatient stay occurs on the ED/
observation date of service or one calendar day after. An ED or observation visit billed on
the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay.
10Denominator: Members 18-64 years of age, who had an outpatient visit, an observation visit or an
ED visit between January 1 – December 24 of the measurement year (2018) with a diagnosis of
acute bronchitis.
Numerator: Dispensed prescription for an antibiotic medication on or three days after IESD
for the Members in denominator.
AAB ANTIBIOTIC MEDICATIONS
Description Prescription
• Amikacin • Tobramycin
Aminoglycosides
• Gentamicin • Streptomycin
Aminopenicillins • Amoxicillin • Ampicillin
• Amoxicillin-clavulanate • Piperacillin-tazobactam
Beta-lactamase inhibitors
• Ticarcillin-clavulanate • Ampicillin-sulbactam
First-generation
• Cefadroxil • Cefazolin • Cephalexin
cephalosporins
Fourth-generation
• Cefepime
cephalosporins
Ketolides • Telithromycin
Lincomycin derivatives • Clindamycin • Lincomycin
• Azithromycin • Erythromycin • Erythromycin
Macrolides • Clarithromycin • Erythromycin lactobionate
ethylsuccinate • Erythromycin stearate
• Aztreonam • Daptomycin • Metronidazole
Miscellaneous antibiotics • Chloramphenicol • Erythromycin- • Vancomycin
• Dalfopristin-quinupristin sulfisoxazole • Linezolid
• Penicillin G benzathine- • Penicillin G procaine • Penicillin V potassium
Natural penicillins procaine • Penicillin G sodium • Penicillin G
• Penicillin G potassium benzathine
Penicillinase resistant
• Dicloxacillin • Nafcillin • Oxacillin
penicillins
• Ciprofloxacin • Levofloxacin • Norfloxacin
Quinolones
• Gemifloxacin • Moxifloxacin • Ofloxacin
Rifamycin derivatives • Rifampin
Second-generation • Cefaclor • Cefoxitin • Cefuroxime
cephalosporin • Cefotetan • Cefprozil
Sulfonamides • Sulfadiazine • Sulfamethoxazole-trimethoprim
Tetracyclines • Doxycycline • Minocycline • Tetracycline
• Cefdinir • Cefotaxime • Ceftibuten
Third-generation
• Cefditoren • Cefpodoxime • Ceftriaxone
cephalosporins
• Cefixime • Ceftazidime
• Fosfomycin • Nitrofurantoin macrocrystals-monohydrate
Urinary anti-infectives • Nitrofurantoin • Nitrofurantoin macrocrystals
• Trimethoprim
11Comprehensive Diabetes Care (CDC) – HbA1c Control (
• Members who met any of the following criteria are excluded: 1. Members in hospice are excluded. 2. Members who did not have a diagnosis of diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017) and who had a diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017). Denominator: Members 18-75 years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had the most recent HbA1c level
ASTHMA CONTROLLER MEDICATIONS:
Description Prescription
Antiasthmatic
• Dyphylline-guaifenesin • Guaifenesin-theophylline
combinations
Antibody inhibitors • Omalizumab
Anti-interleukin-5 • Mepolizumab • Reslizumab
Inhaled steroid • Budesonide-formoterol • Fluticasone-vilanterol
combinations • Fluticasone-salmeterol • Mometasone-formoterol
• Beclomethasone • Flunisolide
Inhaled corticosteroids • Budesonide • Fluticasone CFC free
• Ciclesonide • Mometasone
Leukotriene modifiers • Montelukast • Zafirlukast • Zileuton
Mast cell stabilizers • Cromolyn
Methylxanthines • Dyphylline • Theophylline
ASTHMA RELIEVER MEDICATIONS
Description Prescriptions
Short-acting, inhaled beta-2 agonists • Albuterol • Levalbuterol • Pirbuterol
• Members who meet any of the following criteria are excluded:
1. Members who had no asthma controller medications dispensed during the
measurement year (2018).
2. Members in hospice are excluded.
3. Members with the following diagnosis any time during the Member’s history
through December 31 of the measurement year (2018) are excluded: COPD, Acute
Respiratory Failure, Cystic Fibrosis, Chronic respiratory conditions and Emphysema.
Denominator: Members 5–64 years of age during the measurement year (2018) who were
identified as having persistent asthma and were dispensed appropriate medications that they
remained on during the treatment period.
Numerator: Members in denominator who remained on an asthma controller medication for
at least 75% of their treatment period.
14Population: Adult and Adolescent
Screening for Clinical Depression in Primary Care
Methodology: IEHP-defined Quality Metric – Modified from PQRS measure (NQF 0418)
Measure Description: The percentage of Members aged 12 years and older screened
for clinical depression on the date of the encounter using an age appropriate standardized
depression screening tool during the measurement year (2018).
