Integrated Healthcare Association California Pay for Performance Program Final
Integrated Healthcare Association California Pay for Performance Program Final Measurement Year 2012 P4P Manual Updated November 30, 2012 These performance measures, specifications and guidance for evaluating performance are developed and owned by the National Committee for Quality Assurance (NCQA) and the Integrated Healthcare Association (IHA). These materials are not clinical guidelines and do not establish a standard of medical care. NCQA and IHA make no representations, warranties or endorsement about the quality of any organization or physician that uses or reports these materials, and have no liability to anyone who relies on the materials. NCQA and IHA hold a copyright for these materials and may rescind or alter them at any time. These materials may only be modified by NCQA or IHA. Anyone desiring to use or reproduce the materials for noncommercial use, without modification, may do so without obtaining approval from NCQA and IHA. Commercial use must be approved by NCQA and IHA and is subject to a license at the discretion of NCQA and IHA. © 2012 National Committee for Quality Assurance and Integrated Healthcare Association, all rights reserved. This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of submitting data for the Integrated Healthcare Association's Pay for Performance (P4P) Program. National Committee for Quality Assurance 1100 13th Street, NW, Suite 1000 Washington, DC 20005 All rights reserved. Printed in the U.S.A. Table of Contents Table of Contents Overview P4P Background ............................................................................................................................................ 1 Measure Set Evolution and Priorities ............................................................................................................ 1 Medicare Measurement and Reporting ......................................................................................................... 2 Key Organizations Involved in P4P Data Collection, Aggregation and Reporting ........................................ 2 P4P Data Aggregation ................................................................................................................................... 3 P4P Participation and Use of Results ........................................................................................................... 4 Key Dates for MY 2012 Corrections .............................................................................................................. 6 P4P Data Collection and Reporting Timeline ................................................................................................ 7 What’s in P4P MY 2012? ............................................................................................................................... 8 If You Have Questions About the Specifications ......................................................................................... 14 General Guidelines for Data Collection and Reporting Reporting Options ........................................................................................................................................ 16 Encounter/Claims Submission ..................................................................................................................... 17 P4P Reporting ............................................................................................................................................. 17 Required Enrollment Periods and Benefits ................................................................................................. 21 Guidelines for Data Submission and Reporting .......................................................................................... 23 Data Collection ............................................................................................................................................ 23 Coding Conventions .................................................................................................................................... 28 P4P Data Submission .................................................................................................................................. 31 The P4P Audit Review ................................................................................................................................. 32 C,M Clinical Domain Technical Specifications Overview ...................................................................................................................................................... 36 Encounter Rate for Clinical Measures C ENRST Encounter Rate by Service Type ............................................................................................. 38 M AAP Adults’ Access to Preventive/Ambulatory Health Services ...................................................... 43 Cardiovascular C MPM Annual Monitoring for Patients on Persistent Medications ...................................................... 45 CMC Cholesterol Management for Patients With Cardiovascular Conditions .................................... 50 C,M LDL Screening C LDL Control (<100) PDC Proportion of Days Covered by Medications ............................................................................. 54 C,M Renin Angiotensin System (RAS) Antagonists C,M Statins Diabetes PDC Proportion of Days Covered by Medications ............................................................................ 54 C,M Oral Diabetes Medications ____________ C Commercial measure Medicare measure M November 30, 2012 Measurement Year 2012 P4P Manual Table of Contents CDC Diabetes Care ........................................................................................................................... 60 C HbA1c Testing C,M HbA1c Poor Control (>9.0%) C HbA1c Control (<8.0%) C HbA1c Control (<7.0%) for a selected population M Eye Exam C,M LDL-C Screening C,M LDL-C Control (<100 mg/dL) C,M Nephropathy Monitoring C Blood Pressure Control (<140/90 mm Hg) C Optimal Diabetes Care Musculoskeletal C LBP Use of Imaging Studies for Low Back Pain ............................................................................. 76 M ART Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis ........................... 79 M OMW Osteoporosis Management in Women Who Had a Fracture .................................................. 82 Prevention C CIS Childhood Immunization Status ............................................................................................... 86 C IMA Immunizations for Adolescents ............................................................................................... 90 C HPV Human Papillomavirus Vaccine for Female Adolescents ........................................................ 92 C CHL Chlamydia Screening in Women ............................................................................................. 94 C ECS Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women ......... 98 C,M BCS Breast Cancer Screening ................................................................................................... 103 C,M COL Colorectal Cancer Screening ............................................................................................. 106 M ABA Adult BMI Assessment ......................................................................................................... 108 M GSO Glaucoma Screening in Older Adults .................................................................................... 110 Respiratory C AMR Asthma Medication Ratio ...................................................................................................... 112 C CWP Appropriate Testing for Children With Pharyngitis ................................................................ 118 C URI Appropriate Treatment for Children With Upper Respiratory Infection ................................. 122 C AAB Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis ..................................... 126 Utilization M PCR All-Cause Readmissions ....................................................................................................... 131 C Meaningful Use of Health IT Domain Overview ............................................................................................................................................... 143 Description ............................................................................................................................................ 144 Who We Measure .................................................................................................................................. 144 Domain Structure ................................................................................................................................... 144 Computing the Results........................................................................................................................... 145 Administrative Policies .......................................................................................................................... 146 ____________ C Commercial measure Medicare measure M Measurement Year 2012 P4P Manual November 30, 2012 Table of Contents Measures in Meaningful Use of Health IT ................................................................................................. 147 PO Denomnator. ................................................................................................................................. 148 Measure 1: Use computerized provider order entry (CPOE) ............................................................ 149 Measure 2: Implement drug-drug and drug-allergy interaction checks ............................................ 150 Measure 3: Maintain an up-to date problem list of current and active diagnoses ............................ 151 Measure 4: Generate and transmit permissible prescriptions electronically (eRx) .......................... 152 Measure 5: Maintain active medication list ....................................................................................... 153 Measure 6: Maintain active medication allergy list ........................................................................... 154 Measure 7: Record demographics: preferred language, gender, race, ethnicity, date of birth ........ 155 Measure 8: Record and chart changes in vital signs ........................................................................ 156 Measure 9: Record smoking status for patients 13 years old or older ............................................. 157 Measure 10: Report ambulatory clinical quality measures ................................................................. 158 Measure 11: Implement one clinical decision support rule ................................................................. 159 Measure 12: Provide patients with an electronic copy of their health information .............................. 160 Measure 13: Provide clinical summaries for patients for each office visit .......................................... 161 Measure 14: Capability to exchange key clinical information ............................................................. 162 Measure 15: Protect electronic health information created or maintained by the certified EHR technology ...................................................................................................................... 163 Measures 16–20: Any five CMS/ONC menu set measures................................................................ 164 Measure 21: Chronic care management for diabetes, depression and one other clinically important condition ......................................................................................................................... 171 Attestation of Accuracy. ...................................................................................................................... 174 C Patient Experience Domain Overview................................................................................................................................................. 176 Description.............................................................................................................................................. 176 Participation ............................................................................................................................................ 170 PO Requirements ................................................................................................................................... 177 Performance Areas ................................................................................................................................ 178 Doctor-Patient Interaction Composite for PCPs Doctor-Patient Interaction Composite for Specialists Coordination of Care Composite Timely Care and Service Composite for PCPs Timely Care and Service Composite for Specialists Overall Ratings of Care Composite Office Staff Composite Health Promotion Composite Specifications: Patient Population Surveyed .......................................................................................... 180 Sampling................................................................................................................................................. 180 Fielding Surveys ..................................................................................................................................... 181 Response File Preparation ..................................................................................................................... 181 Analysis of Survey Data ......................................................................................................................... 181 Reports ................................................................................................................................................... 182 For More Information .............................................................................................................................. 182 ____________ C Commercial measure Medicare measure M November 30, 2012 Measurement Year 2012 P4P Manual Table of Contents C,M Appropriate Resource Use Domain Overview ................................................................................................................................................ 184 C IRN Inpatient Readmissions Within 30 Days ................................................................................. 187 C IPU Inpatient Utilization—Acute Care Discharges ......................................................................... 191 C IPBD Inpatient Utilization—Bed Days .............................................................................................. 195 C OSU Outpatient Procedures Utilization—Percentage Done in Preferred Facility ........................... 199 C EDV Emergency Department Visits ................................................................................................. 202 C GRX Generic Prescribing ................................................................................................................. 205 C TCC Total Cost of Care ................................................................................................................... 208 C FSP Frequency of Selected Procedures ......................................................................................... 211 M PCR All-Cause Readmissions ......................................................................................................... 214 C,M Relative Improvement Overview ................................................................................................................................................ 216 Testing Measures Overview ................................................................................................................................................ 218 CIS Childhood Immunization Status: Hepatitis A.... .......................................................................... 219 C HPV HPV Testing in Male Adolescents ............................................................................................ 221 C UNC Unexpected Newborn Complications ....................................................................................... 223 C LBW Infant Under 1500 gm Delivered at Appropriate Level of Care ................................................ 226 C EPS Incidence of Episiotomy ............................................................................................................ 228 C CSX Cesarean Section Rate for Low-Risk Birth .............................................................................. 230 C VBC Vaginal Birth After Cesarean Delivery Rate ............................................................................. 233 C PCR All-Cause Readmissions ........................................................................................................... 235 M COA Care for Older Adults ................................................................................................................ 236 MY 2012 P4P Summary of Changes Table of Summary of Changes .............................................................................................................. 239 ____________ C Commercial measure Medicare measure M Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview 1 Overview P4P Background The California Pay for Performance (P4P) program is the largest non-governmental physician incentive program in the United States. Founded in 2001, it is a statewide initiative managed by the Integrated Healthcare Association (IHA) on behalf of eight health plans representing nearly 10 million insured persons. IHA is responsible for collecting data, deploying a common measure set and reporting results for approximately 35,000 physicians in about 200 physician organizations (PO). This program represents the longest running U.S. example of data aggregation and standardized results reporting across diverse regions and multiple health plans. California consumers benefit from the availability of standardized performance results from a common measure set, available to the public through the State of California, Office of the Patient Advocate (OPA) Health Care Quality Report Card. In July 2000, IHA convened health care stakeholders to address and coordinate statewide efforts to measure and improve clinical quality, patient experience, use of information technology, and publicly report provider performance results. Three goals resulted: 1. Measure PO performance using a common set of key measures that rely on national standards or on evidence-based medical practices. 2. Aggregate members from different health plans to increase PO sample sizes for credible public reporting, thereby helping consumers make informed provider choices. 3. Performance-based health plan incentive payments to POs based on aggregated results. The planning phase and design of actual measures for a statewide P4P initiative were completed in late 2001. By January 2002, IHA stakeholders had developed a compelling vision for a collaborative initiative and a blueprint to secure health plan sponsorship. Funding and leadership by the California HealthCare Foundation (CHCF) were important contributions to the formation and early operation of the program. Leading physician organizations then appealed to major California health plans to adopt a uniform set of quality performance measures and a single public report card. After much consensus-building, six health plans endorsed the initiative: Aetna, Blue Cross of California (now Anthem Blue Cross), Blue Shield of California, Cigna HealthCare of California, Health Net, and PacifiCare (now UnitedHealthcare). The group was later joined by Western Health Advantage and Kaiser Permanente (public reporting only). P4P Measure Set Evolution and Priorities Since 2003, IHA has had an established common measure set for the P4P program, accompanied by standard processes, procedures and timelines for updating the measure set. IHA seeks to evolve the P4P measure set to reflect the changes in the healthcare environment. Specifically, IHA aims to ensure that the measure set: Assesses aspects of care that are most relevant to stakeholders. Reflects the move toward more coordinated, integrated team care, such as in-patient centered medical homes and ACOs. Incorporates new measures and new methods (e.g., EHRs, HIEs) as they are adopted. Incorporates cost, resource use and quality. Moves toward defining measurement suites for defined clinical areas that include measures of clinical quality, outcomes, patient experience and cost/efficiency of care. November 30, 2012 Measurement Year 2012 P4P Manual 2 MY 2012 P4P Overview Three strategies and three tactics have been identified to guide the evolution of the P4P measure set. The strategies maximize the established collaborative environment, strengthen/integrate the measure set and encourage improvement in measure results. The tactics conduct active surveillance and seek broad input for measures; identify and implement measures of specialty care; and expand and integrate measures of cost and efficiency of care. In short, IHA seeks to ensure that the P4P measure set continues to provide stakeholders with the most relevant, meaningful, valuable, effective information on health care quality and resource use, and that it does so in the most efficient way possible. Medicare Measurement and Reporting Introduction of the Centers for Medicare & Medicaid Services (CMS) Star Rating incentive program for Medicare Advantage plans prompted expansion of PO-level performance measurement and reporting to the Medicare Advantage population. While CMS’ Star Rating program reports at the plan level, plans felt that measuring the same indicators at the PO level would be more actionable for quality improvement. The HEDIS-based Star measure results are collected, aggregated and reported at the PO level using the same process as for the commercial P4P program. Each measure specification indicates whether the measure is for commercial or for Medicare Advantage, or both. Medicare Advantage results will be publicly reported, and health plans may choose to use the results as the basis of performance incentive payments, although no standard P4P program for Medicare Advantage currently exists. Key Organizations Involved in P4P Data Collection, Aggregation and Reporting IHA NCQA The Integrated Healthcare Association manages P4P and convenes all relevant committees. IHA arranges for all necessary services, including measure development, data aggregation and publication of the results in a public report card. The National Committee for Quality Assurance develops and maintains the clinical measures and audit methodologies, aggregates all clinical data across health plans for each PO, evaluates and audits Meaningful Use of Health IT domain Survey Tool responses and reports results to all parties. The majority of clinical quality measures are ®1 adapted from the NCQA Healthcare Effectiveness Data and Information Set (HEDIS) measures, the most widely used set of performance measures in the managed care industry. NCQA is a nonprofit organization committed to assessing, reporting on and improving the quality of care provided by organized delivery systems. TransUnion HealthCare TransUnion HealthCare (formerly the Diversified Data Design Corporation, a subsidiary of TransUnion LLC), helps NCQA collect clinical data from POs and health plans. PBGH/ CCHRI The Pacific Business Group on Health, which operates the California Cooperative Healthcare Reporting Initiative, administers the Patient Assessment Survey (PAS), which is used to measure performance in P4P’s Patient Experience domain. PBGH reports relevant PAS results to NCQA for inclusion in the P4P reports. Truven Truven Health Analytics (formerly Thomson Reuters) helps develop and maintain the Appropriate Resource Use (ARU) and Total Cost of Care (TCC) measures; collects and standardizes claims, encounter and eligibility data from health plans; aggregates data across health plans for each PO and calculates the ARU and TCC measures; and creates reports for all parties. ____________ 1 ® HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview OPA 3 The Office of the Patient Advocate is an independent state office created to represent the interests of health plan members in getting the care they deserve and to promote transparency and quality health care. OPA uses P4P results as the basis of its annual Medical Group Quality of Care Report Card, at http://www.opa.ca.gov. P4P Data Aggregation NCQA responsibilities Supports IHA in establishing the process for quality data collection and reporting. Collects clinical results from P4P health plans and self-reporting POs (via TransUnion HealthCare). Validates and reviews P4P audited results from health plans and self-reporting POs to ensure that only audited data are used. Combines and aggregates health plan numerators and denominators for each clinical measure to create aggregated PO performance scores for each PO. Compares PO self-reported clinical measure submissions with aggregated health plan submissions, selecting and reporting the higher rates. Calculates relative PO improvement scores for each measure whose specifications did not change from the previous year. Calculates attainment points, improvement points, domain scores, and a Quality Composite Score to support the P4P-recommended standard payment methodology and Value Based P4P. Collects Meaningful Use of Health IT surveys and accompanying documentation. Combines clinical data with available data from PAS, the Meaningful Use of Health IT domain and improvement scores into a complete report for each PO and health plan. Calculates data distributions using relative thresholds. Produces and disseminates preliminary PO quality results to each PO and health plan. Supports a Quality Results Questions and Appeals period, giving POs an opportunity to review initial health plan and self reported results for Clinical, Meaningful Use of Health IT, Patient Experience and Relative Improvement before results are finalized. Works with the health plans, P4P auditors and POs to review and resolve questions asked during the Quality Results Questions and Appeals period, and to coordinate resubmissions as appropriate. Recalculates scores as needed, and produces and disseminates final PO quality results to each PO and health plan and to the report card vendor. Truven responsibilities Supports IHA in establishing the process for data collection and reporting for ARU and TCC measures. Develops health plan file specifications. Collects, standardizes and data quality checks enrollment, claims, encounter and lump-sum cost data from health plans for each contracted PO that signed a P4P Consent to Disclosure Agreement. Produces PO-level results for ARU and TCC, applying risk adjustment and outlier methodologies, where appropriate, and disseminates preliminary results to each PO and health plan. November 30, 2012 Measurement Year 2012 P4P Manual 4 MY 2012 P4P Overview Supports a Questions and Appeals period, giving health plans and POs an opportunity to address issues regarding ARU and TCC results before they are finalized. Works with health plans and POs to review and resolve questions asked during the Questions and Appeals period, and coordinates corrections as appropriate. Calculates summary statistics and distributions of ARU and TCC results using relative thresholds. Produces final PO-level results for ARU and TCC and disseminates to each PO and health plan. P4P Participation and Use of Results The IHA P4P program measures all POs in California—regardless of specialty or geographic area—that contract with one or more of eight health plans participating in the IHA P4P program to provide care for their commercial HMO or POS members . P4P results for each PO are aggregated across participating health plans, and are intended to be used as the basis for health plan quality incentive payments and public reporting, and in determining P4P public recognition award winners. P4P produces results across four domains: Clinical, Meaningful Use of Health IT, Patient Experience and Appropriate Resource Use. Domains use these data sources: Clinical domain results are calculated and submitted by health plans contracting with each PO, and/or by self-reporting POs. Meaningful Use of Health IT domain data are collected directly from POs by NCQA. Patient Experience domain data are collected via the Patient Assessment Survey (PAS) and processed by the Center for the Study of Systems (CSS) on behalf of CCHRI. ARU domain results are calculated by Truven using data submitted by health plans contracting with each PO. Domains and Reporting Entities Domain Clinical Meaningful Use of Health IT Patient Experience Appropriate Resource Use Health Plans Report POs Voluntarily Self-Report CSS/CCHRI * Truven *POs voluntarily participate in the Patient Experience domain, and must register with CCHRI to confirm participation. All POs that contract for commercial HMO or POS members with one or more health plans participating in P4P are eligible for P4P. POs must sign the P4P Consent to Disclosure Agreement to confirm their participation in P4P. No data are collected or reported for POs that have not signed a Consent to Disclosure Agreement. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview 5 P4P generates several reports of PO measurement results. PO Report Types, Content and Uses Report Type PO Quality Preliminary Report (commercial) PO Quality Preliminary Report (Medicare) PO Quality Final Report (commercial) PO Quality Final Report (Medicare) PO Appropriate Resource Use Preliminary Report PO Appropriate Resource Use Final Report PO Total Cost of Care Preliminary Report PO Total Cost of Care Final Report Aggregated Results Questions, Issues and Appeals Accepted * * Reflects changes** Reflects changes** Reflects changes** Reflects changes** Health Plan Incentive Payment Public Reporting * Quality Preliminary Reports contain both plan-specific and aggregated results. ARU Preliminary and Final Reports contain both plan-specific and aggregated results. ** Reflects changes identified and addressed during the results Questions and Appeals periods. P4P provides health plans with P4P measurement results for commercial HMO or POS members,for each PO they are contracted with (if the PO signed the P4P Consent to Disclosure Agreement). Health Plan Report Types, Content and Uses Report Type Health Plan Quality Preliminary Report (commercial) Health Plan Quality Preliminary Report (Medicare) Health Plan Quality Final Report (commercial) Health Plan Quality Final Report (Medicare) Health Plan Appropriate Resource Use Preliminary Report Health Plan Appropriate Resource Use Final Report Health Plan Total Cost of Care Preliminary Report Health Plan Total Cost of Care Final Report Aggregated Results Questions, Issues and Appeals Appeals Accepted Reflects changes* Reflects changes* Reflects changes* Reflects changes* Health Plan Incentive Payment Public Reporting *Reflects changes addressed during the results Questions and Appeals periods. November 30, 2012 Measurement Year 2012 P4P Manual 6 MY 2012 P4P Overview P4P strives to improve PO and health plan reports each year, and we welcome your comments. We are particularly interested in feedback on the reports’ usefulness to your organization. Please send feedback to [email protected]. P4P staff will consider all comments and discuss them with P4P committees, as appropriate. Key Dates for MY 2012 Results Corrections IHA is committed to providing POs and health plans an opportunity to review their P4P results and to submit questions and requests for changes if they believe any of their results are in error. The same process and time frame are used for each set of P4P results (Quality, Appropriate Resource Use, Total Cost of Care). The full timeline for reviewing P4P results and requesting corrections or changes is documented in the Data Collection and Reporting Timeline. P4P program staff encourage participants to seek corrections and additional information throughout the measurement cycle. Organizations have at least 21 days to review preliminary results. Corrections or changes to results may be requested from the first date when the PO Preliminary Reports become available, through the last date of the Results Questions and Appeals Periods. Detailed instructions on how to submit an appeal are provided before the Quality and Appropriate Resource Use Results Questions and Appeals Periods. Quality preliminary reports are released on June 3, 2013, and the final date to submit an appeal is June 24, 2013. IHA and NCQA work with health plans, CCHRI and NCQA auditors to answer PO questions about results provided in the PO Quality Preliminary Reports. ARU Preliminary Reports are released on June 28, 2013, and the final date to submit an appeal is July 19, 2013. IHA and Truven work with health plans to answer PO questions about results provided in the PO Appropriate Resource Use Preliminary Report. Total Cost of Care Preliminary Reports are released June 28, 2013, and the final date to submit an appeal is July 19, 2013. IHA and Truven work with health plans to answer PO questions about results provided in the PO Total Cost of Care Preliminary Report. If questions and requests are not addressed to the satisfaction of the organization submitting it, an appeal may be submitted any time during the results Questions and Appeals Period. The burden of evidence is the responsibility of the organization submitting the appeal. A multi-stakeholder appeals review panel will consider the evidence presented, and make a binding determination on the appeal. POs and health plans must comply with the determination of the Appeals Review Panel, including resubmission of data, if necesary. No further reconsideration is available. The P4P program process requires a firm deadline to finalize results for all participants and share them with health plans for payout, and with OPA for public reporting. Although late requests for additional data submission or reconsideration of results will be acknowledged, they will not be incorporated into the report. An exception may be made if the data aggregator (NCQA or Truven) made an error that was discovered after the deadline. Throughout the measurement cycle, participants can request additional information or clarification on program processes and methodology by contacting the appropriate P4P contact listed on the IHA Web site: http://www.iha.org/contact.php/. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview 7 P4P Data Collection and Reporting Timeline The timeline includes major milestones in the P4P Quality, Appropriate Resource Use, and Total Cost of Care data collection and reporting processes. It ensures that data are as complete as possible, as early as possible, to maximize administrative reporting for P4P. General P4P Program Dates Activity or Milestone Updated MY 2012 Manual: Updated P4P MY 2012 Manual posted to IHA Web site. Summary of Proposed Changes for MY 2013: Posted to IHA Web site for Public Comment. P4P Public Comment: P4P accepts Public Comments. Declaration of Intent to Participate: POs submit their declaration of intent to participate in the P4P program. Final MY 2012 Manual: Final P4P MY 2012 Manual posted to the IHA Web site. Time Frame or Deadline September 4, 2012 September 4, 2012 September 4–October 1, 2012 October 1–31, 2012 November 30, 2012 Quality (Clinical, Meaningful Use of Health IT, Patient Experience Domains) Activity or Milestone PAS: Application process for participating POs begins. Auditors Guideline: P4P MY 2012 Auditors Guideline and MY 2012 NDC lists posted to NCQA and IHA Web site. Data Submission File Layout: MY 2012 data submission file layout posted to NCQA and IHA Web sites. E-mail notification will also be sent out to health plans and self-reporting POs notifying them of the most recent postings. Q1-Q4 Encounter Data: POs that use TransUnion HealthCare as the encounter data intermediary must submit all remaining Q4 2012 encounter data to TransUnion HealthCare. POs that use a different data intermediary or supply encounters directly to health plans should confirm the final acceptance date of encounter data to be included in P4P reporting. Meaningful Use of Health IT: Online tool and corresponding documentation completed. Data Layout Test Files: Self-reporting POs and health plans submit data layout test files to TransUnion HealthCare. Submission Files to Auditors: Self-reporting POs and health plans send submission files to auditors. Auditor-Locked P4P Results: Self-reporting POs and health plans submit auditor-locked P4P clinical results to TransUnion HealthCare. Health plans must submit results for all clinical measures for each contracted PO with a signed P4P Consent to Disclosure Agreement. PO Quality Preliminary Reports: NCQA posts POs’ quality preliminary reports on the P4P log-in page (p4p.ncqa.org). Health Plan Quality Preliminary Reports: NCQA posts health plan quality preliminary reports on the P4P log-in page (p4p.ncqa.org). Quality Results Questions and Appeals Period: IHA and NCQA work with POs and Health Plans to address any data issues or questions related to quality results. Plans and POs may submit an appeal during this time. June 3–9: POs submit initial questions to IHA/NCQA. June 10–16: IHA and NCQA work with health plans and applicable vendors to research and respond to PO questions. June 16–24: Back-and-forth between POs, IHA, NCQA, and health plans to resolve questions or escalate to an appeal. Quality Appeals Hearing: The P4P Appeals Panel reviews and decides on all appeals to change quality results, if needed. Resubmission of Auditor-Locked P4P Results: Self-reporting POs and health plans submit auditor-locked P4P clinical results to TransUnion HealthCare, if needed. Health Plan Quality Final Report: NCQA releases quality final reports to health plans. PO Quality Final Report: NCQA posts POs’ quality final reports on the P4P log-in page (p4p.ncqa.org). November 30, 2012 Time Frame or Deadline September 6, 2012 November 15, 2012 January 2, 2013 February 18, 2013 February 1–March 1, 2013 March 22–May 2, 2013 May 6, 2013 May 10, 2013 June 3, 2013 June 6, 2013 June 3–24, 2013 June 27, 2013 July 3, 2013 July 11, 2013 July 19, 2013 Measurement Year 2012 P4P Manual 8 MY 2012 P4P Overview Appropriate Resource Use Activity or Milestone Appropriate Resource Use (ARU) Data Submission: Health plans submit final files of claims, encounter and eligibility data to Truven for each contracted PO with a signed P4P Consent to Disclosure Agreement. Health Plan Appropriate Resource Use Preliminary Report: Truven releases ARU preliminary reports to health plans. PO Appropriate Resource Use Preliminary Report: NCQA posts POs’ ARU preliminary reports on the P4P log-in page (p4p.ncqa.org). ARU Results Questions and Appeals Period: IHA and Truven work with POs and health plans to address any questions or issues related to ARU results. Health Plan Appropriate Resource Use Final Report: Truven releases ARU final reports to health plans. PO Appropriate Resource Use Final Report: NCQA posts POs’ ARU final reports on the P4P log-in page (p4p.ncqa.org). Time Frame or Deadline May 17, 2013 June 28, 2013 June 28, 2013 June 28–July 19, 2013 July 30, 2013 August 9, 2013 Total Cost of Care Activity or Milestone Total Cost of Care Data Submission: Health plans submit to Truven final files of lump sum payment amount for each member of contracted POs with a signed P4P Consent to Disclosure Agreement. Health Plan Total Cost of Care Preliminary Report: Truven releases TCC preliminary reports to health plans. PO Total Cost of Care Preliminary Report: NCQA posts POs’ TCC preliminary reports on the P4P log-in page (p4p.ncqa.org). TCC Results Questions and Appeals Period: IHA and Truven work with POs and health plans to address any questions or issues related to TCC results. Health Plan Total Cost of Care Final Report: Truven releases TCC final reports to health plans. PO Total Cost of Care Final Report: NCQA posts POs’ TCC final reports on the P4P log-in page (p4p.ncqa.org). Time Frame or Deadline May 31, 2013 June 28, 2013 June 28, 2013 June 28–July 19, 2013 July 30, 2013 August 9, 2013 What’s in P4P MY 2012? Clinical Domain The P4P clinical measures are both HEDIS based and non-HEDIS based for measurement at the PO level. Health plans and self-reporting POs report data for the Clinical domain. Each participating health plan submits clinical results for each of its contracted POs that serve commercial HMO and POS members. POs may also voluntarily choose to self-report their own clinical results for one or more clinical measures. All clinical results must be audited to ensure that results are an accurate reflection of PO performance. Audit review of the P4P clinical measures is based on NCQA’s HEDIS Compliance Audit™ program. NCQA staff work with P4P participants to incorporate the relevant components of the HEDIS Compliance Audit, adapt policies and procedures where necessary and enhance the process based on previous years’ experience. Because this program is an adaptation, it is considered a P4P audit review. The MY 2012 P4P Audit Review Guidelines manual for Measurement Year (MY) 2012 is scheduled for release in November 2012. NCQA aggregates data across health plans and compares the data with data from self-reporting POs (where applicable), selecting and reporting the higher rate for each measure. The MY 2012 measure set for payment and public reporting in 2013 includes the following measures. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview 9 Commercial Measures Encounter Rate Cardiovascular Encounter Rate by Service Type (ENRST). Note: ENRST will not be reported, but may be used by health plans as a requirement for PO incentive payments. Annual Monitoring for Patients on Persistent Medications (MPM). Cholesterol Management for Patients With Cardiovascular Conditions (CMC)— LDL Screening and Control (<100). Proportion of Days Covered by Medications (PDC)—Renin Angiotensin System (RAS) Antagonists and Statins. Diabetes Proportion of Days Covered by Medications (PDC)—Oral Diabetes Medications. Diabetes Care (CDC)—HbA1c Testing, HbA1c Poor Control (>9.0%), HbA1c Control (<8.0%), HbA1c Control (<7.0%) for a Selected Population, LDL Screening and Control (<100), Nephropathy Monitoring, Blood Pressure Control (<140/90), Optimal Diabetes Care. Musculoskeletal Prevention Use of Imaging Studies for Low Back Pain (LBP). Childhood Immunization Status—24-Month Continuous Enrollment (CIS). Immunizations for Adolescents (IMA). Human Papillomavirus Vaccine for Female Adolescents (HPV). Chlamydia Screening in Women (CHL). Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women (ECS). Breast Cancer Screening (BCS). Colorectal Cancer Screening (COL). Respiratory Asthma Medication Ratio (AMR). Appropriate Testing for Children With Pharyngitis (CWP). Appropriate Treatment for Children With Upper Respiratory Infection (URI). Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis (AAB). November 30, 2012 Measurement Year 2012 P4P Manual 10 MY 2012 P4P Overview Medicare Stars Measures Adults’ Access to Preventive/Ambulatory Health Services (AAP). Cholesterol Management for Patients With Cardiovascular Conditions (CMC)—LDL Screening. Proportion of Days Covered by Medications (PDC)—Renin Angiotensin System (RAS) Antagonists, Statins and Oral Diabetes Medications. Diabetes Care (CDC)—HbA1c Poor Control (>9.0%), Eye Exam, LDL Screening and Control (<100) and Nephropathy Monitoring. Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART). Osteoporosis Management in Women Who Had a Fracture (OMW). Breast Cancer Screening (BCS). Colorectal Cancer Screening (COL). Adult BMI Assessment (ABA). Glaucoma Screening in Older Adults (GSO). All-Cause Readmissions (PCR). Meaningful Use of Health IT The IT-Enabled Systemness Domain was revamped and renamed ―Meaningful Use of Health IT (MUHIT),‖ effective MY 2011. The Systemness domain had been in place for four years and the P4P committees agreed it was time to evolve. During this same time period, CMS committed significant resources to support the adoption and use of electronic health records (EHR), and developed ―meaningful use‖ measures designed to improve clinical outcomes by leveraging technology. POs voluntarily self-report this domain; health plans do not submit data for this domain. Measure 1 Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines. Measure 2 Implement drug-drug and drug-allergy interaction checks. Measure 3 Maintain an up-to-date problem list of current and active diagnoses. Measure 4 Generate and transmit permissible prescriptions electronically (eRx). Measure 5 Maintain an active medication list. Measure 6 Maintain an active medication allergy list. Measure 7 Record demographics: preferred language, gender, race, ethnicity, date of birth. Measure 8 Record and chart changes in vital signs: height, weight, blood pressure; calculate and display BMI; plot and display growth charts for children 2–20 years, including BMI. Measure 9 Record smoking status for patients 13 years of age or older. Measure 10 Report ambulatory clinical quality measures. Measure 11 Implement one clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance with that rule. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview Measure 12 Provide patients with an electronic copy of their health information. Measure 13 Provide clinical summaries for patients for each office visit. Measure 14 Capability to exchange key clinical information. Measure 15 Protect electronic health information created or maintained by the certified EHR technology. Measures 16–20 Measure 21 11 Any five CMS/ONC menu-set measures. Chronic care management for diabetes, depression and one other clinically important condition. Patient Experience Domain Starting in MY 2012, the survey used to collect data for the Patient Experience domain will be the national ®2 standard CAHPS Clinician & Group (CG-CAHPS) Patient Experience Survey endorsed by the National Quality Forum (NQF). The CG-CAHPS was developed by the Agency for HealthCare Research and Quality (AHRQ) and its research partners in the CAHPS consortium. The survey has both primary care practitioner (PCP) and specialist versions, which overlap substantially. The following areas of measurement are included in P4P scoring: Doctor-Patient Interaction Composite for PCPs. Doctor-Patient Interaction Composite for Specialists. Coordination of Care Composite. Timely Care and Service Composite for PCPs. Timely Care and Service Composite for Specialists. Overall Rating of Care Composite. - Rating of PCP. - Rating of All Healthcare. Office Staff Composite. Health Promotion Composite (based on a two year roll-up). POs voluntarily participate in the Patient Experience domain through the PAS survey; health plans do not submit data for this domain. ____________ 2 ® CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). November 30, 2012 Measurement Year 2012 P4P Manual 12 MY 2012 P4P Overview Appropriate Resource Use Domain This domain assesses use of key health care services to identify variation and maximize limited resources. The following measures are included in the ARU domain: Inpatient Readmission Within 30 Days (IRN). Inpatient Utilization—Acute Care Discharges (IPU). Inpatient Utilization—Bed Days (IPBD). Outpatient Procedures Utilization—Percentage Done in Preferred Facility (OSU). Emergency Department Visits (EDV). Generic Prescribing (GRX). Total Cost of Care (TCC).* Frequency of Selected Procedures (FSP).* *These measures are for internal reporting only. Health plans submit claims, encounter and eligibility data to Truven, which calculates the measures in the ARU domain; POs and health plans do not report this domain. ARU results are not yet publicly reported, but may be used by health plans as the basis for performance incentives. Relative Improvement Definition Relative improvement calculations measure the percentage of the distance the PO has moved from the previous year’s rate toward a goal of 100 percent (with the exception of HbA1c Poor Control, where the relative improvement goal is 0 percent). Scores are calculated for each measure that had no major specification change, for each PO that had a reportable result for both the current and the previous measurement year. Recommended Standard Payment Methodology The P4P-recommended Standard Payment Methodology assesses a PO’s performance on each Clinical and Patient Experience measure for both attainment and improvement, and takes the better of the two for payment. All points earned for measures in a domain are summed and converted to a domain score, and payment is based on each domain score. Attainment points: Each measure is given 0–10 points, based on the PO’s measure performance relative to benchmarks. A PO must meet the previous year’s 75th percentile score to earn any attainment points, and must meet the previous year’s 95th percentile score to earn the full 10 attainment points. Higher points indicate better performance, even for HbA1c Poor Control. Improvement points: Each measure is given 0–10 points, based on the PO’s relative improvement over its previous year score for that measure. Higher points indicate more improvement. Points earned: The higher of attainment and improvement points (maximum 10 points). Higher points indicate better performance. Domain score: The sum of points earned for all measures in a domain, divided by the possible points, multiplied by 100. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Overview 13 Testing Measures The P4P measure set includes testing measures for voluntary data collection and submission. P4P uses the results to evaluate measures for inclusion in the measure set in future years. There is opportunity for Public Comment before testing measures are finalized by the P4P Technical Measurement and Governance Committees in November 2012. Selected measures will be tested in 2013 and are expected to be added to the MY 2013 P4P measure set (barring problems identified during testing). The P4P Governance Committee will confirm adoption of these measures in November 2013, with input from Public Comment and recommendations from the P4P Technical Measurement Committee. All health plans and self-reporting POs are strongly encouraged to participate in testing. Clinical Childhood Immunization Status: Hepatitis A (CIS). Human Papillomavirus Vaccine for Male Adolescents (HPV). Unexpected Newborn Complications (UNC). Infants Under 1500gm Delivered at Appropriate Level of Care (LBW). Incidence of Episiotomy (EPS). Meaningful Use of Health IT None. Patient Experience None. Appropriate Resource Use Cesarean Section Rate for Low-Risk Birth (CSX). Vaginal Birth After Cesarean Delivery Rate (VBC). All-Cause Readmissions (PCR)* Medicare Care for Older Adults (COA) will be a second-year testing measure for MY 2012. *In MY 2012 PCR is a mandatory testing measure for the commercial product line; it is part of the measure set for the Medicare product line. Measure revisions NCQA and IHA update the technical specifications twice a year. MY 2012 Updated P4P Manual, released on September 4, 2012, reflects applicable changes in HEDIS 2013 Volume 2: Technical Specifications (released in July 2012). MY 2012 Final P4P Manual, released on November 30, 2012, reflects applicable changes in HEDIS 2013 Volume 2: Technical Specifications Update (released in October 2012). Specifications in the MY 2012 P4P Manual that are posted to the IHA Web site on November 30, 2012, are frozen. The National Drug Code (NDC) lists are published in November on the NCQA Web site. Health plans and POs are accountable for all changes included in the November manual and the November NDC lists. Auditors assess compliance based on these. Read the entire guidelines section and measure specifications before implementing the P4P MY 2012 measures. November 30, 2012 Measurement Year 2012 P4P Manual 14 MY 2012 P4P Overview If You Have Questions About the Specifications PCS System NCQA provides different types of policy support to P4P stakeholders, including frequently asked questions (FAQ), Policy Updates and a function that allows stakeholders to submit specific P4P policy interpretation questions to NCQA staff through the Policy Clarification Support (PCS) system. Follow these steps to access the PCS. Step 1 Use the following link: www.ncqa.org/pcs. Step 2 Complete the Information About You section. Step 3 Complete the Information About Your Question section. For product type, click P4P—IHA Pay for Performance in the drop-down box. For publication year, click 2013 (for P4P MY 2012) from the drop-down box. For standard category/HEDIS domain, scroll down and click IHA Pay for Performance (P4P) and select the appropriate P4P category. For standards/measures, scroll down and click the appropriate measure for your question, or click Not Applicable if your question type is not listed. For question, type your specific question (3,000 characters or less). Step 4 Click Submit Question. FAQs The FAQs clarify HEDIS and P4P specifications and are posted to the NCQA Web site at http://app04.ncqa.org/faq/ on the 15th of each month, and on the IHA Web site (www.iha.org) as needed. Measurement Year 2012 P4P Manual November 30, 2012 General Guidelines for Data Collection and Reporting 1B65 2B For P4P MY 2012 Health Plans and Self-Reporting POs 16 MY 2012 P4P General Guidelines for Data Collection and Reporting General Guidelines for Data Collection and Reporting Reporting Options 1. Two Data Sources Health plan reporting Participating health plans produce administrative results for each of their contracted POs that have signed the P4P Consent to Disclosure Agreement by submitting to the quality data aggregator (NCQA/TransUnion HealthCare) results related to all of the clinical measures attributable to the PO’s eligible population. This includes data derived from all encounters, fee-for-service claims and in-network claims. Health plans must follow the P4P clinical specifications and submit results for all clinical measures on behalf of all contracted POs with commercial HMO/POS contracts that have signed the P4P Consent to Disclosure Agreement, regardless of PO eligibility for P4P payments from the health plan. For ARU measures, health plans submit to the efficiency data aggregator (Truven Health Analytics) member-level enrollment, claims and encounter files for all contracted commercial POs that have signed the P4P Consent to Disclosure Agreement, regardless of PO eligibility for P4P payments from the health plan. Truven applies the ARU measure specifications and produces PO results. Self-reporting PO A PO may become self-reporting, collecting and submitting administrative results directly to the data aggregator for any or all clinical measures. A self-reporting PO submits P4P clinical results based on all commercial HMO/POS members belonging to a participating health plan, regardless of its eligibility for P4P payments from the health plan. NCQA produces final PO rates using a combination of health plan-submitted results and PO-submitted results. For each measure, NCQA determines the final rate by choosing the higher reportable rate from the aggregated health plan data or the self-reported PO data. Electronic data only Regardless of data source, IHA requires that only electronic data (automated claims and encounter data and auditor-approved supplemental administrative databases) be used to calculate the measures. Sampling and the HEDIS Hybrid Methodology may not be used to collect data for P4P. All reported clinical measure results must be certified through a P4P Audit Review, described in the Audit Review section. 