Denominator: All Members aged 12 years and older with a PCP visit in the measurement year
(2018). Member counted only once in the denominator.
PRIMARY CARE PROVIDER VISIT CODES:
Code
Service Code Code Description
Type
Office or other outpatient visit for the evaluation and
management of a new patient which requires these three key
Screening for Clinical components: A problem focused history; A problem focused
CPT 99201
Depression in Primary Care examination; Straightforward medical decision making.
Typically, 10 minutes are spent face-to-face with the patient
and/or family.
Office or other outpatient visit for the evaluation and
management of a new patient which requires these three
Screening for Clinical key components: An expanded problem focused history; An
CPT 99202
Depression in Primary Care expanded problem focused examination; Straightforward
medical decision making. Typically, 20 minutes are spent
face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and
management of a new patient which requires these three key
Screening for Clinical components: A detailed history; A detailed examination;
CPT 99203
Depression in Primary Care Medical decision making of low complexity. Typically, 30
minutes are spent face-to- face with the patient and/or
family.
Office or other outpatient visit for the evaluation and
management of a new patient which requires these three key
Screening for Clinical components: A comprehensive history; A comprehensive
CPT 99204
Depression in Primary Care examination; Medical decision making of moderate
complexity. Typically, 45 minutes are spent face-to-face with
the patient and/or family.
15PRIMARY CARE PROVIDER VISIT CODES:
Code
Service Code Code Description
Type
Office or other outpatient visit for the evaluation and
management of a new patient which requires these three key
Screening for Clinical components: A comprehensive history; A comprehensive
CPT 99205
Depression in Primary Care examination; Medical decision making of high complexity.
Typically, 60 minutes are spent face-to-face with the patient
and/or family.
Office or other outpatient visit for the evaluation and
management of an established patient which requires at least
Screening for Clinical two of these 3 key components: A problem focused history;
CPT 99212
Depression in Primary Care A problem focused examination; Straightforward medical
decision making. Typically, 10 minutes are spent face-to-face
with the patient and/or family.
Office or other outpatient visit for the evaluation and
management of an established patient which requires at
Screening for Clinical least two of these 3 key components: An expanded problem
CPT 99213
Depression in Primary Care focused history; An expanded problem focused examination;
Medical decision making of low complexity. Typically, 15
minutes are spent face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and
management of an established patient which requires at
Screening for Clinical least two of these 3 key components: A detailed history; A
CPT 99214
Depression in Primary Care detailed examination; Medical decision making of moderate
complexity. Typically, 25 minutes are spent face-to-face with
the patient and/or family.
Office or other outpatient visit for the evaluation and
management of an established patient which requires at least
Screening for Clinical two of these 3 key components: A comprehensive history;
CPT 99215
Depression in Primary Care A comprehensive examination; Medical decision making of
high complexity. Typically, 40 minutes are spent face-to-face
with the patient and/or family.
Office or other outpatient visit for the evaluation and
management of an established patient which requires at least
Screening for Clinical two of these 3 key components: A comprehensive history;
HCPCS G0101
Depression in Primary Care A comprehensive examination; Medical decision making of
high complexity. Typically, 40 minutes are spent face-to-face
with the patient and/or family.
Screening for Clinical Initial preventive physical examination face-to-face visits
HCPCS G0402
Depression in Primary Care services limited to new beneficiary during the first 12 months.
Screening for Clinical Annual wellness visit includes a personalized prevention
HCPCS G0438
Depression in Primary Care plan of service (pps) initial visit.
Screening for Clinical Annual wellness visit includes a personalized prevention
HCPCS G0439
Depression in Primary Care plan of service (pps) subsequent visit.
16PRIMARY CARE PROVIDER VISIT CODES:
Code
Service Code Code Description
Type
Screening for Clinical
HCPCS G0444 Annual depression screening 15 minutes.
Depression in Primary Care
Screening for Clinical
CPT 97003 Occupational therapy evaluation
Depression in Primary Care
Numerator: Members screened for clinical depression on the date of the encounter using an
age appropriate standardized tool during the measurement year (2018).
CODES TO IDENTIFY SCREENING FOR CLINICAL DEPRESSION:
Service Code Type Code Code Description
Screening for Clinical
CPT 1220F Patient screened for depression (sud)
Depression in Primary Care
Negative screen for depressive symptoms as categorized
Screening for Clinical
CPT 3351F by using a standardized depression screening/
Depression in Primary Care
assessment tool (mdd)
Screening for Clinical No significant depressive symptoms as categorized by
CPT 3352F
Depression in Primary Care using a stan dardized depression assessment tool (mdd)
Mild to moderate depressive symptoms as categorized
Screening for Clinical
CPT 3353F by using a standardized depression screening/
Depression in Primary Care
assessment tool (mdd)
Clinically significant depressive symptoms as
Screening for Clinical
CPT 3354F categorized by usin g a standardized depression
Depression in Primary Care
screening/assessment tool (mdd)
Screening for Clinical
CPT 3725F Screening for depression performed (dem)
Depression in Primary Care
Screening for Clinical
HCPCS G0444 Annual depression screening 15 minutes
Depression in Primary Care
Screening for Clinical Positive screen for clinical depression using a
HCPCS G8431
Depression in Primary Care standardized tool and a follow-up plan documented
Screening for Clinical Screening for clinical depression using a standardized
HCPCS G8433
Depression in Primary Care tool not documented patient not eligible/appropriate
Negative screen for clinical depression using a
Screening for Clinical
HCPCS G8510 standardized tool patient not eligible/appropriate for
Depression in Primary Care
follow-up plan documented
Screen for clinical depression using a standardize tool
Screening for Clinical
HCPCS G8511 documented follow up plan not documented reason
Depression in Primary Care
not specified
Screening for clinical depression documented
Screening for Clinical
HCPCS G8940 follow-up plan not documented patient not eligible/
Depression in Primary Care
appropriate
17Definitions: Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the Member population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to: • Adolescent Screening Tools (12-17 years): Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2 • Adult Screening Tools (18 years and older): Patient Health Questionnaire (PHQ-9 or PHQ-2), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 18
Positive Depression Screening with Follow Up Plan
Methodology: IEHP-defined Quality Metric – Modified from PQRS measure (NQF 0418)
Measure Description: The percentage of Members aged 12 years and older who screened
positive for clinical depression using an age appropriate standardized depression screening tool
who also have a follow-up plan documented during the measurement year (2018).
Denominator: All Members aged 12 years and older with a PCP visit with a positive
depression screening in the measurement year (2018). Member counted only once in
the denominator.
CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING DURING A PRIMARY
CARE PROVIDER VISIT:
Service Code Type Code Code Description
Mild to moderate depressive symptoms as
Positive Depression Screening
CPT 3353F categorized by using a standardized depression
with Follow Up Plan
screening/assessment tool (mdd)
Clinically significant depressive symptoms as
Positive Depression Screening
CPT 3354F categorized by using a standardized depression
with Follow Up Plan
screening/assessment tool (mdd)
Positive Depression Screening Positive screen for clinical depression using a
HCPCS G8431
with Follow Up Plan standardized tool and a follow-up plan documented
Screen for clinical depression using a standardize tool
Positive Depression Screening
HCPCS G8511 documented follow up plan not documented reason
with Follow Up Plan
not specified
Screening for clinical depression documented
Positive Depression Screening
HCPCS G8940 follow-up plan not documented patient not eligible/
with Follow Up Plan
appropriate
Numerator: Members screened positive for clinical depression with a follow-up plan
documented during the measurement year (2018).
19CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING WITH
FOLLOW-UP PLAN:
Service Code Type Code Code Description
Positive Depression Screening Plan for follow-up care for major depressive disorder
CPT 0545F
with Follow Up Plan documented (mdd adol)
Positive Depression Screening Positive screen for clinical depression using a
HCPCS G8431
with Follow Up Plan standardized tool and a follow-up plan documented
Screening for clinical depression documented
Positive Depression Screening
HCPCS G8940 follow-up plan not documented patient not eligible/
with Follow Up Plan
appropriate
Definitions:
Follow-Up Plan – Documented follow-up for a positive depression screening must include
one or more of the following:
• Additional evaluation for depression
• Suicide Risk Assessment
• Referral to a practitioner who is qualified to diagnose and treat depression
• Pharmacological interventions
• Other interventions or follow-up for the diagnosis or treatment of depression
20Population: Women
Breast Cancer Screening (BCS)
Methodology: HEDIS®
Measure Description: The percentage of women 50–74 years of age who had a mammogram
to screen for breast cancer any time on or between October 1 two years prior to the measurement
year (2016) and December 31 of the measurement year (2018).
• The eligible population in the measure meets all of the following criteria:
1. Women 52-74 years as of December 31 of the measurement year (2018).
2. Continuous enrollment from October 1 two years prior to the measurement year
(2016) through December 31 of the measurement year (2018) with no more than
one gap in enrollment of up to 45 days for each calendar year of continuous enrollment.
No gaps in enrollment are allowed from October 1 two years prior to the measurement
year (2016) through December 31 two years prior to the measurement year (2016).