2. Reporting Level P4P requires NCQA to aggregate data at either the PO ―parent‖ level or the PO ―subgroup‖ level. For P4P to report data at the subgroup level for a PO, all of the PO’s contracted P4P health plans must also report clinical data at the PO subgroup level. If even one health plan cannot report at the more granular level, all P4P health plans must report the PO’s data at the PO parent level (i.e., the ―00‖ level). Additionally, to report final P4P data at the PO subgroup level, the PO must have separate PAS surveys and Meaningful Use of Health IT submissions for each PO subgroup, if the PO participates in those domains. Note: Before enrollment in PAS, POs must decide if they can report at a PO subgroup level (most POs report at the parent level only). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 17 Encounter/Claims Submission 3. Submitting Data All POs eligible for P4P (i.e., with a commercial HMO/POS contract during 2012, with any P4P participating health plan)—self-reporting or not—must submit encounter data to their contracted P4P health plans throughout the year. POs should follow the dates in the Data Collection and Reporting Timeline and other information communicated by contracted health plans to maximize the probability that their data are included in any P4P health plan-generated PO results. Although the encounter rate threshold requirement for clinical data to be included in aggregation was removed beginning in MY 2012, full encounter submission is still expected. Encounter Rate by Service Type will continue to be collected and reported internally, and health plans may continue to require that POs meet an encounter rate threshold to qualify for incentive payments. P4P Reporting 4. P4P Policy on Handling Mergers and Acquisitions Every year, there are a few PO acquisitions and mergers. Each of these legal structural changes comes with its own set of complex circumstances. P4P has an established policy on handling mergers and acquisitions, which accommodates a variety of circumstances and ensures fairness by following a consistent process. To view the P4P policy on handling mergers and acquisitions, go to the IHA Web site: http://www.iha.org/pdfs_documents/p4p_california/P4P_Merger_Acquisition_Policy_effective2_11.pdf. 5. P4P Consent to Disclosure Agreement POs must sign the P4P Consent to Disclosure Agreement to confirm their participation in P4P. No data are collected or reported for POs that have not signed a Consent to Disclosure Agreement. P4P posts reports for all POs that sign the Consent to Disclosure Agreement. 6. Attribution P4P attributes patients to a PO in each of the following ways: Enrollment at the health plan level, communicated to the PO. Encounter data from the PO, including member identification or physician identification (so health plans can correctly attribute it)., and Continuous enrollment in the PO; enrollment in the PO on the anchor date; and required benefits, as specified for each measure. 7. Peer Groups P4P defines peer groups as ―all POs participating in the P4P program.‖ POs eligible to participate in the P4P program are those with a commercial HMO/POS contract with any P4P participating health plan during the measurement year. These POs have been delegated the responsibility of managing a patient population for both the primary and specialty care provided in ambulatory and inpatient settings. November 30, 2012 Measurement Year 2012 P4P Manual 18 MY 2012 P4P General Guidelines for Data Collection and Reporting 8. Risk Adjustment Clinical Quality NCQA is the measure developer for P4P clinical quality measures; therefore, P4P follows NCQA’s risk adjustment protocol. NCQA’s Committee on Performance Measurement and its Board of Directors determined that risk adjustment would not be appropriate for HEDIS measures because the processes and outcomes being measured should be achieved, regardless of the nature of the population. NCQA also creates the technical specifications for clinical quality measures that are not HEDIS based. Because those measures are also process and outcomes measures, NCQA determined that risk adjustment was not appropriate. Patient Experience For Patient Experience measures, each PO’s results are adjusted for patient casemix, to control for differences across PO populations. Characteristics controlled for in the case-mix adjustment model are included in the Patient Experience Specifications. Appropriate Resource Use Most ARU measures are risk adjusted. The specifications provide a description of the type of risk adjustment used for each measure. Meaningful Use of Health IT Meaningful Use of Health IT measures are not risk adjusted, to align with CMS/ONC regulations. 9. Reliability Testing/Minimum Number of Observations P4P considers measurement error and reliability for each of the three categories of measures, as follows. For Clinical Quality measures, the organization uses administrative data based on the universe of a PO’s members. There is no sampling. Because statistical errors can result from small numbers, P4P requires a total eligible population of 30 or more for a particular measure. In addition, P4P excludes any measure with a bias of 5 percent or more, as determined by the auditor. Meaningful Use of Health IT measures are standards reported by the PO rather than rates, and are therefore not subject to statistical error. Patient Experience data are based on surveying a sample of eligible members, and P4P does not use any results with reliability below 0.70. For ARU measures, a statistical method called ―shrinkage estimation‖ is applied to improve the reliability of rates. 10. Eligible Population The eligible population for any measure is all members who satisfy all criteria specified in the measure, including any age, continuous enrollment (including allowable gap), benefit, event or anchor-date requirement. The rate is calculated using the eligible population after exclusions. 11. Optional Exclusions Some measures allow the PO or health plan to exclude from the eligible population, members identified as having a specific comorbidity or having had a specific procedure (e.g., exclude women who have had a bilateral mastectomy from the Breast Cancer Screening measure). The technical specifications indicate instructions the PO or plan should follow for each measure that includes optional exclusions. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 19 As a rule, look for exclusions only for individuals where administrative data indicate that the specified numerator service/procedure did not occur. The PO or plan must first determine for members in the eligible population whether administrative data show that the numerator service/procedure was rendered within the time frame specified in the measure, and must count the members as having satisfied the measure (i.e., count these members in the numerator). The PO or plan should then look for exclusions for members who do not meet the numerator criteria, and verify that the exclusion occurred by the time specified in the measure. 12. Product-Line Reporting P4P clinical results must be collected and reported separately for two populations: The commercial HMO/POS population. The Medicare Advantage population. Results should not include Medi-Cal or PPO members. 13. Members Who Switch Health Plans or POs Members are considered continuously enrolled if they switch to a different organization or to a sister organization, if the organization assumes ownership of or responsibility for their administrative data for the entire period of continuous enrollment specified in the measure. A health plan or PO that reports these members as continuously enrolled must follow the same definition of ―continuous enrollment‖ as in General Guideline 20 and General Guideline 21, and must follow all other guidelines affecting continuous enrollment (i.e., allow switching between products [HMO, POS] or product lines [commercial, Medicare]) consistently across all measures. 14. Members Who Switch Health Plans or POs as the Result of a Merger or Acquisition Members who switch entities because of a merger that occurred during the measurement year may be counted as continuously enrolled. A health plan or PO that adopts this guideline must do so consistently across all measures. 15. Members With Dual Coverage in Different Health Plans Organizations should not try to account for coordination of benefits with other insurance carriers because the burden of doing so is excessive and the impact on the final rate is likely to be small. Members with dual coverage in at least one P4P health plan should be included in all health plan’s P4P reports. 16. Members with Dual Membership in the Same Health Plan Members with dual coverage in the same plan (e.g., children enrolled under each parent) should be represented only once in each measure. Include members enrolled in each product only once in the HMO/ POS combined report. November 30, 2012 Measurement Year 2012 P4P Manual 20 MY 2012 P4P General Guidelines for Data Collection and Reporting 17. Self-Insured Members Administrative Services Only Include self-insured ASO members in the organization’s P4P reports. Exclude self-insured members in either one of the following circumstances and only with auditor approval. The contract prohibits the health plan/PO from contacting members under any circumstances (―no-touch‖ policy). A no-touch contractual agreement is a contract or other written agreement between the organization (i.e., HMO or PPO) and the ASO purchaser specifically stating that the organization cannot contact these members under any circumstances. The plan/PO may exclude no-touch members from P4P results because they are not managed in the same way as other members. ASO members can only be excluded due to ―no touch‖ contractual agreements with identified purchasers. The health plan/PO is not responsible for administering both in-network and out-of-network claims for members (i.e., employer carve-out) unless claims are administered through a third party on behalf of the plan/PO. 18. Members Who Switch Product Lines Measures with a continuous enrollment requirement Members enrolled in different product lines (commercial, Medicaid, Medicare) at different times during the measurement year should be reported in the product line to which they belonged at the end of the continuous enrollment period. For example, a member of a Medicaid product line who switches to the commercial product line during the continuous enrollment period is reported in the commercial P4P report. Members who ―age in‖ to a Medicare product line mid-year are considered continuously enrolled if they were members of the organization through another product line (e.g., commercial) during the continuous enrollment period and their enrollment did not exceed allowable gaps. Measures without a continuous enrollment requirement Assign members to a category based on the product line in which they were enrolled on the date of service (outpatient services) or date of discharge (inpatient services). 19. Members Who Switch Products Measures with a continuous enrollment requirement Members who switch from the commercial HMO product to the commercial POS product (or vice versa) in the time specified for continuous enrollment for a measure are considered continuously enrolled. Enrollment in a PPO or in a Medicare Private Fee-for-Service (PFFS) plan is considered a gap in HMO/POS enrollment. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 21 Required Enrollment Periods and Benefits 20. Continuous Enrollment and Allowable Gaps Continuous enrollment specifies the minimum amount of time a member must be enrolled in the organization before becoming eligible for a measure. The member must also be continuously enrolled in the benefit specified for each measure (e.g. pharmacy or mental health) accounting for any allowable gaps to be considered continuously enrolled. One of several criteria used to identify the eligible population, continuous enrollment ensures that the health plan or PO had sufficient time to render services to its members to be accountable for providing those services. The continuous enrollment period and allowable gaps are specified in each measure. A gap is the time during which a member is not covered by the organization (i.e., the time between disenrollment and re-enrollment). For example, if a member disenrolls on June 30 and re-enrolls on July 1, there is no gap because the member was covered on both June 30 and July 1. If the member disenrolls on June 30 and re-enrolls on July 2, there is a one-day gap because the member was not covered on July 1. Allowable gaps (less than 45 days) can occur at any time during continuous enrollment. For example, the Diabetes Care measure requires continuous enrollment from January 1–December 31 and allows one gap of up to 45 days. A member who enrolls for the first time on February 8 of the measurement year is continuously enrolled if there are no other gaps throughout the remainder of the measurement year (the member had a 38day gap, January 1–February 7). Enrollment in a Medicare PFFS plan is considered a gap in HMO/POS enrollment. 21. Continuous Enrollment and Allowable Gaps Over Multiple Years Unless otherwise specified, members are allowed one gap of up to 45 days during each year of continuous enrollment for measures spanning more than 1 year. A gap that extends over multiple years of a continuous enrollment period may exceed 45 days. For example, in the MY 2012 Breast Cancer Screening measure (which requires 2 years of continuous enrollment), a member who disenrolls on November 30, 2011 (the year prior to the measurement year), and re-enrolls on February 1, 2012 (the measurement year), is considered continuously enrolled as long as there were no other gaps in enrollment during either year. The member has one gap of 31 days (December 1–31) in 2011 and one gap of 31 days (January 1–31) in 2012. 22. Anchor Dates If a measure requires a member to be enrolled and to have a specified benefit on a particular date, the specified allowable gap must not include that date; the member must also have the benefit on that date. For example, a 55-year-old with only one gap in enrollment from November 30 of the measurement year through the remainder of the year is not eligible for the Colorectal Cancer Screening measure. Although the member meets the continuous enrollment criteria, she does not meet the anchor date criteria, which requires her to be enrolled as of December 31 of the measurement year. November 30, 2012 Measurement Year 2012 P4P Manual 22 MY 2012 P4P General Guidelines for Data Collection and Reporting 23. Continuous Enrollment for Health Plans For each measure, members are assessed for continuous enrollment in the health plan and continuous enrollment in the PO (parent level). Plans that report P4P measures determine continuous enrollment using the following steps. Step 1 Determine if the member was continuously enrolled in the plan, including allowable gaps. Step 2 Determine if the member was continuously enrolled in the PO (parent level), including allowable gaps. Step 3 Determine if the member was enrolled in the plan and the PO (parent level) on the anchor date. Step 4 For POs eligible to report at the subgroup level, determine the subgroup the member was assigned to on the anchor date. 24. Continuous Enrollment for POs The P4P measures require calculation of continuous enrollment at the PO parent level. POs that self-report P4P measures determine continuous enrollment using the following steps. Step 1 Determine if the member was continuously enrolled in the PO (parent level), including allowable gaps. Step 2 Determine if the member was enrolled in the PO (parent level) and a P4P health plan on the anchor date. Step 3 For POs eligible to report at the subgroup level, determine the subgroup to which the member was assigned on the anchor date. Note Each PO approved to self-report at the subgroup level must also ensure that all plans reporting data for it report at the subgroup level. Members assigned to a PO must be included, whether or not they sought services from the PO. Members who change subgroups within a PO during the continuous enrollment period are considered continuously enrolled as long as they meet the other continuous enrollment criteria. 25. Required Benefits Some measures require benefits in addition to medical (e.g., pharmacy) as part of the eligible population criteria. Health plans and POs must determine which benefits a member has before the member is included in a measure. …at the health plan level …at the member level Health plans and POs must report P4P measures that require a specific benefit if the plan provides the benefit, either directly or through a contractor. Health plans and POs are not required to report measures that require a benefit that the plan does not offer. Members who do not have the benefit specified in the measure should not be counted in that measure by health plans or POs. For example, the Annual Monitoring for Patients on Persistent Medication measure requires a pharmacy benefit. Exclude members who do not have a pharmacy benefit. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 23 Exhausted benefits (optional) For measures that require benefits other than medical (e.g., pharmacy), the benefits must be active for the period of continuous enrollment, accounting for any allowable gaps. Health plans and POs have the option to exclude a member if the period when the benefit is exhausted exceeds allowable gaps or includes the anchor date. For example, the Annual Monitoring for Patients on Persistent Medication measure requires a pharmacy benefit during the measurement year. Health plans and POs may exclude a member whose pharmacy benefit is exhausted in September of the measurement year because this gap exceeds the 45-day allowable gap period. Including members whose benefits are carved out (optional) Some health plans and POs can obtain information from a carved-out entity and may include these members in the measures. For example, if an employer contracts directly with a pharmacy benefit manager (PBM) that shares pharmacy information, the health plan and PO may include the employer’s members in the measure. Guidelines for Data Submission and Reporting 26. Measure Rotation Because P4P measures use administrative data only, they are not eligible for rotation. Health plans that participate in the P4P program may rotate their HEDIS measures, but they must collect and submit all P4P measures using the Administrative Methodology. 27. Reporting Small Numbers Health plans and POs must report all available denominators, numerators and rates to the data aggregator even if the denominators are small. Only measures with aggregated denominators (the total for all health plans) of 30 or more will be publicly reported. Measures with denominators less than 30 will be publicly reported as ―Too Few Patients in Sample to Report.‖ Data Collection 28. Administrative Method The Administrative Method of data collection requires health plans and POs to use transaction or supplemental electronic clinical data from acceptable sources (e.g., administrative databases, registries, electronic medical records [EMR]). The PO’s reported rate is based on all members who meet the eligible population criteria and who are found through administrative data to have received the service identified in the numerator. 29. What Services Count? With the exception of the ARU measures, health plans and self reporting POs should use all services related to each measure, including all paid, suspended, pending and denied claims. For ARU measures, health plans should submit to Truven all services for which the organization actually paid or expects to pay (i.e., claims incurred but not paid). Do not include services and days denied for any reason. In cases where a member is enrolled retroactively, count all services for which the organization has paid for or expects to pay. November 30, 2012 Measurement Year 2012 P4P Manual 24 MY 2012 P4P General Guidelines for Data Collection and Reporting 30. Supplemental Data Supplemental database Organizations may use sources other than claims and encounters to collect data about their members and about delivery of health services to their members, and may use the data to create files to supplement claims data for calculating P4P measures. Data used to create supplemental databases may come from a variety of sources, and may be in different formats. Supplemental databases can be used to help determine: The numerator. Optional exclusions. Eligible-population required exclusions not related to the timing of the denominator event or diagnosis. For example: – For the Use of Imaging Studies for Lower Back Pain measure, the organization may create a supplemental database for members who have cancer, but may not create one for members whose recent trauma, IV drug abuse or neurological impairment must be assessed in relation to the low back pain event. – For the Appropriate Testing for Children With Pharyngitis measure, the organization may not use a supplemental database to find additional diagnoses for any claim that qualifies for the eligible population. Only ―claims‖ with multiple diagnoses can be excluded. Note Organizations may create a database of members with a chronic condition, such as diabetes, and may exclude these members if the condition does not resolve and if it was diagnosed before the measures’ effective dates. Supplemental databases may be used for any measure, but must follow the specifications outlined in each measure. Supplemental databases cannot be used to correct incorrect billing practices. This results in a change to claims data and is not allowed. For example, organizations cannot exclude members from the OMW measure if the medical record shows that a fracture did not occur in the timeframe required by the measure, but was still billed by a provider for ongoing therapy. External data Internal data Standard files Data supplied by contracted practitioners, vendors or public agencies (e.g., pharmacies, labs, hospitals, schools, state public health agencies). External data may also come from an electronic medical record (EMR), which is typically developed and maintained at a hospital or a physician’s office and which may be integrated (or linked) to the organization’s system. External data files may be standard or nonstandard. Nonstandard data files provided by the organization that supplement the claim or encounter data in the performance measurement repository. Data may come from internal systems, such as disease management (DM) programs. Electronic files that have a well-documented standard format that remains stable from year to year. Laboratory or pharmacy data in CALINX format. Immunization data in county or state registries (may vary from county to county, but are consistent for all records in each county’s registry). Encounter data from behavioral healthcare vendors. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting Nonstandard files 25 Electronic data sources that might not follow a standard layout. Formats might differ from source to source. EMR files. Electronic files from disease management or case management systems. Electronic files from measure-exclusion database. Required data elements All source data—and consequently, the supplemental database—must include all data elements required by the measure (e.g., date and place of service, procedure, prescription and practitioner type). Dates must be specific enough to determine that an event occurred during the time established by the measure. For data obtained from an EMR, the organization must be able to distinguish between ordered and completed visits, procedures and lab and radiology orders. Only completed events count toward compliance. Providerreported data The organization may create questionnaires for providers and use the information from these written forms to build supplemental databases. Provider forms should include all data elements required for the measure. Forms may not be simple attestations (i.e., a ―yes or no‖ response to the members’ compliance or exclusion), but must have all necessary data and should be signed by the practitioner or clinician. For provider forms, the organization must ensure that: Providers were selected appropriately. Forms contain all information necessary to meet the measure requirements. Auditors must review the forms (before mailing); approve the list of members and selected providers; validate that the organization imported, evaluated and reported the data properly; and perform primary source verification. Note: Provider forms may not be acceptable as a primary source; review of the original chart is at the auditor’s discretion. Memberreported data The organization may only use member-reported information obtained by a provider or clinician in the following circumstances. While taking a patient’s history, orally or from a questionnaire completed by the patient and presented to the provider, if the following criteria are met: – The information is in the medical record by the deadline established for the measure. – The medical record includes a note indicating the date of service and the result or finding (for measures requiring a result or finding). While taking the patient’s history or experience and recording it in a disease management system. All forms and questionnaires used to track this information, as well as evidence of the conversation or intervention, must be available for the auditor’s review. Biometric values (e.g., BP readings, HbA1c levels, LDL-C levels, BMI) from selfadministered tests are not acceptable for P4P reporting. Health assessment (HA) data are considered member-reported data and are subject to the requirements specified in this guideline. November 30, 2012 Measurement Year 2012 P4P Manual 26 MY 2012 P4P General Guidelines for Data Collection and Reporting Organizations may use member-supplied reports from qualified providers; for example, lab results indicating that services were rendered or results were received. Organizations should have policies and procedures for obtaining reports from current member records or sending reports to providers for inclusion in records. Reports must meet all measure requirements. Member survey data Organizations and providers may not use information obtained from member surveys. Primary source verification For supplemental databases derived from nonstandard files, the Certified HEDIS Compliance Auditor must perform primary source verification, which includes reviewing a subset of records to the initial data source that the organization used to acquire the information (e.g., patient charts or records; registries; disease-tracking systems, including recorded conversations). Audit requirements …for standard files …for nonstandard files All supplemental electronic data are subject to audit review and differ only in the degree of review required. The auditor is not required to conduct primary source verification to check the accuracy and validity of data obtained from standard files such as laboratory data, but must request documentation to ensure that the agency or organization responsible for the data has reasonable processes in place for data collection and accuracy. For internal or external nonstandard files, the auditor must perform primary source verification every year that the database is changed and the previous verification is not applicable. If the auditor does not perform primary source verification, the work papers should include a database-specific explanation. Primary source verification involves the following tasks: Create a randomly selected sample using acceptable methods (e.g., the sample feature in Excel). After evaluating the measures and databases, the auditor is responsible for selecting the appropriate number of records for primary source verification. Review of the original paper record or the electronic record (e.g., EMR screen) for each member in the sample. Timing of access: The audit review may occur before or after the database is used to help calculate measures. The auditor must assess the effect on the measures based on the timing of the review. Timing relevance: A supplemental database may be created and augmented across multiple years. The auditor must assess and review records pertaining only to the year being measured. Use for multiple measures: The auditor must determine the primary source validation based on the number of measures affected and the number of records affecting each measure. The database may not be used if the auditor is not granted access to the primary source. Because of the variety of files, sources and results, the auditor must assess the processes and their impact, perform primary source verification and determine the validity of the database for use in calculating the selected measures. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting …for all files 27 The auditor will evaluate the policies and procedures for collecting and managing, mapping, importing and reporting the data. For each supplemental database, the auditor needs the following documentation. The method used to create supplemental database. The quality assurance or oversight used. The data quality controls in place. The data security in place. Ongoing maintenance. The method used to transmit the supplemental data file. Note Organizations should not create records or an ongoing database of exclusions for clinical conditions that might change. For example, it would be inappropriate to include a member with gestational diabetes in an ongoing database of exclusions for the Diabetes Care measures. 31. Date Specificity P4P measures require a date to be specific enough to determine that an event occurred during the time established in the measure. For example, in the Childhood Immunization Status measure, members should receive three hepatitis B vaccines. Assume a member was born on February 5, 2010. Documentation that the first hepatitis B vaccine was given ―at birth‖ is specific enough to determine that it was given prior to the deadline for this measure (i.e., the child’s second birthday), but if the documentation states that the third hepatitis B vaccine was given in February 2012, the organization cannot count the immunization because the date is not specific enough to confirm that it occurred prior to the member’s second birthday. There are instances when documentation of the year alone is adequate; these include most optional exclusions and measures that look for events in the ―measurement year or year prior to the measurement year.‖ Terms such as ―recent,‖ ―most recent‖ or ―at a prior visit‖ are not acceptable. For documented history of an event (e.g., documented history of a disease), undated documentation may be used as long as it is specific enough to determine that the event occurred during the time frame specified in the measure. For example, for the Breast Cancer Screening measure, undated documentation on a problem list stating ―bilateral mastectomy in 1999‖ is specific enough to determine that this exclusion occurred prior to December 31 of the measurement year. 32. Measures That Use Pharmacy Data Some measures require the use of available pharmacy data. Self-reporting POs must have pharmacy data from all contracted P4P plans to run these measures. For measures requiring pharmacy data, the tables in the specifications include a Description column, which indicates the therapeutic category, and a Prescription column, which includes all appropriate medications in their generic form. Additionally, NCQA specifies a standardized list of medications known as the National Drug Code (NDC) list that applies to each pharmacydependent measure. POs and health plans are required to use the list for applicable measures. The most current NDC list can be found on NCQA’s Web site at http://www.ncqa.org: select HEDIS 2013 for (P4P MY 2012). NCQA posts the final NDC lists for pharmacy-related measures on the NCQA Web site on November 15, 2012. November 30, 2012 Measurement Year 2012 P4P Manual 28 MY 2012 P4P General Guidelines for Data Collection and Reporting 33. Identifying Events/Diagnoses Using Laboratory Data Laboratory data may not be used to identify an event, disease or condition (e.g., acute myocardial infarction 3 [AMI], diabetes) unless listed in a code table that contains LOINC codes. Many organizations find a high rate of false positives when they use laboratory data to identify members with a disease or condition. Diagnosis codes are frequently reported on laboratory tests in cases where the condition is being ruled out; therefore, organizations should not use laboratory data or claims when identifying the following criteria: Eligible population event/diagnosis. Negative comorbid condition history. Negative diagnosis history. Exclusions. Negative competing diagnosis. Numerator events. Laboratory claims and data may be used for code tables that contain LOINC codes. 34. Facility Data With the exception of ARU measures, P4P measures do not require facility data (e.g., inpatient, ED) for reporting rates, but facility data may be used as specified. Professional codes associated with facility-based events may help capture some services, such as ED care for asthmatics. Coding Conventions 35. Coding Systems Included in HEDIS P4P includes codes from the following coding systems. CMS Place of Service (POS). 4 Current Procedural Terminology (CPT). Medicare Severity Diagnosis-Related Group (MS-DRG). Healthcare Common Procedure Coding System (HCPCS) Level II. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)*. Logical Observation Identifiers Names and Codes (LOINC). Uniform Bill (UB) Revenue and type of bill (TOB). *Updates to the ICD-9-CM Diagnosis and Procedure codes are released annually on October 1 by the American Hospital Association (AHA). The HEDIS Technical Update is released on the same date and therefore does not include the AHA’s coding updates. Content from the October HEDIS Technical Update is the last update to the P4P specifications before they are frozen at the end of November. Consequently, AHA’s coding updates are not included in the final P4P specifications for that year, and should not be used for P4P reporting. This policy ensures consistency in reporting across health plans and POs and reduces burden by eliminating updates to the P4P specifications after the freeze date. The codes will be considered for the following P4P cycle. ____________ 3 4 ® LOINC is a registered trademark of the Regenstrief Institute. CPT codes copyright 2012 American Medical Association. All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 29 37. Using Code Tables When reading P4P coding tables, assume the word ―or‖ in between each column unless otherwise noted; each code set does not depend on another code set unless otherwise noted. 38. Principal vs. Secondary Diagnosis Principal and secondary diagnoses are mentioned throughout the specifications. Generally, a principal diagnosis is the diagnosis given at discharge and is listed in the first position on a claim/encounter form. A secondary diagnosis is any diagnosis listed on a claim or encounter form that is not classified as the principal diagnosis. A claim or encounter can contain several secondary diagnoses. Organizations should follow the measure specifications to determine if a diagnosis must be the principal diagnosis or if it can be secondary. If the specification does not state that the principal or primary diagnosis must be used, any applicable diagnosis must be used. Some measures require a specific principal diagnosis for a member to be in the eligible population; other measures allow any diagnosis (principal or secondary) for a member to be eligible. For example, the Diabetes Care measure specifies a member with any diagnosis of diabetes as eligible. If a member’s claim lists the principal diagnosis as severe head injury trauma, but diabetes is listed as a second, third, fourth or fifth diagnosis on the same claim, the member should be included in the Diabetes Care measure. If the measure specifies that a principal diagnosis is required, health plans and POs should search for only the principal diagnosis (e.g., identifying the eligible population for the Use of Imaging Studies for Low Back Pain). On a UB-04 claim form, the principal diagnosis is listed in Form Locator 67, Principal Diagnosis Code, and secondary diagnoses are listed in Form Locators 67A–Q, Other Diagnosis Codes. Data in Form Locators 69, Admitting Diagnosis Code and 70a–c, Patient’s Reason for Visit, should not be included in HEDIS reporting. On a CMS1500 claim form, the principal diagnosis is listed in Item Number 21, line 1; secondary diagnoses are listed in Item Number 21, lines 2–4. 39. CPT Code Modifiers Current Procedural Terminology (CPT) modifiers are two- or five-digit extensions that may be added to CPT codes to provide additional information about a service or procedure. In general, if a specified CPT code appears with any modifier, the code may be counted in the measure. xxxxx-26 indicates the professional component of a service (xxxxx-TC is used by some organizations to indicate the technical component of the same service). The organization should count one or the other of these codes for a given procedure. xxxxx-54 denotes surgical care only; xxxxx-55 denotes postoperative management only; xxxxx-56 denotes preoperative management only. The organization should count only one of these codes for a given procedure. xxxxx-80 and xxxxx-82 indicate charges for surgical assistant services; xxxxx-81 indicates a charge for minimum surgical assistant services. The organization should count only one of these codes if the primary surgeon does not submit a claim for a procedure, and should not count any of these codes if the primary surgeon submits a claim. Unless otherwise specified, a CPT code specified in P4P specifications that appears in the organization’s database with any modifier other than those specified above may be counted in the HEDIS measure. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 30 MY 2012 P4P General Guidelines for Data Collection and Reporting 40. Uniform Bill Codes Specificity Uniform Bill (UB) codes, primarily type of bill and revenue codes, are used to identify services. As with the ICD-9-CM codes, an ―x‖ may be used in place of a digit. P4P specifies UB Type of Bill codes using three digits. Health plans and POs may use the equivalent four-digit version of the code (which consists of the three-digit code plus a leading zero; for example, 13x or 013x may be used to identify ambulatory surgery). 41. Mapping Proprietary or Other Codes For all measures, health plans and POs that do not use the coding systems specified (e.g., CPT, ICD-9-CM, LOINC, DRG, CMS 1500 forms, place of service codes, UB) must ―map‖ the codes they used to the codes specified in the manual. Mapping is restricted to proprietary and NDC codes. It is important that health plans and POs match the clinical specificity required when mapping codes. NDC code mapping should be linked to the generic name, strength/dose and route indicated in the NDC lists posted on the NCQA Web site (www.ncqa.org). For audit purposes, health plans and POs should document methods used to map codes. At a minimum, documentation should include a crosswalk containing the relevant codes, descriptions and clinical information. Health plans and POs must document the policies and procedures they use to implement codes other than the specified coding systems. For Level III and state-specific Level II HCPCS mapping, organizations must provide state instructions for using state-specific codes. Auditors may request additional information. 42. Retiring Codes NCQA annually tracks obsolete billing, diagnostic and procedure codes, but does not remove codes in the year in which they receive the designation of ―obsolete‖ because of the look-back period in many P4P measures. Codes designated obsolete are not deleted from the P4P specifications until the look-back period for applicable measures is exhausted, plus one additional year. For example, since the Breast Cancer Screening measure counts a mammogram in the measurement year or the year prior to the measurement year, it has a two-year look-back period. A mammogram code that is designated obsolete effective January 1, 2011, is not deleted from the specifications until MY 2013 after the two-year look-back period (2012, 2013) plus one additional year (2011) is exhausted. NCQA uses the NDC system. Obsolete NDC codes are phased out of the specification based on the lookback period for the measure, plus three years. This allows pharmacies to use up their inventory and change their systems to reflect the NDC code changes. NCQA encourages plans and POs to update their information systems and to ensure that complete, accurate and consistent coding is used for all encounters and claims so that measure specifications can be followed. This will help the industry move toward a uniform system of performance measurement. 43. Table Format Measure specifications contain tables to present specification requirements. A standardized naming system is used to refer to the tables. Table names begin with the three-character abbreviation for the measure; for example, Diabetes Care tables begin with ―CDC.‖ Specification tables Tables that are part of the specifications (i.e., coding and pharmaceutical tables) begin with the measure abbreviation and end with a hyphen (-) and a capital letter to distinguish its order in the measure’s specifications. For example, the first table in the Diabetes Care measure is assigned ―CDC-A.‖ Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 31 P4P Data Submission 44. Reporting Date The previous calendar year is the standard measurement year for P4P clinical data. IHA supplies the data submission file format to POs and health plans, and the Certified Auditor validates and locks the submission file before it is sent to TransUnion HealthCare. All health plan and PO-reported audited clinical data should be submitted to TransUnion HealthCare on or before the date specified in the Data Collection and Reporting Timeline. Note POs that use TransUnion HealthCare as the encounter data intermediary must submit all Q1–Q4 2012 encounter data to TransUnion HealthCare by February 18, 2013. No new data will be accepted after this deadline. POs that use a different data intermediary or supply encounters directly to health plans should confirm the final acceptance date of encounter data to be included in P4P reporting. Self-reporting POs and health plans must submit auditor-locked P4P clinical results by May 10, 2013. Health plans must submit results for all clinical measures for each contrated PO with a signed P4P Consent to Disclosure Agreement. 45. Required Data Elements Health plans and POs should report data based on all services delivered through December 31 of the measurement year, not encounters submitted or claims paid through that date. Data elements that must be submitted for each measure are listed below. Record type (Header—HDR, Detail—DTL, Trailer—TRL). PO ID (parent level; or, for eligible POs, the subgroup level). P4P enrollment (HMO and POS separately) with the PO as of December 31, 2011. Measure ID. Numerator. Denominator. Rate. Audit result. The Certified Auditor approves and locks the submission file before it is sent to TransUnion HealthCare. November 30, 2012 Measurement Year 2012 P4P Manual 32 MY 2012 P4P General Guidelines for Data Collection and Reporting The P4P Audit Review 46. Audit Review Principles P4P requires health plans and self-reporting POs to undergo an audit review of clinical results conducted by an NCQA Certified Auditor. This review ensures that results are an accurate report of PO performance. The P4P Audit Review incorporates P4P-relevant components of the HEDIS Compliance Audit described in the current volume, HEDIS Compliance Audit™: Standards, Policies and Procedures. A separate manual with P4P Audit Specifications will be posted to the IHA Web site on November 30, 2012. The underlying principles of the Audit Review are: Ensure accurate, reliable, publicly reportable data that can be used to compare POs. Verify that measure calculation processes conform to technical specifications, including, but not limited to, use of administrative only data, correct calculation of encounter rates and appropriate application of continuous enrollment requirement. Assess information system capabilities and evaluate an organization’s ability to process medical, member and practitioner information to report clinical measures accurately. Ensure consistency across audit reviews by having the audit review conducted by an NCQA Licensed Organization and a Certified HEDIS Compliance Auditor using NCQA’s P4P standard audit methodology. The audit review is conducted during the data collection process, allowing the auditor to detect errors while there is time to correct them and minimize the possibility of a Biased Rate (BR). The audit review process includes initial offsite activities, an onsite visit, post-onsite activities and data reporting. A PO that does not self-report clinical measures does not need an audit. 47. Audit Components P4P audit review components depend on the reporting option. Health plan reporting A health plan that undergoes a HEDIS Compliance Audit and also reports P4P data on behalf of contracted POs must have a Certified Auditor review the PO results. The auditor reviews and confirms any additional activities required for calculating results at the PO level, including the following. The health plan’s ability to attribute members to POs, including enrollment spans, and report the data at the PO level. The health plan’s ability to produce P4P measures according to P4P specifications. The algorithms and source code used to report rates by PO. PO selfreporting A PO that collects and reports P4P clinical measures must undergo an audit review adapted from NCQA’s HEDIS Compliance Audit. The review includes all PO-relevant HEDIS Compliance Audit standards and policies and procedures described in the P4P Audit Review Guidelines. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P General Guidelines for Data Collection and Reporting 33 48. Audit Results P4P Audit Reviews result in audited rates at the measure level and indicate if a measure can be publicly reported. All P4P clinical measures and encounter rate metrics must have a final, audited rate/result. Health plan results Rate/Result 0–XXX Audit reviews for health plans provide assessments for each of their contracted POs, indicating each measure’s suitability for data aggregation. The auditor gives a designation for the rate of each measure included in the audit, as shown in the table below, and additional instructions for data submission are as follows: Description Reportable BR Biased Rate NB No Benefit NR Not Reported PO results Notes Reportable rate for P4P measure. The rate of 0 includes instances when the health plan calculated the rate but found that no members met the criteria specified in the denominator. The calculated rate was materially biased. The auditor determines a result is not reportable due to material bias. The health plan did not offer the health benefit required by the measure (e.g., pharmacy). The health plan did not report the measure (may only be used for testing measures). For self-reporting POs, audit results indicate the suitability of each measure for public reporting. The auditor approves the rate or result of each measure included in the audit, as shown in the table below, and additional instructions for data submission are as follows: If the denominator for any measure is 0, then the result should be 0, BR, NB or NR. The rate of 0 indicates that the PO calculated the measure, but found that no members met the criteria specified for the denominator. Rate/Result 0–XXX Description Reportable BR Biased Rate SD Small Denominator NB No Benefit NR Not Reported Notes Reportable rate for P4P measure. The rate of 0 includes instances when the PO calculated the rate but found that no members met the criteria specified in the denominator. The calculated rate was materially biased. The auditor determines a result is not reportable due to material bias. The PO calculated the result, but the denominator was too small to report a valid rate (denominator between 1 and 29 members). The health plan did not offer the health benefit required by the measure (e.g., pharmacy). The PO did not report the measure. 49. Multiple Audit Designations Measures with multiple rates may have multiple audit results. For example, it is possible for the Childhood Immunization measure to be assigned a reportable rate for the MMR rate but a BR for VZV. 50. Material Bias Any error that causes a (+/-) 5 percentage point or greater difference in the reported rate is considered materially biased and receives a BR for the affected measures. November 30, 2012 Measurement Year 2012 P4P Manual 34 MY 2012 P4P General Guidelines for Data Collection and Reporting 51. Marketing Release of P4P audit results must be in accordance with NCQA’s Guidelines for Advertising and Marketing, posted on the NCQA Web site at www.ncqa.org. Organizations may release the entire Final Audit Report without prior authorization from NCQA, but must obtain written authorization from NCQA before releasing abridged, summarized or quoted information from the Final Audit Report. Organizations that refer to the P4P audit or any P4P data audited by a Certified HEDIS Compliance Auditor must adhere to the guidelines. Measurement Year 2012 P4P Manual November 30, 2012 Clinical Domain Technical Specifications For P4P MY 2012 Health Plans and Self-Reporting POs 36 MY 2012 P4P Clinical Specifications: Overview Overview This section includes the P4P technical specifications for use in collecting California PO clinical performance data in 2013 for MY 2012. The P4P specifications are based on HEDIS measures and non-HEDIS measures. For P4P, NCQA adapts measures for assessing performance at the PO level. All measures are collected using administrative data systems, including EHRs, registries and other clinical databases. The Hybrid Methodology or medical chart review is not permitted. The following P4P Clinical Domain Technical Specifications apply to P4P health plans and self-reporting POs. Differences between the HEDIS Technical Specifications and the P4P Clinical Domain Technical Specifications are clearly noted under each measure’s Modifications From HEDIS section. 