CODES USED TO IDENTIFY MAMMOGRAPHY
Service Code Type Code Code Description
Breast Cancer Screening CPT 77055 Mammography Unilateral
Breast Cancer Screening CPT 77056 Mammography Bilateral
Screening Mammography Bilateral
Breast Cancer Screening CPT 77057
(2-view Film Study Of Each Breast)
Breast Cancer Screening CPT 77061 Digital Breast Tomosynthesis Unilateral
Breast Cancer Screening CPT 77062 Digital Breast Tomosynthesis Bilateral
Screening Digital Breast Tomosynthesis Bilateral
Breast Cancer Screening CPT 77063
(list Separately In Addition To Code For Primary Procedure)
Diagnostic Mammography W/computer-aided
Breast Cancer Screening CPT 77065
Detection; Unilateral
Diagnostic Mammography W/computer-aided
Breast Cancer Screening CPT 77066
Detection; Bilateral
Screening Mammography Bilateral (2-view Film Study Of
Breast Cancer Screening CPT 77067
Each Breast Including Computer-aided Detection (cad)
Screening Mammography, Bilateral (2-view Study Of Each
Breast Cancer Screening HCPCS G0202 Breast), Including Computer-aided Detection (cad)
When Performed (g0202)
Diagnostic Mammography, Including Computer-aided
Breast Cancer Screening HCPCS G0204
Detection (cad) When Performed; Bilateral (g0204)
Diagnostic Mammography, Including Computer-aided
Breast Cancer Screening HCPCS G0206
Detection (cad) When Performed; Unilateral (g0206)
21• Members who meet any of the following criteria are excluded:
1. Members who have had a bilateral mastectomy any time during their history
through December 31, 2018 may be excluded.
To exclude Members who meet the exclusion criteria, please complete Member
Historical Data Form and fax to IEHP’s Quality Informatics Team at 909-477-8568.
A copy of the Historical Data Form is available in Appendix 3.
2. Members in hospice are excluded.
Denominator: Women 52-74 years of age who met the criteria for eligible population.
Numerator: Members in denominator who had one or more mammograms any time on or
between October 1 two years prior to the measurement year (2016) and December 31 of the
measurement year (2018).
Cervical Cancer Screening (CCS)
Methodology: HEDIS®
Measure Description: The percentage of Women 21–64 years of age who were screened for
cervical cancer using either of the following criteria:
• Women age 21–64 who had cervical cytology performed every 3 years.
• Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing
performed every 5 years.
• The eligible population in the measure meets all of the following criteria:
1. Women 24-64 years as of December 31 of the measurement year (2018).
2. Continuous enrollment during the measurement year (2018) with no more than
one gap in enrollment of up to 45 days.
CODES TO IDENTIFY CERVICAL CYTOLOGY
Service Code Type Code Code Description
Cytopathology Cervical Or Vaginal (any Reporting System)
Cervical Cancer
CPT 88141 Requiring Interpretation By Physician (List separately In addition
Screening
to code for technical service.)
Cytopathology Cervical Or Vaginal (any Reporting System)
Cervical Cancer
CPT 88142 Collected In Preservative Fluid Automated Thin Layer
Screening
Preparation Manual screening under Physician supervision
22CODES TO IDENTIFY CERVICAL CYTOLOGY
Service Code Type Code Code Description
Cytopathology Cervical Or Vaginal (any Reporting System)
Collec Ted In Preservative Fluid Automated Thin Layer
Cervical Cancer
CPT 88143 Preparation; manual screening Under Physician Supervision:
Screening
With manual screening and rescreening Under Physician
Supervision
Cervical Cancer Cytopathology Smears Cervical Or Vaginal Screening By
CPT 88147
Screening Automated System Under Physician Supervision
Cytopathology Smears Cervical Or Vaginal Screening By
Cervical Cancer
CPT 88148 Automated System With Manual Rescreening Under Physician
Screening
Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal Manual Screening
CPT 88150
Screening Under Physician Supervision
Cytopathology Slides Cervical Or Vaginal With Manual
Cervical Cancer
CPT 88152 Screening And Computer-assisted Rescreening Under Physician
Screening
Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal With Manual
CPT 88153
Screening Screening And Rescreening Under Physician Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal With Manual
CPT 88154 Screening And Computer-assisted Rescreening Using Cell
Screening Selection And Review Under Physician Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal (the Bethesda System)
CPT 88164
Screening Manual Screening Under Physician Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal (the Bethesda System)
CPT 88165 With Manual Screening And Rescreening Under Physician
Screening Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal (the Bethesda System)
CPT 88166 With Manual Screening And Computer-assisted Rescreening
Screening Under Physician Supervision
Cervical Cancer Cytopathology Slides Cervical Or Vaginal (the Bethesda System)
CPT 88167 With Manual Screening And Computer-assisted Rescreening
Screening Using cell selection and review Under Physician Supervision
Cervical Cancer Cytopathology Cervical Or Vaginal (any Reporting System)
CPT 88174 Collected In Preservative Fluid Automated Thin Layer
Screening Preparation
Cervical Cancer Cytopathology Cervical Or Vaginal (any Reporting System)
CPT 88175
Screening Collected In Preservative Fluid Screening Automated By System
Screening Cytopathology, Cervical Or Vaginal (any Reporting
Cervical Cancer System), Collected In Preservative Fluid, Automated Thin Layer
HCPCS G0123
Screening Preparation, Screening By Cytotechnologist Under Physician
Supervision (g0123)
Screening Cytopathology, Cervical Or Vaginal (any Reporting
Cervical Cancer
HCPCS G0124 System), Collected In Preservative Fluid, Automated Thin Layer
Screening
Preparation, Requiring Interpretation By Physician (g0124)
23CODES TO IDENTIFY CERVICAL CYTOLOGY
Service Code Type Code Code Description
Screening Cytopathology Smears, Cervical Or Vaginal,
Cervical Cancer
HCPCS G0141 Performed By Automated System, With Manual Rescreening,
Screening
Requiring Interpretation By Physician (g0141)
Screening Cytopathology, Cervical Or Vaginal (any Reporting
Cervical Cancer System), Collected In Preservative Fluid, Automated Thin Layer
HCPCS G0143
Screening Preparation, With Manual Screening And Rescreening By
Cytotechnologist Under Physician Supervision (g0143)
Screening Cytopathology, Cervical Or Vaginal (any Reporting
Cervical Cancer System), Collected In Preservative Fluid, Automated Thin Layer
HCPCS G0144
Screening Preparation, With Screening By Automated System, Under
Physician Supervision (g0144)
Screening Cytopathology, Cervical Or Vaginal (any Reporting
Cervical Cancer System), Collected In Preservative Fluid, Automated Thin Layer
HCPCS G0145
Screening Preparation, With Screening By Automated System And Manual
Rescreening Under Physician Supervision (g0145)
Screening Cytopathology Smears, Cervical Or Vaginal,
Cervical Cancer
HCPCS G0147 Performed By Automated System Under Physician Supervision
Screening
(g0147)
Screening Cytopathology Smears, Cervical Or Vaginal,
Cervical Cancer
HCPCS G0148 Performed By Automated System With Manual Rescreening
Screening
(g0148)
Cervical Cancer Screening Papanicolaou Smear, Cervical Or Vaginal, Up To Three
HCPCS P3000
Screening Smears, By Technician Under Physician Supervision (p3000)
Cervical Cancer Screening Papanicolaou Smear, Cervical Or Vaginal, Up To Three
HCPCS P3001
Screening Smears, Requiring Interpretation By Physician (p3001)
Screening Papanicolaou Smear; Obtaining, Preparing And
Cervical Cancer
HCPCS Q0091 Conveyance Of Cervical Or Vaginal Smear To Laboratory
Screening
(q0091)
Cervical Cancer
LOINC 10524-7 Microscopic Observation [identifier] In Cervix By Cyto Stain
Screening
Cervical Cancer Microscopic Observation [identifier] In Cervix By Cyto Stain
LOINC 18500-9
Screening Thinprep
Cervical Cancer General Categories [interpretation] Of Cervical Or Vaginal
LOINC 19762-4
Screening Smear Or Scraping By Cyto Stain
Cervical Cancer Statement Of Adequacy [interpretation] Of Cervical Or Vaginal
LOINC 19764-0
Screening Smear Or Scraping By Cyto Stain
Cervical Cancer Microscopic Observation [identifier] In Cervical Or Vaginal
LOINC 19765-7
Screening Smear Or Scraping By Cyto Stain
Cervical Cancer Microscopic Observation [identifier] In Cervical Or Vaginal
LOINC 19766-5
Screening Smear Or Scraping By Cyto Stain Narrative
Cervical Cancer Cytology Study Comment Cervical Or Vaginal Smear Or
LOINC 19774-9
Screening Scraping Cyto Stain
24CODES TO IDENTIFY CERVICAL CYTOLOGY
Service Code Type Code Code Description
Cervical Cancer
LOINC 33717-0 Cytology Cervical Or Vaginal Smear Or Scraping Study
Screening
Cervical Cancer Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto
LOINC 47527-7
Screening Stain.thin Prep
Cervical Cancer Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto
LOINC 47528-5
Screening Stain
CODES TO IDENTIFY HPV TESTS
Service Code Type Code Code Description
Cervical Cancer Infectious Agent Detection By Nucleic Acid (dna Or Rna)
CPT 87620
Screening Papillom Avirus Human Direct Probe Technique
Cervical Cancer Infectious Agent Detection By Nucleic Acid (dna Or Rna)
CPT 87621
Screening Papillom Avirus Human Amplified Probe Technique
Cervical Cancer Infectious Agent Detection By Nucleic Acid (dna Or Rna)
CPT 87622
Screening Papillom Avirus Human Quantification
Infectious Agent Detection By Nucleic Acid (dna Or Rna)
Cervical Cancer
CPT 87624 Human Pap Illomavirus (hpv) High-risk Types (eg 16 18 31 33 35
Screening
39 45 51 52 56 58 59 68)
Infectious Agent Detection By Nucleic Acid (dna Or Rna)
Cervical Cancer
CPT 87625 Human Pap Illomavirus (hpv) Types 16 And 18 Only Includes
Screening
Type 45, If Performed
Infectious Agent Detection By Nucleic Acid (dna Or Rna);
Cervical Cancer Human Papillomavirus (hpv), High-risk Types (e.g., 16, 18,
HCPCS G0476
Screening 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) For Cervical Cancer
Screening, Must Be Performed In Addition To Pap Test (g0476)
Cervical Cancer Human Papilloma Virus 16+18+31+33+35+45+51+52+56 Dna
LOINC 21440-3
Screening [presence] In Cervix By Dna Probe
Human Papilloma Virus 16+18+31+33+35+39+45+51+52+5
Cervical Cancer
LOINC 30167-1 6+58+59+68 Dna [presence] In Cervix By Probe And Signal
Screening
Amplification Method
Human Papilloma Virus 6+11+16+18+31+33+35+39+42+43+4
Cervical Cancer
LOINC 38372-9 4+45+51+52+56+58+59+68 Dna [presence] In Cervix By Probe
Screening
And Signal Amplification Method
Cervical Cancer Human Papilloma Virus 16 Dna [presence] In Cervix By Probe
LOINC 59263-4
Screening And Signal Amplification Method
Cervical Cancer Human Papilloma Virus 18 Dna [presence] In Cervix By Probe
LOINC 59264-2
Screening And Signal Amplification Method
Human Papilloma Virus 16+18+31+33+35+39+45+51+52+56
Cervical Cancer
LOINC 59420-0 +58+59+66+68 Dna [presence] In Cervix By Probe And Signal
Screening
Amplification Method
Cervical Cancer Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By
LOINC 69002-4
Screening Probe And Target Amplification Method
25CODES TO IDENTIFY HPV TESTS
Service Code Type Code Code Description
Human Papilloma Virus 31+33+35+39+45+51+52+56+58
Cervical Cancer
LOINC 71431-1 +59+66+68 Dna [presence] In Cervix By Probe And Target
Screening
Amplification Method
Cervical Cancer Human Papilloma Virus 18+45 E6+e7 Mrna [presence] In Cervix
LOINC 75694-0
Screening By Probe And Target Amplification Method
Cervical Cancer Human Papiloma Virus 16 And 18 And 31+33+35+39+45+51+5
LOINC 77379-6
Screening 2+56+58+59+66+68 Dna [interpretation] In Cervix
Cervical Cancer Human Papilloma Virus 16 Dna [presence] In Cervix By Probe
LOINC 77399-4
Screening And Target Amplification Method
Cervical Cancer Human Papilloma Virus 18 Dna [presence] In Cervix By Probe
LOINC 77400-0
Screening And Target Amplification Method
Cervical Cancer Human Papilloma Virus 16 And 18+45 E6+e7 Mrna [identifier]
LOINC 82354-2
Screening In Cervix By Probe And Target Amplification Method
Cervical Cancer Human Papilloma Virus 16 E6+e7 Mrna [presence] In Cervix By
LOINC 82456-5
Screening Probe And Target Amplification Method
Human Papilloma Virus 16+18+31+33+35+39+45+51+52+56
Cervical Cancer
LOINC 82675-0 +58+59+66+68 Dna [presence] In Cervix By Probe And Target
Screening
Amplification Method
• Members who meet any of the following criteria are excluded:
1. Members who have had a hysterectomy with no residual cervix, cervical agenesis
or acquired absence of cervix any time during their history through December 31,
2018 may be excluded.
To exclude Members who meet the exclusion criteria, please complete Member
Historical Data Form and fax to IEHP’s Quality Informatics Team at: 909-477-8568.
A copy of the Historical Data Form is available in Appendix 3.
2. Members in hospice are excluded.
Denominator: Women 24-64 years of age who met the criteria for eligible population.
Numerator: Women in the denominator who received a timely screen for cervical cancer.
26Timeliness of Prenatal Care (PPC)
Methodology: HEDIS®
Measure Description: The percentage of deliveries of live births on or between November 6,
2017 and November 5, 2018 that received a prenatal care visit as a Member of the organization
in the first trimester on the enrollment start date or within 42 days of enrollment in the
organization.
• The eligible population in this measure meets all of the following criteria:
1. Continuous enrollment 43 days prior to delivery through 56 days after delivery with
no allowable gap.
2. Member who delivered a live birth on or between November 6 of the year prior to
the measurement year (2017) and November 5 of the measurement year (2018).
Include women who delivered in any setting. Multiple births - Women who had
two separate deliveries (different dates of service) between November 6 of the year
prior to the measurement year (2017) and November 5 of the measurement year
(2018) count twice. Women who had multiple live births during one pregnancy
count once.
CODES TO IDENTIFY STAND ALONE PRENATAL VISITS
Service Code Type Code Code Description
Prenatal Visit CPT 0500F Initial Prenatal Care Visit
Prenatal Visit CPT 0501F Prenatal Flow Sheet
Prenatal Visit CPT 0502F Subsequent Prenatal Care Visit
Prenatal Visit CPT 99500 Home Visit Prenatal
Prenatal Visit HCPCS H1000 Prenatal Care, At-risk Assessment
Prenatal Visit HCPCS H1001 Prenatal Care, At-risk Enhanced Service; Antepartum Management
Prenatal Visit HCPCS H1002 Prenatal Care, At Risk Enhanced Service; Care Coordination
Prenatal Visit HCPCS H1003 Prenatal Care, At-risk Enhanced Service; Education
Prenatal Visit HCPCS H1004 Prenatal Care, At-risk Enhanced Service; Follow-up Home Visit
Prenatal Visit HCPCS Z1032 Initial Antepartum Office Visit
Prenatal Visit HCPCS Z1034 Antepartum Follow-Up Visit
Prenatal care visit to an OB/GYN or other prenatal care practitioner or PCP. For visits to a
PCP, a diagnosis of pregnancy must be present. Documentation in the medical record must
include a note indicating the date when the prenatal care visit occurred, and evidence of one
of the following.
• A basic physical obstetrical examination that includes auscultation for fetal heart tone,
or pelvic exam with obstetric observations, or measurement of fundus height
(a standardized prenatal flow sheet may be used).
27• Evidence that a prenatal care procedure was performed, such as: – Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), OR – TORCH antibody panel alone, OR – A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, OR – Echography of a pregnant uterus. • Documentation of LMP or EDD in conjunction with either of the following. – Prenatal risk assessment and counseling/education. – Complete obstetrical history. • Members in hospice are excluded. Denominator: Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). Numerator: Members in the denominator who had a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Postpartum Care (PPC) Methodology: HEDIS® Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that had a postpartum visit on or between 21 and 56 days after delivery. • The eligible population in this measure meets all of the following criteria: 1. Continuous enrollment 43 days prior to delivery through 56 days after delivery with no allowable gap. 2. Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). This includes women who delivered in any setting. Multiple births - Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018) count twice. Women who had multiple live births during one pregnancy count once. 28
CODES TO IDENTIFY POSTPARTUM CARE
Service Code Type Code Code Description
Postpartum
CPT 57170 Diaphragm Or Cervical Cap Fitting With Instructions
Care
Postpartum
CPT 58300 Insertion Of Intrauterine Device (iud)
Care
Postpartum
CPT 59430 Postpartum Care Only (separate Procedure)
Care
Postpartum
CPT 99501 Home Visit Postnatal
Care
Postpartum
CPT-CAT-II 0503F Postpartum Care Visit
Care
Postpartum Cervical Or Vaginal Cancer Screening; Pelvic And Clinical Breast
HCPCS G0101
Care Examination (g0101)
Postpartum [z01.411] Encounter For Gynecological Examination (general)
ICD10CM Z01.411
Care (routine) With Abnormal Findings
Postpartum [z01.419] Encounter For Gynecological Examination (general)
ICD10CM Z01.419
Care (routine) Without Abnormal Findings
Postpartum [z01.42] Encounter For Cervical Smear To Confirm Findings Of
ICD10CM Z01.42
Care Recent Normal Smear Following Initial Abnormal Smear
Postpartum [z30.430] Encounter For Insertion Of Intrauterine Contraceptive
ICD10CM Z30.430
Care Device
Postpartum
ICD10CM Z39.1 [z39.1] Encounter For Care And Examination Of Lactating Mother
Care
Postpartum
ICD10CM Z39.2 [z39.2] Encounter For Routine Postpartum Follow-up
Care
Postpartum
HCPCS Z1038 Postpartum Follow-Up Office Visit
Care
• Members in hospice are excluded.
Denominator: Members who delivered a live birth on or between November 6 of the year
prior to the measurement year (2017) and November 5 of the measurement year (2018).
Numerator: Members in the denominator who had a postpartum visit on or between 21 and
56 days after delivery.
29Population: Child
Childhood Immunizations (CIS) – Combo 10
Methodology: HEDIS®
Measure Description: The percentage of children 2 years of age who had four diphtheria,
tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella
(MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox
(VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus
(RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for
each vaccine and one combination rate.
• Combo 10 includes the timely completion of the following antigens:
- DTaP; IPV; MMR; HiB; HepB; VZV; PCV; HepA; Rotavirus; Flu
• The eligible population in this measure meets all of the following criteria:
1. Children who turn 2 years of age during the measurement year (2018).
2. Continuous enrollment 12 months prior to the child’s second birthday with no
more than one gap in enrollment of up to 45 days during the 12 months prior to
the child’s second birthday.
CHILDHOOD IMMUNIZATION CODE SET:
Antigen Code Type Code Code Description
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And
DTaP CPT 90698 Hemophilus Influenza B Vaccine And Activated Poliovirus Vaccine,
(DTaP-IPV/Hib), For Intramuscular Use
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine (dta P) For
DTaP CPT 90700
Intramuscular Use
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And
DTaP CPT 90721
Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use
Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and
DTaP CPT 90723
Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular Use
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And
IPV CPT 90698 Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP-
IPV/Hib), For Intramuscular Use
IPV CPT 90713 Poliovirus Vaccine Inactivated (ipv) For Subcutaneous Use
Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and
IPV CPT 90723
Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular Use
Measles Mumps And Rubella Virus Vaccine (mmr) Live For Subcuta
MMR CPT 90707
Neous Use
30CHILDHOOD IMMUNIZATION CODE SET:
Antigen Code Type Code Code Description
Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For
MMR CPT 90710
Subcutaneous Use
Meningococcal Conjugate Vaccine, Serogroups C & Y And Hemophilus
HiB CPT 90644 Influenzae Type B Vaccine (hib-mency), 4 dose schedule, When
Administered to children 6 wks to 18 mos of age, for intramuscular use
Hemophilus Influenza B Vaccine (hib) Hboc Conjugate (4 Dose Schedule)
HiB CPT 90645
For Intramuscular Use
Hemophilus Influenza B Vaccine (hib) Prp-d Conjugate For Booster Use
HiB CPT 90646
Only Intramuscular Use
Hemophilus Influenza B Vaccine (hib) Prp-omp Conjugate
HiB CPT 90647
(3 Dose S Chedule) For Intramuscular Use
Hemophilus Influenza B Vaccine (hib)prp-t Conjugate
HiB CPT 90648
(4 Dose Sche Dule) For Intramuscular Use
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And
HiB CPT 90698 Hemophilus Influenza B Vaccine and activated poliovirus vaccine,
(DTaP-IPV/Hib), for intramuscular use
Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And
HiB CPT 90721
Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use
Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For
HiB CPT 90748
Intramuscular Use
Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and
HepB CPT 90723
Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular use
Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage (3
HepB CPT 90740
Dose Schedule) For Intramuscular Use
Hepatitis B Vaccine Pediatric/adolescent Dosage (3 Dose Schedule )
HepB CPT 90744
For Intramuscular Use
Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage
HepB CPT 90747
(4 Dose Schedule) For Intramuscular Use
Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For
HepB CPT 90748
Intramuscular Use
HepB HCPCS G0010 Administration Of Hepatitis B Vaccine (g0010)
Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For
VZV CPT 90710
Subcutaneous Use
VZV CPT 90716 Varicella Virus Vaccine Live For Subcutaneous Use
Pneumococcal Conjugate Vaccine Polyvalent For Children Under Five
PCV CPT 90669
Years For Intramuscular Use
PCV CPT 90670 Pneumococcal Conjucate Vaccine 13 Valent For Intramuscular Use
PCV HCPCS G0009 Administration Of Pneumococcal Vaccine (g0009)
Hepatitis A Vaccine Pediatric/adolescent Dosage-2 Dose Schedule For
HepA CPT 90633
Intramuscular Use
Rotavirus
CPT 90681 Rotavirus Vaccine Human Attenuated 2 Dose Schedule Live For Oral Use.
- 2 Dose
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