1. Clinical Measures The MY 2012 P4P measures being collected are listed in the table below. Health plans report all measures; self-reporting POs choose which measures to voluntarily report. Priority Area Encounter Rate for Clinical Measures Cardiovascular Diabetes Clinical Measures Encounter Rate by Service Type Adults’ Access to Preventive/Ambulatory Health Services Annual Monitoring for Patients on Persistent Medications Cholesterol Management for Patients With Cardiovascular Conditions—LDL Screening Cholesterol Management for Patients With Cardiovascular Conditions—LDL Control (<100) Proportion of Days Covered by Medications— Renin Angiotensin System (RAS) Antagonists Proportion of Days Covered by Medications— Statins Proportion of Days Covered by Medications— Oral Diabetes Medications Diabetes Care—HbA1c Testing Diabetes Care—HbA1c Poor Control (9.0%) Diabetes Care—HbA1c Control (<8.0%) Diabetes Care—HbA1c Control (<7.0%) for a Selected Population Diabetes Care—Eye Exam Diabetes Care—LDL Screening Diabetes Care—LDL Control (<100) Diabetes Care—Nephropathy Monitoring Diabetes Care—Blood Pressure Control (<140/90) Diabetes Care—Optimal Diabetes Care Measurement Year 2012 P4P Manual Commercial HMO/POS Medicare* NonHEDIS Differs from HEDIS November 30, 2012 MY 2012 P4P Clinical Specifications: Overview Priority Area Musculoskeletal Prevention Respiratory Utilization Clinical Measures Use of Imaging Studies for Low Back Pain Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Osteoporosis Management in Women Who Had a Fracture Childhood Immunization Status—24-Month Continuous Enrollment Immunizations for Adolescents Human Papillomavirus Vaccine for Female Adolescents Chlamydia Screening in Women Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women Breast Cancer Screening Colorectal Cancer Screening Adult BMI Assessment Glaucoma Screening in Older Adults Asthma Medication Ratio Appropriate Testing for Children With Pharyngitis Appropriate Treatment for Children With Upper Respiratory Infection Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis All-Cause Readmissions Commercial HMO/POS Medicare* NonHEDIS 37 Differs from HEDIS *All Medicare measures are CMS Stars measures. November 30, 2012 Measurement Year 2012 P4P Manual 38 MY 2012 P4P Clinical Specifications: Encounter Rate by Service Type Encounter Rate by Service Type (ENRST) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Removed reference to physician organizations in Calculation section. Deleted obsolete HCPCS code G0344 from Table ENR-B. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed obsolete HCPCS code G0394 from table ENR-D. Added new HCPCS code G0450 to table ENR-D. Removed UB Revenue codes 036x, 049x, 075x and 079x from table ENR-F (Option B). Added UB Revenue codes 0360, 0361, 0362, 0367, 0369, 0490, 0499, 0750 and 0790 to table ENR-F (Option B). MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Removed Encounter Rate by Service Type 1–6: Overall Rate threshold requirement. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure. Description The encounter rate is the number of encounters and claims by service type for each PO. Each health plan calculates the rate for each PO with which it contracts and uses it to measure data completeness. The method for identifying encounters by service type is based on the HEDIS Use of Service measures and the General Guidelines. Each service type is calculated as a separate rate. Calculation The encounter rate is total encounters and claims/total member years. Plans should report the total number of unduplicated encounters or claims for each service type and the member years. Definitions Member years Calculate the member years of enrollment for the measurement year for all members. Include all members (adults and children) in the commercial HMO and POS lines of business, regardless of the type of reimbursement contract. This will be the denominator for rates 1–6. Step 1 Determine the PO’s total member months for a health plan using a specified day of each month (e.g., the 15th or the last day of the month), to be determined according to the health plan’s administrative processes. The day selected must be consistent from member to member, month to month and year to year. For example, if the health plan or PO computes membership on the 15th of the month and Ms. X is enrolled in the PO on January 15, Ms. X contributes one member month in January. Step 2 Use the member’s product line and PO affiliation on the specified day of each month to determine the product line and PO to which the member months will be contributed. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Encounter Rate by Service Type Step 3 39 For each PO, calculate member years by dividing total member months by 12. X member months/12 months = Y member years Encounter An encounter differs from a claim in that it represents a service for which there is no claim for payment sent to the health plan (i.e., all member encounters are covered in the health plan’s capitation payment), or a service where the PO may pay the provider a fee for service for the encounter but does not bill the health plan for the service. Follow these guidelines for determining encounters. Include all encounters and claims for services rendered, whether or not they were approved or paid by the PO. Determining encounters/ claims Count any CPT, HCPCS, ICD-9-CM or UB Revenue or Type of Bill code that represents a unique date of service, a unique provider identifier and a unique patient. Count multiple lab tests in one day by the same lab provider as one unique encounter. An encounter for the same date of service, provider and patient that contains multiple types of services should be counted in each category, as appropriate (e.g., an office visit with lab procedures should be included in both categories). Allow at least a two-month lag in submission and count all commercial HMO and POS member encounters or transactions (including out of network POS claims) with a date of service in 2012. Do not include encounters with 2010 or 2011 dates of service that were received in 2012 or 2013. Report services without regard to practitioner type, training or licensing. Include afterhours, nonemergency urgent care, nursing home visits and outpatient surgical procedures. IHA encourages detailed service reporting to facilitate comparability and complete reporting, even when the financial reimbursement arrangement does not require it. Overall encounter rate Sum of the numerators for rates 1, 2, 3, 4a, 5a and 6, divided by member years for the PO. Encounter Rate 1: Office and Other Outpatient Services Denominator Member years. Numerator Count the total number of unduplicated office and other outpatient services encounters/ claims using Table ENR-A. Table ENR-A: Codes to Identify Office and Other Outpatient Services Description Office or other outpatient services Home services Nursing facility care Domiciliary or rest home care Newborn care Observation CPT 99201-99205, 99211-99215, 99241-99245 99341-99345, 99347-99350 99304-99310, 99315, 99316, 99318 99324-99328, 99334-99337 99461 99217-99220 UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 0524, 0525 0762 Note Count office-based surgeries/procedures in this category. _________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 40 MY 2012 P4P Clinical Specifications: Encounter Rate by Service Type Encounter Rate 2: Preventive Medicine Denominator Member years. Numerator Count the total number of preventive medicine encounters/claims using Table ENR-B. Table ENR-B: Codes to Identify Preventive Medicine Services ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 CPT 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429 HCPCS G0402, G0438, G0439 Encounter Rate 3: Ophthalmology and Optometry B Denominator Member years. Numerator Count the total number of ophthalmology or optometry encounters/claims using Table ENR-C. Report services without regard to practitioner type, training or licensing. Table ENR-C: Codes to Identify Ophthalmology or Optometry Services CPT 92002, 92004, 92012, 92014 Encounter Rate 4: Laboratory/Pathology Services Denominator Member years. Numerator Rate 4a Count the total number of encounters/claims using Table ENR-D. Note: Identify one encounter/claim as the same person receiving at least one test on the same day from the same (lab) provider. Do not count multiple tests (i.e., CPT codes) separately that occurred on the same day with the same provider (either within the same encounter/claim record or on a different encounter/claim record). Rate 4b Calculate the total number of tests using Table ENR-D. Count all laboratory/pathology procedure codes separately. For example, if an encounter record contains three different CPT codes (i.e., for three different lab tests), record three ―tests.‖ Sum all the tests to calculate the total numerator. Table ENR-D: Codes to Identify Laboratory/Pathology Services CPT 80047–89398 HCPCS G0027, G0103, G0123, G0124, G0141, G0143-G0145, G0147, G0148, G0306, G0307, G0328, G0450, P2028–P9615, Q0111, Q0114, Q0115, S3620, S3625, S3626, S3628, S3645, S3650, S3652, S3655, S3800– S3890 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Encounter Rate by Service Type 41 Encounter Rate 5: Radiology and Imaging Denominator Member years. Numerator Rate 5a Count the total number of radiology and imaging encounters/claims using Table ENR-E. Note: Identify one encounter/claim as the same person receiving at least one test on the same day from the same provider. Do not count multiple tests (e.g., CPT codes) separately that occurred on the same day with the same provider (either within the same encounter/claim record or on a different encounter record). Rate 5b 34 Calculate the total number of tests using Table ENR-E. Count all radiology procedure codes separately for this metric. For example, if an encounter record contains three different CPT codes (i.e., for three different imaging tests), record three ―tests.‖ Sum all the tests to calculate the total numerator. Table ENR-E: Codes to Identify Radiology/Imaging Services CPT 70010–79999 HCPCS G0106, G0120, G0122, G0130, G0202, G0204, G0206, G0219, G0235, G0252, G0275, G0278, G0288, G0389, Q0035, S8035, S8037, S8042, S8055, S8080, S8085, S8092 Encounter Rate 6: Ambulatory Surgery/Procedures Denominator Member years Numerator Count the total number of ambulatory surgery/procedure encounters/claims using Option A (CMS 1500) or Option B (UB). Refer to Table ENR-F below for both options. CMS 1500 and CPT codes are the preferred method for this measure; when necessary, the health plan should use both methods (i.e., CMS 1500 and UB). Report services without regard to practitioner type, training or licensing. The health plan/PO must avoid double counting and report only ambulatory surgery/ procedures performed at a hospital outpatient facility or at a free-standing surgery center. Count every ambulatory surgery/procedure encounter/claim, which is one discrete service date for a specific member at a specific site (regardless of the number of services provided at that site on that day for that member). Table ENR-F: Codes to Identify Ambulatory Surgery/Procedures Option A: Use CMS 1500 codes in conjunction with CPT codes to identify ambulatory surgery/procedures. CPT Only the CPT covered surgical procedure codes included in the CMS 2010 ASC Approved HCPCS Codes and Payment Rates file* and 92953, 92970, 92971, 92975, 92980, 92982, 92986, 92990, 92992, 92993, 92995, 92996, 93501–93533, 93600–93652 POS AND 22, 24 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 42 MY 2012 P4P Clinical Specifications: Encounter Rate by Service Type Option B: Use UB Type of Bill codes in conjunction with UB Revenue codes, CPT codes and ICD-9-CM codes to identify ambulatory surgery/procedures. ICD-9-CM Procedure 01-86, 88.4, 88.5, 98.5 AND UB Revenue 0320, 0321, 0323, 0360, 0361,0362, 0367, 0369, 0480, 0481, 0490, 0499, 0750, 0790 UB Type of Bill AND 13x, 83x * These codes can be found on the CMS Web site (http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/11_Addenda_Updates.html). Click October 2012 ASC Approved HCPCS codes and Payment Rates. Use only the spreadsheet titled, ―Addendum AA–ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2012.‖ Only use 5digit all-numeric CPT codes (Level 1 HCPCS) in the spreadsheet; do not include any codes with an alpha value. Note Do not report office-based surgeries/procedures in this category; report them under Outpatient Services. Do not count emergency department (ED) claims. Exclusions (required) Duplicate encounters/claims within a service type. Do not count multiple encounters/claims within this service type where the member, provider and date of service are the same, regardless of whether the procedure (CPT) codes are the same or different; if this occurs, only record one encounter/claim. Rates 4b and 5b should count the actual number of tests performed and are not subject to de-duplication. – Member. – Provider. – Date of service. ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Adults’ Access to Preventive/Ambulatory Health Services 43 Adults’ Access to Preventive/Ambulatory Health Services (AAP) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Deleted obsolete HCPCS code G0344 from Table AAP-A. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Added HCPCS codes S0620, S0621 to Table AAP-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 Medicare measure set. MODIFICATIONS FROM HEDIS Adapted for Medicare Advantage product lines only. Description Adults’ Access to Preventive/Ambulatory Health Services is the same measure as the CMS Stars measure Access to Primary Care Doctor Visits. The percentage of Medicare members 20 years and older who had an ambulatory or preventive care visit during the measurement year. Eligible Population Product lines Medicare. Ages 20–65 years and older as of December 31 of the measurement year. Report three age stratifications and a total rate. 20–44 years. 45–64 years. 65 years and older. Total. The total is the sum of the three numerators divided by the sum of the three denominators. Continuous enrollment ...for selfreporting POs …for health plans Allowable gap The measurement year in the PO (parent level, or for eligible POs, subgroup level). The measurement year in the health plan and PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Anchor date ...for selfreporting POs …for health plans November 30, 2012 December 31 of the measurement year in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. December 31 of the measurement year in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Measurement Year 2012 P4P Manual 44 MY 2012 P4P Clinical Specifications: Adults’ Access to Preventive/Ambulatory Health Services Benefit Medical. Event/ diagnosis None. Administrative Specification Denominator The eligible population (report each age stratification separately). Numerator Members who had one or more ambulatory or preventive care visits (Table AAP-A) during the measurement year. Table AAP-A: Codes to Identify Preventive/Ambulatory Health Services Description Office or other outpatient services CPT 99201-99205, 99211-99215, 99241-99245 Home services Nursing facility care 99341-99345, 99347-99350 99304-99310, 99315, 99316, 99318 99324-99328, 99334-99337 Domiciliary, rest home or custodial care services Preventive medicine Ophthalmology and optometry General medical examination 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429 92002, 92004, 92012, 92014 HCPCS ICD-9-CM Diagnosis UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 0524, 0525 G0402, G0438, G0439 S0620, S0621 V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications 45 Annual Monitoring for Patients on Persistent Medications (MPM) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Changed language in allowable gap section to refer to measurement year instead of each year of continuous enrollment. Added LOINC code 62425-4 to Table MPM-B. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Clarified that organizations sum the days supply for all medications to determine treatment days in the Event/diagnosis criteria. Deleted Aliskiren-hydrochlorothiazide-amlodipine from the ―Antihypertensive combinations‖ description in Table MPM-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added aliskiren-valsartan, amlodipine-hydrochlorothiazide-valsartan, amlodipine-hydrochlorothiazideolmesartan and amlodipine-telmisartan to Table MPM-A. Deleted LOINC code 62425-4 from Table MPM-B. MODIFICATIONS FROM HEDIS Excluded annual monitoring for the ―members on anticonvulsants‖ rate. Description The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the three rates separately and as a total rate. Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin. Annual monitoring for members on diuretics. Total rate (the sum of the three numerators divided by the sum of the three denominators). Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). Eligible Population Product lines Commercial HMO/POS. Ages 18 years and older as of December 31 of the measurement year. Continuous enrollment …for selfreporting POs November 30, 2012 The measurement year in the PO (parent level). Measurement Year 2012 P4P Manual 46 MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications …for health plans Allowable gap The measurement year in the health plan and the PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. …for health plans Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefits Medical and pharmacy. Event/diagnosis Members on persistent medications—defined as members who received at least 180 treatment days of ambulatory medication in the measurement year. Refer to Additional Eligible Population Criteria for each rate. Treatment days are the actual number of calendar days covered with prescriptions within the measurement year (i.e., a prescription of 90 days supply dispensed on December 1 of the measurement year counts as 30 treatment days). Sum the days supply for all medications and subtract any days supply that extends beyond December 31 of the measurement year. Note: Medications dispensed in the year prior to the measurement year must be counted toward the 180 treatment days. Administrative Specification Report each of the three rates separately and as a combined rate. The total rate is the sum of the three numerators divided by the sum of the three denominators. Rate 1: Annual Monitoring for Members on ACE Inhibitors or ARBs Additional eligible population criteria Members who received at least 180 treatment days of ACE inhibitors or ARBs during the measurement year. Refer to Table MPM-A to identify ACE inhibitors and ARBs. Note: Members may switch therapy with any medication listed in Table MPM-A during the measurement year and have the days supply for those medications count toward the total 180 treatment days (i.e., a member who received 90 days of ACE inhibitors and 90 days of ARBs meets the denominator definition for rate 1). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications 47 Table MPM-A: Drugs to Identify Members on ACE Inhibitors or ARBs Description Angiotensin converting enzyme inhibitors Angiotensin II inhibitors Antihypertensive combinations Benazepril Captopril Enalapril Fosinopril Azilsartan Eprosartan Candesartan Irbesartan Aliskiren-valsartan Amlodipine-benazepril Amlodipinehydrochlorothiazide-valsartan Amlodipinehydrochlorothiazide-olmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Benazepril-hydrochlorothiazide Numerator Prescription Lisinopril Perindopril Moexipril Quinapril Losartan Telmisartan Olmesartan Valsartan Candesartanhydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide Eprosartanhydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Ramipril Trandolapril Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year (Table MPM-B). The member must meet one of the following criteria to be compliant. A code for a lab panel test during the measurement year. A code for a serum potassium and a code for serum creatinine during the measurement year. A code for serum potassium and a code for blood urea nitrogen during the measurement year. Note: The two tests do not need to occur on the same service date, only in the measurement year. Table MPM-B: Codes to Identify Physiologic Monitoring Tests Description Lab panel Serum potassium (K+) Serum creatinine (SCr) Blood urea nitrogen (BUN) CPT 80047, 80048, 80050, 80053, 80069 80051, 84132 82565, 82575 84520, 84525 LOINC 2824-1, 2823-3, 6298-4, 12812-4, 12813-2, 22760-3, 29349-8, 32713-0, 39789-3, 39790-1, 41656-0, 51618-7 2160-0, 2163-4, 2164-2, 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0, 13447-8, 13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 26752-6, 31045-8, 33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1, 38483-4, 39955-0, 39956-8, 39957-6, 39958-4, 39959-2, 39960-0, 39961-8, 39962-6, 39963-4, 39964-2, 39965-9, 39966-7, 39967-5, 39968-3, 39969-1, 39970-9, 39971-7, 39972-5, 39973-3, 39974-1, 39975-8, 39976-6, 40112-5, 40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2, 40119-0, 40120-8, 40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3, 40128-1, 40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2, 40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5, 40269-3, 40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3, 51619-5, 51620-3, 59826-8, 59834-2, 6425-4 3094-0, 6299-2, 11064-3, 11065-0, 12964-3, 12965-0, 12966-8, 14937-7, 44734-2, 49071-4, 59570-2 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 48 MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications Rate 2: Annual Monitoring for Members on Digoxin Denominator Members who received at least 180 treatment days of a digoxin (Table MPM-C) during the measurement year. Table MPM-C: Drugs to Identify Members on Digoxin Description Inotropic agents Numerator Prescription Digoxin At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year (Table MPM-B). The member must meet one of the following criteria to be compliant. A code for a lab panel test during the measurement year. A code for a serum potassium and a code for serum creatinine during the measurement year. A code for serum potassium and a code for blood urea nitrogen during the measurement year. Note: The two tests do not need to occur on the same service date, only within the measurement year. Rate 3: Annual Monitoring for Members on Diuretics Denominator Members who received at least 180 treatment days of a diuretic (Table MPM-D) during the measurement year. Note: Members may switch therapy within any medication listed in Table MPM-D during the measurement year and have the days supply for those medications count toward the total 180 treatment days. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications 49 Table MPM-D: Drugs to Identify Members on Diuretics Description Antihypertensive combinations Loop diuretics Potassium-sparing diuretics Thiazide diuretics Numerator Prescription Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-methyldopa Hydrochlorothiazide-metoprolol Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-propranolol Hydrochlorothiazide-quinapril Hydrochlorothiazide-spironolactone Hydrochlorothiazide-telmisartan Hydrochlorothiazide-timolol Hydrochlorothiazide-triamterene Hydrochlorothiazide-valsartan Aliskiren-hydrochlorothiazide Aliskiren-hydrochlorothiazideamlodipine Amiloride-hydrochlorothiazide Amlodipine-hydrochlorothiazideolmesartan Amlodipine-hydrochlorothiazidevalsartan Atenolol-chlorthalidone Benazepril-hydrochlorothiazide Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Chlorthalidone-clonidine Enalapril-hydrochlorothiazide Eprosartan-hydrochlorothiazide Bumetanide Furosemide Ethacrynic acid Torsemide Amiloride Spironolactone Eplerenone Triamterene Chlorothiazide Indapamide Chlorthalidone Methyclothiazide Hydrochlorothiazide Metolazone At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year (Table MPM-B). The member must meet one of the following criteria to be compliant. A code for a lab panel test during the measurement year. A code for a serum potassium and a code for serum creatinine during the measurement year. A code for serum potassium and a code for blood urea nitrogen during the measurement year. Note: The two tests do not need to occur on the same service date, only in the measurement year. Exclusion (optional) Exclude members from each eligible population rate who had an inpatient stay (acute or nonacute) in the measurement year. November 30, 2012 Measurement Year 2012 P4P Manual 50 MY 2012 P4P Clinical Specifications: Cholesterol Management Cholesterol Management for Patients With Cardiovascular Conditions (CMC) LDL Screening and Control (<100) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added instructions to use both facility and professional claims to identify AMI and CABG for the event/ diagnosis. Added LOINC code 69419-0 to Table CMC-D. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Added instructions to use only facility claims (not professional claims) to identify AMI and CABG for the event/diagnosis. Clarified that codes from Table CMC-D should be used to identify the most recent LDL-C test for the LDL-C Control indicator. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description Cholesterol Management for Patients With Cardiovascular Conditions (CMC)—LDL Screening is the same measure as the CMS Stars measure Cardiovascular Care—Cholesterol Screening. The percentage of members 18–75 years of age who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1– November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year (January 1–December 31) and the year prior to measurement year and had each of the following during the measurement year. LDL-C screening. LDL-C control (<100 mg/dL). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Cholesterol Management 51 Eligible Population Product line Report each product line separately. Commercial HMO/POS Clinical Measures LDL-C Screening LDL-C Control (<100 mg/dL) Ages Medicare 18–75 years as of December 31 of the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement year and the year prior to the measurement year in the PO (parent level). The measurement year and the year prior to the measurement year the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs …for health plans Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefit Medical. Event/ diagnosis Members are identified for the eligible population in one of two ways: event or diagnosis. Both criteria must be used to identify the eligible population, but a member need only be identified in one to be included in the measure. Event. Discharged alive for AMI, CABG or PCI on or between January 1 and November 1 of the year prior to the measurement year. Refer to Table CMC-A for codes to identify AMI, PCI and CABG. Include AMI and CABG from inpatient claims only and use only. Use both facility and professional claims to identify AMI or CABG. All cases of PCI should be included, regardless of setting (e.g., inpatient, outpatient, ED). Table CMC-A: Codes to Identify AMI, PCI and CABG Description AMI (include only inpatient claims) CABG (include only inpatient claims) PCI CPT 33510-33514, 33516-33519, 33521-33523, 33533-33536 92980, 92982, 92995 HCPCS ICD-9-CM Diagnosis 410.x1 ICD-9-CM Procedure S2205-S2209 36.1, 36.2 G0290 00.66, 36.06, 36.07 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 52 MY 2012 P4P Clinical Specifications: Cholesterol Management Diagnosis. Identify members as having IVD who met at least one of the two criteria below, during both the measurement year and the year prior to the measurement year (criteria need not be the same across both years). At least one outpatient visit (Table CMC-C) with any IVD diagnosis (Table CMC-B). At least one acute inpatient visit (Table CMC-C) with any IVD diagnosis (Table CMC-B). Table CMC-B: Codes to Identify IVD Description IVD ICD-9-CM Diagnosis 411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434, 440.1, 440.2, 440.4, 444, 445 Table CMC-C: Codes to Identify Visit Type Description Outpatient Acute inpatient CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983 010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x,021x, 072x, 0987 Administrative Specification Denominator The eligible population. Numerator LDL-C screening An LDL-C test performed any time during the measurement year, as identified by claim/encounter or automated laboratory data. Use any code listed in Table CMC-D. The organization may use a calculated or direct LDL for LDL-C screening and control indicators. Table CMC-D: Codes to Identify LDL-C Screening CPT 80061, 83700, 83701, 83704, 83721 CPT Category II 3048F, 3049F, 3050F LOINC 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2, 49132-4, 55440-2, 69419-0 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Cholesterol Management LDL-C level <100 mg/dL 53 Use codes in Table CMC-D to identify the most recent LDL-C screening test during the measurement year. The member is numerator compliant if the most recent LDL-C level is <100 mg/dL during the measurement year. The member is not compliant if the result for the most recent LDL-C test is ≥100 mg/dL or is missing, or if an LDL-C test was not done during the measurement year. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search all the codes in Table CMC-E and use the most recent code during the measurement year to evaluate whether the member is numerator compliant. Table CMC-E: Codes to Identify LDL-C Levels Description Numerator compliant (LDL-C <100 mg/dL) Not numerator compliant (LDL-C ≥100 mg/dL) CPT Category II 3048F 3049F, 3050F __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 54 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications Proportion of Days Covered by Medications (PDC) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Measure description changed to emphasize that members must have filled at least two prescriptions in a given medication category to be included in the measure. Clarified that if the pharmacy benefit ends, the measurement period ends. Added language to the additional eligible population criteria and the numerator calculation to clarify that only paid, nonreversed claims should be used in the calculation of the measure. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 PDC: ACEI/ARB Medications renamed PDC: Renin Angiotensin System (RAS) Antagonists Continuous enrollment section changed to refer to measure period for both self-reporting POs and health plans. Allowable gap section clarified to reflect that members with two distinct measurement periods are excluded due to a gap in enrollment. Added Direct Renin Inhibitor, Direct Renin Inhibitor Combinations and azilsartan-chlorthalidone to Table PDC-A. Removed lisinopril-nutritional supplement from Table PDC-A. Added sitagliptin-simvastatin to Table PDC-B Deleted all duplicate categories in Table PDC-C. Added sitagliptin-simvastatin and lingaliptin-metformin to Table PDC-C. Added text stating how the measure is labeled by CMS. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 P4P quality and Medicare measure sets. MODIFICATIONS FROM HEDIS This non-HEDIS measure is based on the work of the Pharmacy Quality Alliance (PQA). It is a NQFendorsed measure. Description Proportion of Days Covered by Medications—Renin Angiotensin System (RAS) Antagonists is the same as the CMS Stars measure Medication Adherence for Hypertension (RAS Antagonists). Proportion of Days Covered by Medications—Statins is the same as the CMS Stars measure Medication Adherence for Cholesterol (Statins). Proportion of Days Covered by Medications—Oral Diabetes Medications is the same as the CMS Stars measure Medication Adherence for Oral Diabetes Medications. The percentage of members 18 years of age and older who met the proportion of days covered (PDC) threshold of 80 percent for select medications during the measurement period. Members must have filled at least two prescriptions in a given medication category to be included in the measure. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications 55 Report a performance rate for each of the following: Cardiovascular Proportion of Days Covered by Medications: Renin Angiotensin System (RAS) Antagonists (ACEI, ARB, Direct Renin Inhibitors). Proportion of Days Covered by Medications: HMG-CoA Inhibitors (i.e., statins). Diabetes Proportion of Days Covered by Medications: Oral Diabetes Medications (biguanides, sulfonylureas, thiazolidinediones or DPP-IV inhibitors) Note: Refer to the IHA Web site (http://iha.org/manuals_operations_2012.html) for a comprehensive list of medications and associated codes (PQA June 2012 NDC List). Definitions Index prescription date (IPD) The date of the first fill of the target medication in the measurement year. The member’s measurement period begins on this date. The index date must occur at least 91 days before the end of the measurement period. Member measurement period A member’s index prescription date through the last day of the measurement year or until death or disenrollment. Disenrollment from the pharmacy benefit counts as disenrollment. PDC The proportion of days in the measurement period covered by prescription claims for the same medication or another in its therapeutic category. PDC threshold The level of PDC above which the medication has a reasonable likelihood of achieving most of the potential clinical benefit (i.e., 80 percent). Eligible Population Product lines Commercial HMO/POS, Medicare. Age 18 years and older as of the last day of the measurement period. Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement period: the index prescription date (IPD) through the end of the measurement year or until death or disenrollment from the PO (parent level). The measurement period: the IPD through the end of the measurement year or until death or disenrollment from the health plan and from the PO (parent level). No gaps in enrollment during the continuous enrollment period. If the member has two distinct measurement periods in one measurement year, exclude the member due to a gap in enrollment. Measurement periods begin when an IPD occurs. Anchor date …for selfreporting POs None. …for health plans None. November 30, 2012 Measurement Year 2012 P4P Manual 56 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications Benefit Pharmacy*. Event/ diagnosis Refer to Additional Eligible Population Criteria for each rate. * Although the measure may be calculated with only pharmacy claims, it is not intended to exclude patients who also have a medical benefit. Administrative Specification Report each rate separately. Members may be counted in the denominator for multiple rates if they have been dispensed the relevant medications, though for each rate, the proportion of days covered should only be counted once per member. Rate 1: PDC for Renin Angiotensin System (RAS) Antagonists Additional eligible population criteria Members who filled at least two prescriptions for a RAS antagonist or a RAS antagonist combination (Table PDC-A: Renin Angiotensin System (RAS) Antagonist Medications) on two unique dates of service during the measurement period. Use only paid, nonreversed claims for target medications to determine if members are eligible. Table PDC-A: Renin Angiotensin System (RAS) Antagonists Renin Angiotensin System (RAS) Antagonists Direct renin inhibitor medications Aliskiren Angiotensin receptor blockers (ARB) medications Angiotensin converting enzyme inhibitors (ACEI) medications Antihypertensive combinations Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan Azilsartan Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Direct renin inhibitor combination products Aliskiren-valsartan Amlodipine-benazepril Amlodipine-olmesartan Amlodipine-valsartan Amlodipine-valsartanhydrochlorothiazide Azilsartan-chlorthalidone Benazepril-hydrochlorothiazide Candesartanhydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-felodipine Enalapril-hydrochlorothiazide Aliskiren-amlodipine Aliskiren-amlodipinehydrochlorothiazide Eprosartanhydrochlorothiazide Fosinoprilhydrochlorothiazide Irbesartanhydrochlorothiazide Lisinoprilhydrochlorothiazide Losartanhydrochlorothiazide Moexiprilhydrochlorothiazide Ramipril Trandolapril Olmesartan-amlodipinehydrochlorothiazide OlmesartanhydrochlorothiazideQuinapril-hydrochlorothiazide Telmisartan-amlodipine Telmisartanhydrochlorothiazide Trandolapril-verapamil HCL Valsartanhydrochlorothiazide Aliskirenhydrochlorothiazide Aliskiren-valsartan Note: Active ingredients are limited to oral formulations only. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications Numerator 57 The number of members who met the PDC threshold during the measurement year. Follow the steps below for each member to determine whether the member meets the PDC threshold. Step 1 Determine the member’s measurement period. Step 2 Within the measurement period, count the days the member was covered by at least one drug in the class based on the prescription fill date and days of supply. If prescriptions for the same drug overlap (i.e., at the Generic Code Sequence Number [GCN] level; refer to the detailed medication list on the IHA Web site), adjust the prescription start date to be the day after the previous fill has ended. Use only paid, nonreversed claims for target medications to calculate the days the member was covered. Step 3 Divide the number of covered days found in step 2 by the number of days found in step 1. Multiply this number by 100 to obtain the PDC (as a percentage) for each member. Step 4 Count the number of members who had a PDC greater than 80 percent. Calculate performance rate Divide the number of members from step 4 by the total number of eligible members. Rate 2: PDC for Statin Medications Additional eligible population criteria Members who filled at least two prescriptions for a statin or statin combination (Table PDC-B) on two unique dates of service during the measurement period. Use only paid, nonreversed claims for target medications to determine if members are eligible. Table PDC-B: Statin Medications Statins Lovastatin Rosuvastatin Niacin-lovastatin Atorvastatinamlodipine Statin combinations Statins and Statin Combinations Fluvastatin Pravastatin Atorvastatin Pitavastatin NiacinEzetimibesimvastatin simvastatin PravastatinSitagliptinaspirin simvastatin Simvastatin Note: Active ingredients are limited to oral formulations only. Numerator The number of members who met the PDC threshold during the measurement year. Follow the steps below for each member to determine whether the member meets the PDC threshold. Step 1 Determine the member’s measurement period. Step 2 Within the measurement period, count the days the member was covered by at least one drug in the class based on the prescription fill date and days of supply. If prescriptions for the same drug overlap (i.e., at the Generic Code Sequence Number [GCN] level; refer to the detailed medication list on the IHA Web site), adjust the prescription start date to be the day after the previous fill has ended. Use only paid, nonreversed claims for target medications to calculate the days the member was covered. Step 3 Divide the number of covered days found in step 2 by the number of days found in step 1. Multiply this number by 100 to obtain the PDC (as a percentage) for each member. Step 4 Count the number of members who had a PDC greater than 80 percent. November 30, 2012 Measurement Year 2012 P4P Manual 58 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications Calculate performance rate Divide the number of members from step 4 by the total number of eligible members. Rate 3: PDC for Oral Diabetes Medications Additional eligible population criteria Members who filled at least two prescriptions for any oral diabetes medication (Table PDC-C) on two unique dates of service during the measurement period. Use only paid, nonreversed claims for target medications to determine if members are eligible. Exclusion criteria Members who filled one or more prescriptions for insulin (Table PDC-D) during the measurement period. Table PDC-C: Oral Diabetes Medications Biguanides Biguanide and sulfonylurea combinations Biguanide andthiazolinedione combinations Biguanide and meglitinide combinations Sulfonylureas Sulfonylurea and thiazolinedione combinations Thiazolinediones DPP-IV inhibitors DPP-IV inhibitor combinations Oral Diabetes Medications Metformin Glipizide-metformin Glyburide-metformin Rosiglitazone-metformin Pioglitazone-metformin Repaglinide-metformin Acetohexamide Chlorpropamide Glimepiride Glipizide Rosiglitazone-glimepiride Glyburide Tolazamide Tolbutamide Pioglitazone Sitagliptin Linagliptin Sitagliptin-metformin (IR and SR) Saxagliptin-metformin SR Rosiglitazone Saxagliptin Pioglitazone-glimepiride Sitagliptin-simvastatin Linagliptin-metformin Note: Active ingredients are limited to oral formulations only. Table PDC-D: Insulin Medications Human insulins Human Insulins Insulin aspart Insulin lispro Insulin aspart protamine-aspart Insulin lispro protamine-insulin lispro Insulin detemir Insulin regular (human R) Insulin glargine Insulin regular (human) buffered Insulin glulisine Insulin regular inhalation powder Insulin isophane—regular human Insulin zinc (lente) insulin Insulin zinc extended (human ultralente) Insulin isophane (human N) Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications Numerator 59 The number of members who met the PDC threshold during the measurement year. Follow the steps below for each member to determine whether the member meets the PDC threshold. Step 1 Determine the member’s measurement period. Step 2 Within the measurement period, count the days the member was covered by at least one drug in the class based on the prescription fill date and days of supply. If prescriptions for the same drug overlap (i.e., at the GCN level; refer to the detailed medication list on the IHA Web site), adjust the prescription start date to be the day after the previous fill has ended. Use only paid, nonreversed claims for target medications to calculate the days the member was covered. Step 3 Divide the number of covered days found in step 2 by the number of days found in step 1. Multiply this number by 100 to obtain the PDC (as a percentage) for each member. Step 4 Count the number of members who had a PDC greater than 80 percent. Calculate performance rate Divide the number of members from step 4 by the total number of eligible members. Exclusions (optional) None. November 30, 2012 Measurement Year 2012 P4P Manual 60 MY 2012 P4P Clinical Specifications: Diabetes Care Diabetes Care (CDC) HbA1c Testing, HbA1c Poor Control (>9.0%), HbA1c Control (<8.0%), HbA1c Control (<7.0%) for a Selected Population, Eye Exam, LDL Screening and Control (<100), Nephropathy Monitoring, Blood Pressure Control (<140/90), Optimal Diabetes Care MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Blood Pressure Control (<140/90): Added option for POs and plans to identify appropriate setting for BP reading by using the requirement that the blood pressure reading must be during an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. POs and plans may use either this method or the exclusion criteria for Blood Pressure Control (<140/90) to identify BPs taken in an appropriate setting; POs and plans must choose one of these methods and use it consistently. Changed language in allowable gap section to refer to measurement year instead of each year of continuous enrollment. Added instructions to use both facility and professional claims to identify CABG for the required exclusion for the HbA1c control (<7.0%) for a selected population. Added LOINC code 71875-9 to Table CDC-D. Added LOINC code 69419-0 to Table CDC-K. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added ICD-9 CM Diagnosis code 294.1 to Table CDC-G. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Blood Pressure Control (<140/90): Removed the requirement that the blood pressure reading must be in conjunction with an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. Blood Pressure Control (<140/90): Added exclusion criteria. Added saxagliptin, sitagliptin-simvastatin, liraglutide and metformin-repaglinide to Table CDC-A. Added text stating how the measure is labeled by CMS. Added sitagliptin-simvastatin to the description of ―Antidiabetic combinations‖ in Table CDC-A. Removed insulin regular beef-pork, insulin regular pork, insulin zinc beef-pork, insulin zinc extended human and Insulin zinc pork from Table CDC-A. Deleted CPT codes 92002, 92004, 92012, 92014 from Table CDC-C. Added ICD-9-CM Diagnosis codes 425 and 294.2 to Table CDC-G. Deleted ICD-9-CM Diagnosis code 294.8 from Table CDC-G. Added thoracic aortic aneurysm to the required exclusions for HbA1c control (<7.0%) for a selected population and added corresponding codes to Table CDC-G. Added instructions to use only facility claims to identify CABG for the required exclusion for the HbA1c control (<7.0%) for a selected population (do not use professional claims). Clarified that a negative dilated eye exam in the year prior to the measurement year meets criteria for the Eye Exam indicator. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 61 Deleted ICD-9-CM Procedure codes (which identify procedures that occur in an inpatient setting) from Table CDC-J: Codes to Identify Eye Exams. The intent of the measure is to identify eye visits performed in an outpatient setting, which are identified by CPT and HCPCS. Deleted obsolete CPT code 36145 from Table CDC-N. Deleted obsolete HCPCS codes G0392, G0393 from Table CDC-N. Deleted Aliskiren-hydrochlorothiazide-amlodipine from the ―Antihypertensive combinations‖ description in Table CDC-O. Clarified that an incomplete reading is not compliant for the BP control indicator. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added Eye Exams to the MY 2012 Medicare measure set. Removed CPT codes 36801–36809, 36811–36814 and 36816–36817 from Table CDC-G. Renamed Tables CDC-J–CDC-P. MODIFICATIONS FROM HEDIS Optimal Diabetes Care is a non-HEDIS measure that is an ―all or none‖ combination rate of three HEDIS measures. Blood Pressure Control (<140/90): POs and plans may choose to use either the requirement that the blood pressure reading must be in conjunction with an outpatient visit code or a nonacute inpatient visit code from Table CDC-C or to use optional exclusions to identify BPs taken in the appropriate setting. Description Diabetes Care—LDL-C Screening is the same measure as the CMS Stars measure Diabetes Care— Cholesterol Screening. Diabetes Care—Nephropathy Monitoring is the same measure as the CMS Stars measure Diabetes Care—Kidney Disease Monitoring. Diabetes Care—HbA1c Poor Control (>9.0%) is the same measure as the CMS Stars measure Diabetes Care—Blood Sugar Controlled. Eye Exams for Diabetics is the same measure as the CMS Stars measure Diabetes Care—Eye Exam. Comprehensive Diabetes Care—LDL-C Control (<100mg/dL) is the same as the CMS Stars measure Diabetes Care—Cholesterol Controlled. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 62 MY 2012 P4P Clinical Specifications: Diabetes Care The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who met the numerator criterion for the rates below. HbA1c Testing. HbA1c Poor Control (>9.0%). HbA1c Control (<8.0%). HbA1c Control (<7.0%) for a Selected Population*. Eye Exam. LDL-C Screening. LDL-C Control (<100 mg/dL). Nephropathy Monitoring. Blood Pressure Control (<140/90 mm Hg). Optimal Diabetes Care. – Combination Rate 1: HbA1c Control (<8.0%), LDL-C Control (<100 mg/dL), Nephropathy Monitoring. – Combination Rate 2: All criteria in Combination Rate 1 and BP Control (<140/90 mm Hg). – Additional exclusion criteria are required for this indicator that will result in a different eligible population from all other indicators. *This indicator is only reported for the commercial product line. Note: The Optimal Diabetes Care measure comprises two combination rates with two separate performance rates; ―all or none‖ criterion is used to qualify for each combination rate. For the Optimal Diabetes Care Measure, Combination Rate 1 will be the only measure recommended for public reporting and payment. This measure is based on the Minnesota Community Measurement Program. Eligible Population Product line Report each product line separately. Clinical Measures Diabetes Care—HbA1c Testing Diabetes Care—HbA1c Poor Control (9.0%) Diabetes Care—HbA1c Control (<8.0%) Diabetes Care—HbA1c Control (<7.0%) for a Selected Population Diabetes Care—Eye Exam Diabetes Care—LDL Screening Diabetes Care—LDL Control (<100) Diabetes Care—Nephropathy Monitoring Diabetes Care—Blood Pressure Control (<140/90) Diabetes Care—Optimal Diabetes Care Measurement Year 2012 P4P Manual Commercial HMO/POS Medicare November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care Ages 63 18–75 years as of December 31 of the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement year in the PO (parent level). The measurement year in the health plan and the PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Anchor date …for selfreporting POs …for health plans Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefit Medical. Event/ diagnosis Members are identified for the denominator in two ways: pharmacy data and claim/ encounter data. Both methods must be used to identify the eligible population; however, to be included in the measure, a member need only identified by one method. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year. Pharmacy data. Members who were dispensed insulin or oral hypoglycemics/antihyperglycemias (Table CDC-A) on an ambulatory basis during the measurement year or the year prior to the measurement year. Table CDC-A: Prescriptions to Identify Members With Diabetes Description Alpha-glucosidase inhibitors Amylin analogs Antidiabetic combinations Insulin Meglitinides Miscellaneous antidiabetic agents Sulfonylureas Thiazolidinediones November 30, 2012 Prescription Acarbose Miglitol Pramlinitide Metformin-sitagliptin Glimepiride-pioglitazone Glyburide-metformin Saxagliptin Glimepiride-rosiglitazone Metformin-pioglitazone Glipizide-metformin Sitagliptin-simvastatin Metformin-rosiglitazone Insulin aspart Insulin isophane human Insulin isophane-insulin regular Insulin aspart-insulin aspart protamine Insulin lispro Insulin detemir Insulin glargine Insulin lispro-insulin lispro protamine Insulin glulisine Insulin regular human Insulin inhalation Insulin zinc human Insulin isophane beef-pork Nateglinide Repaglinide Exenatide Liraglutide Sitagliptin Metforminrepaglinide Acetohexamide Glimepiride Glyburide Tolbutamide Glipizide Chlorpropamide Tolazamide Pioglitazone Rosiglitazone Measurement Year 2012 P4P Manual 64 MY 2012 P4P Clinical Specifications: Diabetes Care Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis coding only. NCQA provides a complete list of medications and NDC codes on its Web site (www.ncqa.org). Claim/encounter data. Members who had two face-to-face encounters, in an outpatient setting or nonacute inpatient setting, on different dates of service, with a diagnosis of diabetes (Table CDC-B), or one face-to-face encounter in an acute inpatient or ED setting, with a diagnosis of diabetes, during the measurement year or the year prior to the measurement year. The PO may count services that occur over both years. Refer to Table CDC-B for codes to identify a diabetes diagnosis; refer to Table CDC-C for codes to identify visit type. Table CDC-B: Codes to Identify Diabetes Description Diabetes ICD-9-CM Diagnosis 250, 357.2, 362.0, 366.41, 648.0 Table CDC-C: Codes to Identify Visit Type Description Outpatient Nonacute inpatient Acute inpatient ED CPT 99201-99205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291 99281-99285 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 082x085x, 088x, 0982, 0983 0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x 010x, 0110-0114, 0119, 0120-0124, 0129, 01300134, 0139, 0140-0144, 0149, 0150-0154, 0159, 016x, 020x, 021x,072x, 080x, 0987 045x, 0981 Administrative Specification Denominator The eligible population. Numerator HbA1c Testing An HbA1c test performed during the measurement year as identified through either administrative data or electronically available clinical data. Refer to Table CDC-D for codes to indicate that an HbA1c test was performed. Table CDC-D: Codes to Identify HbA1c Tests CPT 83036, 83037 CPT Category II 3044F, 3045F, 3046F LOINC 4548-4, 4549-2, 17856-6, 59261-8, 62388-4, 71875-9 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care HbA1c Poor Control >9% 65 Use codes in Table CDC-D to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done during the measurement year. The member is not numerator compliant if the result for the most recent HbA1c test during the measurement year is ≤9.0%. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-E and use the most recent code during the measurement year to evaluate whether the member is numerator compliant. Note: For this indicator, a lower rate indicates better performance (i.e., low rates of poor control indicate better care). Table CDC-E: Codes to Identify HbA1c Levels >9.0% Description Numerator compliant (HbA1c >9.0%) Not numerator compliant (HbA1c ≤9.0%) HbA1c Control <8.0% CPT Category II 3046F 3044F, 3045F Use codes in Table CDC-D to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is <8.0%. The member is not numerator compliant if the result for the most recent HbA1c test is ≥8.0% or is missing a result, or if an HbA1c test was not done during the measurement year. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-F and use the most recent code during the measurement year to evaluate whether the member is numerator compliant. Table CDC-F: Codes to Identify HbA1c Levels <8.0% Description Numerator compliant (HbA1c <8.0%) Not numerator compliant (HbA1c ≥8.0%) CPT Category II 3044F 3045F*, 3046F * CPT Category II code 3045F indicates most recent HbA1c (HbA1c) level 7.0%–9.0% and is not specific enough to denote numerator compliance for this indicator. For members with this code, the organization may use other sources (laboratory data) to determine if the HbA1c result was <8%. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 66 MY 2012 P4P Clinical Specifications: Diabetes Care Required exclusions for the HbA1c Control <7.0% for a Selected Population indicator Exclude members who meet any of the following criteria. 65 years of age and older as of December 31 of the measurement year. Coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI). Members discharged alive for CABG or PCI in the measurement year or the year prior to the measurement year. Use the codes listed in Table CDC-G to identify PCI and CABG. CABG cases should be from inpatient claims only. Use both facility and professional claims to identify CABG. Include all cases of PCI, regardless of setting (e.g., inpatient, outpatient, ED). Ischemic vascular disease (IVD). Members who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. – At least one outpatient visit (Table CDC-H) with an IVD diagnosis (Table CDC-G), or – At least one acute inpatient visit (Table CDC-H) with an IVD diagnosis (Table CDC-G). Thoracic aortic aneurysm. Members who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. – At least one outpatient visit (Table CDC-H) with a thoracic aortic aneurysm diagnosis (Table CDC-G), or – At least one acute inpatient claim/encounter (Table CDC-H) with a thoracic aortic aneurysm diagnosis (Table CDC-G). Chronic heart failure (CHF). Members who had at least one encounter/ claim in any setting, with any code to identify CHF (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year. Prior myocardial infarction (MI). Members who had at least one encounter/ claim in any setting, with any code to identify MI (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year. Chronic renal failure (CRF)/end-stage renal disease (ESRD). Members who had at least one encounter/claim in any setting, with any code to identify CRF/ESRD (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year Dementia. Members who had at least one encounter/claim in any setting, with any code to identify dementia (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year. Blindness. Members who had at least one encounter/claim in any setting, with any code to identify blindness (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year. Amputation (lower extremity). Members who had at least one encounter/ claim in any setting, with any code to identify lower extremity amputation (Table CDC-G). Look as far back as possible in the member’s history through December 31 of the measurement year. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 67 Table CDC-G: Codes to Identify Required Exclusions for HbA1c Control <7.0% for a Selected Population Description Thoracic aortic aneurysm CABG (include only inpatient claim ) PCI IVD CHF MI CRF/ESRD CPT 33510-33514, 33516-33519, 33521-33523, 33533-33536 92980, 92982, 92995 36145, 36147, 36800, 36810, 36815, 36818-36821, 3683136833, 90919-90921, 9092390925, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 Dementia ICD-9-CM Diagnosis 441.01, 441.03, 441.1, 441.2, 441.6, 441.7 S2205-S2209 UB Revenue UB Type of Bill POS 36.1, 36.2 G0290 G0257, G0311-G0319, G0321-G0323, G0325G0327, G0392, G0393, S9339 ICD-9-CM Procedure 00.66, 36.06, 36.07 411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434, 440.1, 440.2, 440.4, 444, 445 425, 428 410, 412 585.4, 585.5, 585.6, V42.0, V45.1 38.95, 39.27, 39.42, 39.43, 39.53, 39.9339.95, 54.98 080x, 082x085x, 088x 72x 65 290, 291.2, 292.82, 294.0-294.2, 331.0, 331.1, 331.82 369.0, 369.1, 369.2, 369.4, 369.6, 369.7 Blindness Amputation (lower extremity) HCPCS 27290, 27295, 27590-27592, 27594, 27596, 27598, 27880, 27881, 27882, 27884, 27886, 27888, 27889, 28800, 28805, 28810, 28820, 28825 84.1 __________ Current Procedure Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 68 MY 2012 P4P Clinical Specifications: Diabetes Care Table CDC-H: Codes to Identify Visit Type for IVD Diagnosis Description Outpatient Acute inpatient CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983 010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x,021x, 072x, 0987 Numerator HbA1c Control <7.0% for a Selected Population Use codes in Table CDC-D to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is <7.0%. The member is not numerator compliant if the result for the most recent HbA1c test during the measurement year is ≥7.0% or is missing a result or if an HbA1c test was not done during the measurement year. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-I and use the most recent code during the measurement year to evaluate the member’s numerator compliance. Note: This indicator uses the eligible population with additional eligible population criteria (i.e., removing members with required exclusions.) Table CDC-I: Codes to Identify HbA1c Levels <7.0% Description Numerator compliant (HbA1c <7.0%) Not numerator compliant (HbA1c >7.0%) Eye Exam CPT* Category II 3044F 3045F, 3046F An eye screening for diabetic retinal disease as identified by administrative data. 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 exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. Refer to Table CDC-J for codes to identify eye exams. For exams performed in the year prior to the measurement year, a result must be available. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 69 Table CDC-J: Codes to Identify Eye Exams* CPT CPT Category II** HCPCS 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 2022F, 2024F, S0620, S0621, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 2026F, 3072F*** S0625**, S3000 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 * Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to determine that a dilated exam was performed. ** The organization does not need to limit CPT Category II codes or HCPCS S0625 to an optometrist or an ophthalmologist. These codes indicate an eye exam was performed by an eye care professional. *** CPT Category II code 3072F can only be used if the claim/encounter was during the measurement year because it indicates the member had ―no evidence of retinopathy in the prior year.‖ Additionally, because the code definition itself indicates results were negative, an automated result is not required. LDL-C Screening An LDL-C test performed during the measurement year as identified by claim/ encounter or automated laboratory data. Use any code listed in Table CDC-K. The organization may use a calculated or direct LDL for LDL-C screening and control indicators. Table CDC-K: Codes to Identify LDL-C Screening CPT 80061, 83700, 83701, 83704, 83721 LDL-C Control <100 mg/dL CPT Category II 3048F, 3049F, 3050F LOINC 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2, 49132-4, 55440-2, 69419-0 Use codes in Table CDC-K to identify the most recent LDL-C test during the measurement year. The member is numerator compliant if the most recent LDL-C level during the measurement year is <100 mg/dL. The member is not compliant if the result for the most recent LDL-C test is ≥100 mg/dL or is missing, or if an LDL-C test was not done during the measurement year. If the most recent test during the measurement year is identified by a CPT Category II code, refer to Table CDC-L to evaluate whether the member is numerator compliant. Table CDC-L: Codes to Identify LDL-C Levels Description Numerator compliant (LDL-C <100 mg/dL) Not numerator compliant (LDL-C ≥100 mg/dL) Nephropathy Monitoring CPT Category II 3048F 3049F, 3050F A nephropathy screening test or evidence of nephropathy, as documented through administrative data. Note: A process flow diagram is included at the end of this specification to help implement this specification. Nephropathy Screening Test A nephropathy screening test during the measurement year (Table CDC-M). __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 70 MY 2012 P4P Clinical Specifications: Diabetes Care Table CDC-M: Codes to Identify Nephropathy Screening Tests Description Nephropathy screening test Evidence of nephropathy CPT 82042, 82043, 82044, 84156 CPT Category II 3060F, 3061F LOINC 1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4, 2890-2, 9318-7, 11218-5, 12842-1, 13801-6, 14956-7, 14957-5, 14958-3, 14959-1, 13705-9, 14585-4, 18373-1, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1 Any of the following meet the criteria for evidence of nephropathy. A claim/encounter with a code to indicate evidence of treatment for nephropathy (Table CDC-N) during the measurement year. A nephrologist visit during the measurement year, as identified by specialtyprovider codes (no restriction on the diagnosis or procedure code submitted). A positive urine macroalbumin test in the measurement year, as documented by claim/encounter or automated laboratory data. Refer to Table CDC-N for codes to identify urine macroalbumin tests. ―Trace‖ urine macroalbumin test results are not considered numerator-compliant. Evidence of ACE inhibitor/ARB therapy during the measurement year. Members who had a claim indicating therapy (Table CDC-N), or who received an ambulatory prescription or were dispensed an ambulatory prescription for ACE inhibitors or ARBs during the measurement year are compliant. Table CDC-O lists the ACE inhibitors/ARBs included in this measure. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 71 Table CDC-N: Codes to Identify Evidence of Nephropathy Description Urine macroalbumin test* CPT 81000-81003, 81005 Evidence of treatment for nephropathy 36147, 36800, 36810, 36815, 36818, 36819-36821, 3683136833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 CPT Category II* 3062F 3066F HCPCS G0257, S9339 ICD-9-CM Diagnosis ICD-9-CM Procedure 250.4, 403, 404, 405.01, 405.11, 405.91, 580588, 753.0, 753.1, 791.0, V42.0, V45.1 38.95, 39.27, 39.42, 39.43, 39.53, 39.9339.95, 54.98, 55.4-55.6 UB Revenue 0367, 080x, 082x-085x, 088x UB Type of Bill POS 72x 65 LOINC 5804-0, 20454-5, 50561-0, 535252, 57735-3 4009F ACE inhibitor/ ARB therapy * A CPT Category II code indicates a positive result for urine macroalbumin; the organization must use automated laboratory data to confirm a positive result for tests identified by CPT or LOINC codes. Table CDC-O: ACE Inhibitors/ARBs Description Angiotensin converting enzyme inhibitors Angiotensin II inhibitors Antihypertensive combinations Benazepril Enalapril Captopril Fosinopril Azilsartan Eprosartan Candesartan Irbesartan Aliskiren-valsartan Amlodipine-benazepril Amlodipine-hydrochlorothiazide-valsartan Amlodipine-hydrochlorothiazide-olmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Prescription Lisinopril Perindopril Moexipril Quinapril Losartan Telmisartan Olmesartan Valsartan Benazepril-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Ramipril Trandolapril Hydrochlorothiazide-losartan Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). __________ Current Procedure Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 72 MY 2012 P4P Clinical Specifications: Diabetes Care BP Control <140/90 mm Hg Use automated data to identify the most recent blood pressure reading during the measurement year. The member is numerator compliant if the blood pressure is <140/90 mm Hg. The member is not compliant if the blood pressure is ≥140/90 mm Hg or if there is no reading during the measurement year, or if the reading is incomplete (e.g., the systolic or diastolic level is missing). If there are multiple readings on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-P and use the most recent codes during the measurement year to evaluate whether the member is numerator compliant for both systolic and diastolic levels. Similar to the other P4P measures, Blood Pressure Control for Diabetes is an electronic-only measure. Organizations may rely on CPT II codes, registry data or EHRs to collect blood pressure, but chart review is not an option. The most recent reading during the measurement year must be used; therefore, documentation of systolic and diastolic blood pressure on different dates of service is not permitted. If the most recent reading has multiple measurements on the same date, the lowest systolic and lowest diastolic reading may be used. Table CDC-P: Codes to Identify Systolic and Diastolic BP Levels <140/90 CPT Category II Description Numerator compliant (BP <140/90 mm Hg) Not numerator compliant (BP ≥140/90 mm Hg) Systolic 3074F, 3075F 3077F Diastolic 3078F, 3079F 3080F For the BP control indicator, the BP must be during an outpatient or nonacute inpatient visit. POs and plans can use either of the following methods to identify BPs taken in the appropriate setting; POs and plans must choose one of these methods and use it consistently. Option A: Identify Outpatient and Nonacute Inpatient Visits Use the codes in Table CDC-C to identify outpatient visit codes and nonacute inpatient visits codes. The BP must be in conjunction with one of these codes Option B: Exclusions to Identify Appropriate Setting When identifying the most recent BP reading noted during the measurement year, do not include BP readings that meet the following criteria. BPs taken during an acute inpatient stay, refer to Table CDC-Q. BPs taken during an ED visit, refer to Table CDC-R. BPs taken during an outpatient visit whose sole purpose to have a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole), refer to Table CDC-S. BPs obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy), refer to Table CDC-S. BP readings taken by the member. Note: BP readings taken by the member may not be used for this measure, regardless of which option is used to identify the appropriate setting. ___________ Current Procedure Terminology © 2010 American Medical Association. All rights reserved Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 73 Table CDC-Q Codes to Identify Total Inpatient Discharges Principal ICD-9-CM Diagnosis 001-289, 317-999, V01V29, V40-V90 MS—DRG OR 001-008, 010-013, 020-042, 052-103, 113-117, 121-125, 129-139, 146-159, 163-168, 175-208, 215-264, 280-316, 326-358, 368-395, 405-425, 432-446, 453-517, 533-566, 573-585, 592-607, 614-630, 637-645, 652-675, 682-700, 707-718, 722-730, 734-750, 754-761, 765-770, 774-782, 789-795, 799-804, 808-816, 820-830, 834-849, 853-858, 862-872, 901-909, 913-923, 927-929, 933-935, 939-941, 947-951, 955-959, 963-965, 969-970, 974-977, 981-989, 998, 999 WITH UB Type of Bill 11x, 12x, 41x, 84x OR Revenue Code Any acute inpatient facility code CDC-R: Codes to Identify ED Visits CPT 99281-99285 OR UB Revenue 045x, 0981 OR CPT 10040-69979 AND POS 23 Table CDC-S: Codes to Identify Ambulatory Surgery/Procedures Option A: Use CMS 1500 codes in conjunction with CPT codes to identify ambulatory surgery/procedures. CPT Only the CPT covered surgical procedure codes included in the CMS 2009 ASC Approved HCPCS Codes and Payment Rates file* and 92953, 92970, 92971, 92975, 92980, 92982, 92986, 92990, 92992, 92993, 92995, 92996, 93501–-93533, 93600–93652 POS AND 22, 24 Option B: Use UB Type of Bill codes in conjunction with UB Revenue codes, CPT codes and ICD-9-CM codes to identify ambulatory surgery/procedures. ICD-9-CM Procedure 01-86, 88.4, 88.5, 98.5 AND UB Revenue 0320, 0321, 0323, 0360, 0361,0362, 0367, 0369, 0480, 0481, 0490, 0499, 0750, 0790 UB Type of Bill AND 13x, 83x * These codes can be found on the CMS Web site (http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/11_Addenda_Updates.html). Click October 2012 ASC Approved HCPCS codes and Payment Rates. Use only the spreadsheet titled ―Addendum AA–ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2012.‖ Only use 5-digit all-numeric CPT codes (Level 1 HCPCS) in the spreadsheet; do not include any codes with an alpha value. ___________ Current Procedure Terminology © 2010 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 74 MY 2012 P4P Clinical Specifications: Diabetes Care Optimal Diabetes Care Combination rates Calculate the following combination rates. Combination Rate 1: Members who are compliant for all of the following numerators are compliant for the Combination 1 rate. HbA1c Control (<8.0%). LDL-C Control (<100 mg/dL). Nephropathy Monitoring. Combination Rate 2: Members who are compliant for both of the following numerators are compliant for the Combination 2 rate. All Combination Rate 1 numerators. BP Control (<140/90 mm Hg). Exclusions (optional) Members with polycystic ovaries who did not have any face-to-face encounters in any setting during the measurement year or the year prior to the measurement year, with a diagnosis of diabetes. Diagnosis of polycystic ovaries may occur at any time in the member’s history, but must have occurred by December 31 of the measurement year. Refer to Table CDC-B for codes to identify a diagnosis of diabetes; refer to Table CDC-T for codes to identify a diagnosis of polycystic ovaries. Members with gestational diabetes or steroid-induced diabetes who did not have any face-to-face encounters in any setting during the measurement year or the year prior to the measurement year, with a diagnosis of diabetes. Diagnosis of gestational diabetes or steroid-induced diabetes may occur during the measurement year or the year prior to the measurement year, but must have occurred by December 31 of the measurement year. Refer to Table CDC-B for codes to identify a diagnosis of diabetes; refer to Table CDC-T to identify gestational diabetes and steroid-induced diabetes. Organizations that apply optional exclusions must exclude members from the denominator for all indicators. The denominator for all rates must be the same, with the exception of the denominator for HbA1c Control (<7.0%) for a Selected Population. Table CDC-T: Codes to Identify Exclusions Description Polycystic ovaries Steroid induced Gestational diabetes ICD-9-CM Diagnosis 256.4 249, 251.8, 962.0 648.8 ___________ Current Procedure Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Diabetes Care 75 Monitoring for Diabetic Nephropathy STEP 1: Is there documentation of ESRD, chronic or acute renal failure, renal insufficiency, diabetic nephropathy, dialysis or renal transplant? YES STOP! Member is compliant YES STOP! Member is compliant YES STOP! Member is compliant YES STOP! Member is compliant NO STEP 2: Review for a urinalysis test that indicates a protein test was run or a dipstick was performed for gross protein macroalbuminuria in the measurement year. Was the test positive for the measurement year? NO STEP 3: Review for a microalbumin lab test. Was the test done in the measurement year? NO STEP 4: Review for evidence of ACE inhibitor/ARB therapy. Is there evidence of therapy in the measurement year? NO STOP! Member is not compliant November 30, 2012 Measurement Year 2012 P4P Manual 76 MY 2012 P4P Clinical Specifications: Use of Imaging Studies for Low Back Pain Use of Imaging Studies for Low Back Pain (LBP) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed invalid CPT code 72011 from table LBP-D; replaced it with CPT code 72010. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Replaced codes 724.70, 724.71, 724.79 with code 724.7 in Table LBP-A. Replaced codes 846.0, 846.1, 846.2, 846.3, 846.8, 846.9 with code 846 in Table LBP-A. MODIFICATIONS FROM HEDIS None. Description The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plan X-ray, MRI, CT scan) within 28 days of the diagnosis. Submit the data for the measure as the direct rate not as the inverted calculation of numerator and denominator. After submission, NCQA reports the measure as an inverted rate [1–(numerator/denominator)]. A higher reported rate indicates appropriate treatment of low back pain (i.e., proportion for whom imaging studies did not occur). Definitions Intake Period January 1–December 3 of the measurement year. The Intake Period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain. IESD Index Episode Start Date. The earliest date of service for any outpatient or ED encounter (Table LBP-B) during the Intake Period with a primary diagnosis of low back pain (Table LBP-A). Negative Diagnosis History A period of 180 days (6 months) prior to the IESD during which time member had no claims/encounters with any diagnosis of low back pain (Table LBP-A). Eligible Population Product line Commercial HMO/POS. Ages 18 years as of January 1 of the measurement year to 50 years as of December 31 of the measurement year. ___________ Current Procedure Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Use of Imaging Studies for Low Back Pain 77 Continuous enrollment ...for selfreporting POs …for health plans Allowable gap 180 days prior to the IESD through 28 days after the IESD in the PO (parent level). 180 days prior to the IESD through 28 days after the IESD in the health plan and PO (parent level). No gaps in enrollment during the continuous enrollment period. Anchor date ...for selfreporting POs …for health plans IESD in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. IESD in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefit Medical. Event/ diagnosis Outpatient or ED visit with a primary diagnosis of low back pain. Follow the steps below to identify the eligible population. Step 1 Identify all members who had an outpatient or ED encounter (Table LBP-B) with a primary diagnosis of low back pain (Table LBP-A) during the Intake Period. Table LBP-A: Codes to Identify Low Back Pain ICD-9-CM Diagnosis 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5, 724.6, 724.7, 738.5, 739.3, 739.4, 846, 847.2 Table LBP-B: Codes to Identify Visit Type Description Outpatient ED CPT 98925-98929, 98940-98942, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99385, 99386, 99395, 99396, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 99281-99285 UB Revenue 051x, 0520-0523, 05260529, 057x-059x, 0982, 0983 045x, 0981 *Do not include ED visits that result in an inpatient admission. Step 2 Determine the IESD. For each member identified in step 1, determine the earliest episode of low back pain. If the member had more than one encounter, include only the first encounter. Step 3 Test for Negative Diagnosis History. Exclude members with any low back pain diagnosis during the 180 days (6 months) prior to the IESD. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 78 MY 2012 P4P Clinical Specifications: Use of Imaging Studies for Low Back Pain Step 4 Test for clinically appropriate imaging studies. Refer to Table LBP-C to identify members who have a diagnosis for which an imaging study in the presence of low back pain is clinically indicated. Cancer: Exclude members who have a diagnosis of cancer. Look as far back as possible in the member’s history through the end of the continuous enrollment period. Recent trauma, intravenous drug abuse, neurological impairment: Exclude members who have any of these diagnoses in the 12 months prior to the IESD through the end of the continuous enrollment period. Table LBP-C: Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging) Description Cancer Trauma IV drug abuse Neurologic impairment Step 5 ICD-9-CM Diagnosis 140-209, 230-239, V10 800-839, 850-854, 860-869, 905-909, 926.11, 926.12, 929, 952, 958-959 304.0-304.2, 304.4, 305.4-305.7 344.60, 729.2 Calculate continuous enrollment. Members must be continuously enrolled for 180 days prior to the IESD through 28 days after the IESD. Administrative Specification Denominator The eligible population. Numerator An imaging study conducted on the IESD or in the 28 days following the IESD. Refer to Table LBP-D in order to identify imaging studies. A diagnosis code from Table LBP-A must be in conjunction with an imaging study code in Table LBP-D. Table LBP-D: Codes to Identify Imaging Studies Description Imaging studies CPT 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131-72133, 72141, 72142, 72146-72149, 72156, 72158, 72200, 72202, 72220 UB Revenue 0320, 0329, 0350, 0352, 0359, 0610, 0612, 0614, 0619, 0972 ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Disease-Modifying Anti-Rheumatic Drug Therapy 79 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Replaced ―nonacute inpatient encounters‖ with ―nonacute inpatient discharges‖ to identify the event/ diagnosis and deleted codes that identify nonacute inpatient encounters. The organization should use its own methodology to identify nonacute inpatient discharges. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 Medicare measure set. MODIFICATIONS FROM HEDIS Adapted for Medicare Advantage product lines only. Description Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis is the same measure as the CMS Stars measure Rheumatoid Arthritis Management. The percentage of Medicare members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). Eligible Population Product line Medicare. Ages 18 years and older as of December 31 of the measurement year. Continuous enrollment ...for selfreporting POs …for health plans Allowable gap The measurement year in the PO (parent level). The measurement year in the health plan and PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Anchor date ...for selfreporting POs …for health plans November 30, 2012 December 31 of the measurement year in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. December 31 of the measurement year in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Measurement Year 2012 P4P Manual 80 MY 2012 P4P Clinical Specifications: Disease-Modifying Anti-Rheumatic Drug Therapy Benefit Medical and pharmacy. Event/ diagnosis Two of the following with different dates of service on or between January 1 and November 30 of the measurement year: Outpatient visit (Table ART-B), with any diagnosis of rheumatoid arthritis (Table ART-A). Nonacute inpatient discharge, with any diagnosis of rheumatoid arthritis (Table ART-A). Table ART-A: Codes to Identify Rheumatoid Arthritis Description Rheumatoid arthritis ICD-9-CM Diagnosis 714.0, 714.1, 714.2, 714.81 Table ART-B: Codes to Identify Visit Type Description Outpatient CPT 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983 Administrative Specification Denominator The eligible population. Numerator Members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year. Table ART-C lists the DMARDs included in this measure. Table ART-C: DMARDs Description 5-Aminosalicylates Alkylating agents Aminoquinolines Anti-rheumatics Immunomodulators Immunosuppressive agents Tetracyclines Prescription Sulfasalazine Cyclophosphamide Hydroxychloroquine Auranofin Gold sodium thiomalate Abatacept Adalimumab Anakinra Certolizumab Azathioprine J Codes Leflunomide Methotrexate Penicillamine J1600, J9250, J9260 Certolizumab pegol Etanercept Golimumab Infliximab Rituximab Tocilizumab J0129, J0135, J0718, J1438, J1745, J9310 Cyclosporine Mycophenolate J7502, J7515, J7516, J7517, J7518 Minocycline Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Disease-Modifying Anti-Rheumatic Drug Therapy 81 Exclusion (optional) Members diagnosed with HIV (Table ART-D). Look for evidence of HIV diagnosis as far back as possible in the member’s history through December 31 of the measurement year. Members who have a diagnosis of pregnancy (Table ART-D) during the measurement year. Table ART-D: Codes to Identify Exclusions Description HIV Pregnancy November 30, 2012 ICD-9-CM Diagnosis 042, V08 630-679, V22, V23, V28 Measurement Year 2012 P4P Manual 82 MY 2012 P4P Clinical Specifications: Osteoporosis Management Osteoporosis Management in Women Who Had a Fracture (OMW) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added note that physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Added J code J0897 to description of ―Other agents‖ in Table OMW-C. Added Table OMW-D: Codes to Identify Visit Type. In step 1 of event/diagnosis criteria, a fracture code must be in conjunction with a visit code from Table OMW-D. Added outpatient, ED, nonacute inpatient or acute inpatient encounter (Table OMW-D) for a fracture to the exclusion in step 2. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 Medicare measure set. MODIFICATIONS FROM HEDIS None. Description Osteoporosis Management in Women Who Had a Fracture is the same measure as the CMS Stars measure Osteoporosis Management in Women Who Had a Fracture. The percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. Definitions Intake Period A 12-month (1 year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The Intake Period is used to capture the first fracture. IESD Index Episode Start Date. The earliest date of service for any encounter during the Intake Period with a diagnosis of fracture (Table OMW-A). For an outpatient or ED claim/encounter, the IESD is date of service. For an inpatient claim/encounter, the IESD is the date of discharge. For direct transfers, the IESD is the discharge date from the second admission. Note: Physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. In this scenario, the physician organization uses the physician’s first visit with the member as a proxy for the admission date and uses the last visit as a proxy for the discharge date. This alternative method may be used only by physician organizations that do not have access to inpatient claim/encounter data. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Osteoporosis Management Negative Diagnosis History 83 A period of 60 days (2 months) prior to the IESD when the member had no diagnosis of fracture. For fractures requiring an inpatient stay, use the date of admission to determine Negative Diagnosis History. For direct transfers, use the first admission to determine the Negative Diagnosis History. Eligible Population Product line Medicare. Ages Women 67 years of age and older as of December 31 of the measurement year. Continuous enrollment ...for selfreporting POs 12 months (1 year) before the IESD through 180 days (6 months) after the IESD in the PO (parent level). …for health plans 12 months (1 year) before the IESD through 180 days (6 months) after the IESD in the health plan and PO (parent level). Allowable gap No more than one gap in enrollment of up to 45 days during the continuous enrollment period. Anchor date ...for selfreporting POs …for health plans IESD in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. IESD in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefit Medical and pharmacy. Event/ diagnosis The earliest fracture during the Intake Period. Step 1 Follow the steps below to identify the eligible population. Identify all members who had an outpatient, ED, nonacute inpatient or acute inpatient encounter (Table OMW-D) for a fracture (Table OMW-A) during the Intake Period. If the member had more than one fracture, include only the first fracture. Note: Physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. In this scenario, the physician organization uses the physician’s first visit with the member as a proxy for the admission date and uses the last visit as a proxy for the discharge date. This alternative method may be used only by physician organizations that do not have access to inpatient claim/encounter data. November 30, 2012 Measurement Year 2012 P4P Manual 84 MY 2012 P4P Clinical Specifications: Osteoporosis Management Table OMW-A: Codes to Identify Fractures* CPT 21800, 21805, 21810, 21820, 21825, 22305, 22310, 22318, 22319, 22520, 22521, 22523, 22524, 23500, 23505, 23515, 23570, 23575, 23585, 23600, 23605, 23615, 23616, 23620, 23625, 23630, 23665, 23670, 23675, 23680, 24500, 24505, 24515, 24516, 24530, 24535, 24538, 24545, 24546, 24560, 24565, 24566, 24575-24577, 24579, 24582, 24620, 24635, 24650, 24655, 24665, 24666, 24670, 24675, 24685, 25500, 25505, 25515, 25520, 25525, 25526, 25530, 25535, 25545, 25560, 25565, 25574, 25575, 25600, 2560525609, 25622, 25624, 25628, 25630, 25635, 25645, 25650, 25651, 25652, 25680, 25685, 26600, 26605, 26607, 26608, 26615, 27193, 27194, 27200, 27202, 27215-27218, 27220, 27222, 27226-27228, 27230, 27232, 27235, 27236, 27238, 27240, 27244, 27245, 27246, 27248, 27254, 27267-27269, 27500-27503, 27506-27511, 27513, 27514, 27520, 27524, 27530, 27532, 27535, 27536, 27538, 27540, 27750, 27752, 27756, 27758-27760, 27762, 27766- 27769, 27780, 27781, 27784, 27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, 27822-27828, 28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485, 29850, 29851, 29855, 29856 HCPCS S2360 ICD-9-CM Diagnosis 733.1, 733.93733.98, 805806, 807.0807.4, 808-815, 818-825, 827, 828 ICD-9-CM Procedure 79.01-79.03, 79.0579.07, 79.11-79.13, 79.15-79.17, 79.2179.23, 79.25-79.27, 79.31-79.33, 79.3579.37, 79.61- 79.63, 79.65-79.67, 81.65, 81.66 *Fractures of finger, toe, face and skull are not included in this measure. Table OMW-D: Codes to Identify Visit Type Description Outpatient Nonacute inpatient Acute inpatient ED CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99387, 99397, 9940199404, 99411, 99412, 99420, 99429, 99455, 99456 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291 99281-99285 Step 2 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983 0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x 010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x,021x, 072x, 0987 045x, 0981 Test for Negative Diagnosis History. Exclude members with an outpatient, ED, nonacute inpatient or acute inpatient encounter (Table OMW-D) for a fracture (Table OMW-A) during the 60 days (2 months) prior to the IESD. For fractures requiring an inpatient stay, use the admission date to determine Negative Diagnosis History. For direct transfers, use the first admission to determine the Negative Diagnosis History. Step 3 Calculate continuous enrollment. Members must be continuously enrolled during the 12 months prior to the fracture through 180 days (6 months) post-fracture. Step 4 Exclude members who had a BMD test (Table OMW-B) or who received any osteoporosis treatment (Table OMW-C) during the 365 days (12 months) prior to the IESD. For an inpatient claim/encounter, use the admission date to determine the 365 days (12 months) prior to the IESD. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Osteoporosis Management 85 Administrative Specification Denominator The eligible population. Numerator Appropriate testing or treatment for osteoporosis after the fracture defined by any of the following criteria. A BMD test (Table OMW-B) on the IESD or in the 180-day (6-month) period after the IESD, or A BMD test (Table OMW-B) during the inpatient stay for the fracture (applies only to fractures requiring hospitalization), or A dispensed prescription (Table OMW-C) to treat osteoporosis on the IESD or in the 180-day (6-month) period after the IESD. Table OMW-B: Codes to Identify Bone Mineral Density Test CPT 76977, 77078-77083, 78350, 78351 HCPCS G0130 ICD-9-CM Procedure 88.98 Table OMW-C: FDA-Approved Osteoporosis Therapies Description Biphosphonates Estrogens Other agents Sex hormone combinations Alendronate Alendronate-cholecalciferol Calcium carbonate-risedronate Conjugated estrogens Conjugated estrogens synthetic Esterified estrogens Calcitonin Denosumab Conjugated estrogens— medroxy-progesterone Estradiol-levonorgestrel Prescription Ibandronate Risedronate Zoledronic acid Estradiol Estradiol valerate Estradiol acetate Estropipate Estradiol cypionate Raloxifene Teriparatide Estradiol-norethindrone Estradiol-norgestimate Ethinyl estradiol-norethindrone J Codes J1740, J3488, J3487 J1000 J0630, J3110, J0897 Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 86 MY 2012 P4P Clinical Specifications: Childhood Immunization Status Childhood Immunization Status (CIS) 24-Month Continuous Enrollment MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Renamed Combination—All Antigen to Combination 3. Added specifications for rotavirus; added CPT codes 90681 and 90680 to Table CIS-A. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Clarified the exclusion text to state that contraindicated children may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered in its entirety. Added ICD-9-CM Diagnosis code 999.42 to Table CIS-B. Added a footnote to Table CIS-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. Added rotavirus for internal reporting only. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Continuous enrollment for P4P is 24 months (instead of 12 months for HEDIS). Continuous enrollment is calculated at the PO level. One gap is allowed in each year of continuous enrollment. Two antigens in the HEDIS measure are not included in the P4P measure: hepatitis A (HepA) and influenza (flu). Description The percentage of enrolled children two years of age who were identified as having completed the following antigen series by their second birthday. The measure calculates a rate for each vaccine and one separate combination rate. Four diphtheria, tetanus and acellular pertussis (DTaP). Three hepatitis B. Three polio (IPV). One chicken pox (VZV). One measles, mumps, rubella (MMR). Four pneumococcal conjugate (PCV). Three H influenza type B (HiB). Two or three rotavirus. Combination 3: Four DTaP vaccinations; three IPV vaccinations; one MMR vaccination; three HiB vaccinations; three hepatitis B vaccinations; one VZV vaccination; and four PCV vaccinations. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Childhood Immunization Status 87 Eligible Population Product line Commercial HMO/POS. Age Children who turn 2 years of age during the measurement year. Continuous enrollment …for selfreporting POs From birth to the child’s second birthday in the PO (parent level). …for health From birth to the child’s second birthday in the health plan and in the PO (parent level). plans Allowable gap No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on the child’s second birthday. …for health Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup plans level) on the child’s second birthday. Benefit Medical. Event/diagnosis None. Administrative Specification Denominator The eligible population. Numerators For MMR, hepatitis B, and VZV count any of the following. Evidence of the antigen or combination vaccine, or Documented history of the illness, or A seropositive test result for each antigen. For DTaP, IPV, HiB, pneumococcal conjugate and rotavirus count only: Evidence of the antigen or combination vaccine. For combination vaccinations that require more than one antigen (i.e., DTaP and MMR), the organization must find evidence of all the antigens. DTaP At least four DTaP vaccinations with different dates of service on or before the second birthday. Do not count any vaccination administered prior to 42 days after birth. IPV At least three IPV vaccinations with different dates of service on or before the second birthday. Do not count IPV administered prior to 42 days after birth. MMR At least one MMR vaccination with a date of service on or before the second birthday. HiB At least three HiB vaccinations with different dates of service on or before the second birthday. Do not count HiB administered prior to 42 days after birth. November 30, 2012 Measurement Year 2012 P4P Manual 88 MY 2012 P4P Clinical Specifications: Childhood Immunization Status Hepatitis B VZV At least three hepatitis B vaccinations with different dates of service on or before the second birthday. At least one VZV with the date of service on or before the second birthday. Pneumococcal conjugate At least four pneumococcal conjugate vaccinations with different dates of service on or before the second birthday. Do not count any vaccination administered prior to 42 days after birth. Rotavirus The child must receive the required number of rotavirus vaccinations on different dates of service on or before the second birthday. Do not count a vaccination administered prior to 42 days after birth. The following vaccine combinations are compliant: Two doses of the two-dose vaccine, or One dose of the two-dose vaccine and two doses of the three-dose vaccine, or Three doses of the three-dose vaccine. The vaccines are identified by different CPT codes (Table CIS-A). Combination rate Calculate the following rate for Combination—All Antigens. Combination Vaccination for Childhood Immunization Status Combination Combination— All Antigens DTaP IPV MMR HiB Hep B VZV PCV Table CIS-A: Codes to Identify Childhood Immunizations Immunization DTaP IPV MMR Measles and rubella Measles Mumps Rubella HiB Hepatitis B** VZV Pneumococcal conjugate Rotavirus (two-dose schedule) Rotavirus (three-dose schedule) CPT 90698, 90700, 90721, 90723 90698, 90713, 90723 90707, 90710 90708 90705 90704 90706 90645-90648, 90698, 90721, 90748 90723, 90740, 90744, 90747, 90748 90710, 90716 90669, 90670 HCPCS G0010 ICD-9-CM Diagnosis* ICD-9-CM Procedure 99.39 99.41 99.48 055 072 056 99.45 99.46 99.47 070.2, 070.3, V02.61 052, 053 G0009 90681 90680 * ICD-9-CM Diagnosis codes indicate evidence of disease. ** The two-dose hepatitis B antigen Recombivax is recommended for children between 11 and 14 years of age only and is not included in this table. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Childhood Immunization Status 89 Exclusions (optional) Children who had a contraindication for a specific vaccine should be excluded from the denominator for all antigen rates and the combination rate. The denominator for all rates must be the same. Contraindicated children may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered in its entirety. The exclusion must have occurred by the second birthday. Look for contraindications as far back as possible in the member’s history and use the contraindications and codes in Table CIS-B to identify allowable exclusions. Table CIS-B: Codes to Identify Exclusions Immunization Any particular vaccine Description Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis 999.42* DTaP Encephalopathy 323.51 with (E948.4 or E948.5 or E948.6) IPV Anaphylactic reaction to streptomycin, polymyxin B or neomycin Immunodeficiency, including genetic (congenital) immunodeficiency syndromes 279 HIV disease; asymptomatic HIV 042, V08 Cancer of lymphoreticular or histiocytic tissue 200-202 Multiple myeloma 203 Leukemia 204-208 MMR and VZV Hepatitis B Anaphylactic reaction to neomycin Anaphylactic reaction to common baker’s yeast *Use ICD-9-CM Diagnosis code 999.4 (without the fifth digit) to identify anaphylactic reaction prior to October 1, 2011; the date of service must be before October 1, 2011. November 30, 2012 Measurement Year 2012 P4P Manual 90 MY 2012 P4P Clinical Specifications: Immunizations for Adolescents Immunizations for Adolescents (IMA) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added ICD-9-CM Diagnosis code 999.42 to Table IMA-B. Added a footnote to Table IMA-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate. Eligible Population Product lines Commercial HMO/POS. Age Adolescents who turn 13 years of age during the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap 12 months prior to the member’s 13th birthday in the PO (parent level). 12 months prior to the member’s 13th birthday in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during the 12 months prior to the 13th birthday. Anchor date …for selfreporting POs Enrolled in the PO (parent level; or for eligible POs, the subgroup level) and in a P4P plan on the member’s 13th birthday. …for health plans Enrolled in the health plan and the PO (parent level; or for eligible POs, the subgroup level) on the member’s 13th birthday. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Immunizations for Adolescents Benefit Medical. Event/diagnosis None. 91 Administrative Specification Denominator The eligible population. Numerators For meningococcal and Tdap or Td, count only evidence of the antigen or combination vaccine. Meningococcal One meningococcal conjugate (MCV4) or meningococcal polysaccharide vaccine (MPSV4) on or between the 11th and 13th birthdays. Tdap/Td One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the 10th and 13th birthdays. Combination 1 (meningococcal, Tdap/Td) Adolescents who received one meningococcal vaccine on or between the members 11th and 13th birthday and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the 10th and 13th birthdays. Table IMA-A: Codes to Identify Adolescent Immunizations Immunization Meningococcal Tdap Td Tetanus Diphtheria CPT 90733, 90734 90715 90714, 90718 90703 90719 ICD-9-CM Procedure 99.39 99.38 99.36 Exclusion (optional) Adolescents who had a contraindication for a specific vaccine may be excluded from the denominator for all antigen rates and the combination rate. The denominator for all rates must be the same. Contraindicated adolescents may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered. The exclusion must have occurred by the 13th birthday. The organization should look for exclusions as far back as possible in the member’s history and use the codes in Table IMA-B to identify exclusions. Table IMA-B: Codes to Identify Exclusions Immunization Any particular vaccine Description Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis 999.42* * Use ICD-9-CM Diagnosis code 999.4 (without fifth digit) to identify anaphylactic reaction prior to October 1, 2011; the date of service must be before October 1, 2011. Note NCQA follows the Centers for Disease Control and Prevention (CDC) and Advisory Council on Immunization Practices (ACIP) guidelines for immunizations. HEDIS implements the guidelines after three years to account for the measure’s look-back period and to allow the industry time to adapt to the new guidelines. ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 92 MY 2012 P4P Clinical Specifications: HPV for Female Adolescents Human Papillomavirus Vaccine for Female Adolescents (HPV) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added ICD-9-CM Diagnosis code 999.42 to Table HPV-B. Added a footnote to Table HPV-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 P4P quality measure set. MODIFICATIONS FROM HEDIS None. Description The percentage of female adolescents 13 years of age who had three doses of human Papillomavirus (HPV) vaccine by their 13th birthday. Eligible Population Product lines Commercial HMO/POS. Age Female adolescents who turn 13 years of age during the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap 12 months prior to the member’s 13th birthday in the PO (parent level). 12 months prior to the member’s 13th birthday in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during the 12 months prior to the 13th birthday. Anchor date …for selfreporting POs Enrolled in the PO (parent level; or for eligible POs, the subgroup level) and in a P4P plan on the member’s 13th birthday. …for health plans Enrolled in the health plan and the PO (parent level; or for eligible POs, the subgroup level) on the member’s 13th birthday. Benefit Event/diagnosis Medical. None. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: HPV for Female Adolescents 93 Administrative Specification Denominator The eligible population. Numerators At least three HPV vaccinations with different dates of service, on or between the member’s 9th and 13th birthdays. HPV vaccines administered prior to the 9th birthday cannot be counted. Table HPV-A: Codes to Identify Adolescent Immunizations Immunization HPV CPT 90649, 90650 Exclusion (optional) Adolescents who had a contraindication for the HPV vaccine may be excluded from the denominator. The exclusion must have occurred by the member’s 13th birthday. Look for exclusions as far back as possible in the member’s history and use the codes in Table HPV-B to identify exclusions. Table HPV-B: Codes to Identify Exclusions Immunization Any particular vaccine Description Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis 999.42* * Use ICD-9-CM Diagnosis code 999.4 (without fifth digit) to identify anaphylactic reaction prior to October 1, 2011; the date of service must be before October 1, 2011. Note NCQA follows the Centers for Disease Control and Prevention (CDC) and Advisory Council on Immunization Practices (ACIP) guidelines for immunizations. HEDIS implements the guidelines after three years to account for the measure’s look-back period and to allow the industry time to adapt to the new guidelines. ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 94 MY 2012 P4P Clinical Specifications: Chlamydia Screening in Women Chlamydia Screening in Women (CHL) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added LOINC codes 71793-4, 71431-1 to Table CHL-B. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added HCPCS code G0450 to Table CHL-B. Added ICD-9-CM Diagnosis codes 302.76, 625.0 to Table CHL-B. Added LOINC codes 63464-2, 64088-8, 64094-6 and 69002-4 to Table CHL-B. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Eligible Population Product line Commercial HMO/POS. Ages 16–24 years as of December 31 of the measurement year. Report two age stratifications and an overall rate. 16–20-year-old women. 21–24-year-old women. Total rate. – The total rate is the sum of the two numerators divided by the sum of the denominators. Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement year in the PO (parent level). The measurement year in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Chlamydia Screening in Women 95 Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. …for health plans Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefit Medical. Event/diagnosis Sexually active. Two methods identify sexually active women: pharmacy data and claim/encounter data. Both methods must be used to identify the eligible population, but a member need only appear in one to be eligible for the measure. Pharmacy data Claim/encounter data Members dispensed prescription contraceptives during the measurement year (Table CHL-A). Members who had at least one encounter during the measurement year with any code listed in Table CHL-B. Table CHL-A: Prescriptions to Identify Contraceptives Description Contraceptives Diaphragm Spermicide Prescription Desogestrel-ethinyl estradiol Ethinyl estradiol-norgestimate Drospirenone-ethinyl estradiol Ethinyl estradiol-norgestrel Estradiol-medroxyprogesterone Etonogestrel Ethinyl estradiol-ethynodiol Levonorgestrel Ethinyl estradiol-etonogestrel Medroxyprogesterone Ethinyl estradiol-levonorgestrel Mestranol-norethindrone Ethinyl estradiol-norelgestromin Norethindrone Ethinyl estradiol-norethindrone Diaphragm Nonxynol 9 Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). November 30, 2012 Measurement Year 2012 P4P Manual 96 MY 2012 P4P Clinical Specifications: Chlamydia Screening in Women Table CHL-B: Codes to Identify Sexually Active Women Description CPT HCPCS ICD-9-CM Diagnosis ICD-9-CM Procedure UB Revenue LOINC Codes 11975-11977, 57022, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58970, 58974, 58976, 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, 59850-59852, 59855-59857, 59866, 59870, 59871, 59897, 59898, 59899, 76801, 76805, 76811, 76813, 76815-76821, 76825-76828, 76941, 76945-76946, 80055, 81025, 82105, 82106, 82143, 82731, 83632, 83661-83664, 84163, 84702-84704, 86592, 86593, 86631-86632, 87110, 87164, 87166, 87270, 87320, 87490-87492, 87590-87592, 8762087622, 87660, 87808, 87810, 87850, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175, 88235, 88267, 88269 G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, G0450, H1000, H1001, H1003-H1005, P3000, P3001, Q0091, S0199, S4981, S8055 042, 054.10, 054.11, 054.12, 054.19, 078.11, 078.88, 079.4, 079.51-079.53, 079.88, 079.98, 091-097, 098.0, 098.10, 098.11, 098.15-098.19, 098.2, 098.30, 098.31, 098.35-098.8, 099, 131, 302.76, 339.82, 614, 615, 622.3, 623.4, 625.0, 626.7, 628, 630-679, 795.0, 795.1, 796.7, 996.32, V01.6, V02.7, V02.8, V08, V15.7, V22-V25, V26.0-V26.4, V26.51, V26.8, V26.9, V27, V28, V45.5, V61.5-V61.7, V69.2, V72.3, V72.4, V73.81, V73.88, V73.98, V74.5, V76.2 69.01, 69.02, 69.51, 69.52, 69.7, 72-75, 88.78, 97.24, 97.71, 97.73 0112, 0122, 0132, 0142, 0152, 0720-0722, 0724, 0729, 0923, 0925 557-9, 560-3, 660-1, 688-2, 690-8, 691-6, 692-4, 693-2, 698-1, 1832-5, 1834-1, 2106-3, 2107-1, 2110-5, 2111-3, 2112-1, 2113-9, 2114-7, 2115-4, 2118-8, 2119-6, 4993-2, 5028-6, 5291-0, 5292-8, 5392-6, 5393-4, 5394-2, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 6487-3, 6488-1, 6489-9, 6510-2, 6511-0, 6514-4, 6516-9, 6561-5, 6562-3, 7975-6, 8041-6, 10524-7, 10705-2, 11083-3, 11084-1, 11481-9, 11597-2, 12222-6, 122234, 14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14499-8, 14500-3, 14502-9, 14503-7, 14504-5, 14506-0, 14509-4, 14510-2, 14513-6, 15019-3, 16280-0, 16600-9, 16601-7, 17398-9, 17399-7, 17400-3, 17401-1, 17402-9, 17403-7, 17404-5, 17405-2, 17406-0, 17407-8, 17408-6, 17409-4, 17410-2, 17411-0, 17412-8, 17723-8, 17724-6, 17725-3, 17726-1, 17727-9, 17728-7, 17729-5, 18500-9, 19080-1, 19171-8, 19176-7, 19177-5, 19180-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 20403-2, 20404-0, 20415-6, 20507-0, 20508-8, 20994-0, 21189-6, 21190-4, 21191-2, 21192-0, 21198-7, 21414-8, 21415-5, 21416-3, 21440-3, 21441-1, 21613-5, 22461-8, 22462-6, 22587-0, 22590-4, 22592-0, 22594-6, 23838-6, 24110-9, 24111-7, 24312-1, 25372-4, 25373-2, 26009-1, 29311-8, 30167-1, 31147-2, 31771-9, 31772-7, 31775-0, 31777-6, 31905-3, 31906-1, 31993-9, 32198-4, 32199-2, 32705-6, 33717-0, 33773-3, 34147-9, 34382-2, 34493-7, 34656-9, 34670-0, 34718-7, 35457-1, 36902-5, 36903-3, 38372-9, 40679-3, 40680-1, 41273-4, 41274-2, 42316-0, 42481-2, 42931-6, 43304-5, 43305-2, 43403-5, 43404-3, 43406-8, 43798-8, 44543-7, 44544-5, 44546-0, 44547-8, 44549-4, 44550-2, 44806-8, 44807-6, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 45194-8, 45327-4, 45331-6, 45332-4, 46731-6, 46989-0, 47211-8, 47212-6, 47236-5, 47237-3, 47238-1, 47387-6, 47527-7, 47528-5, 48030-1, 48039-2, 48560-7, 48781-9, 49096-1, 49246-2, 49318-9, 49891-5, 49896-4, 50387-0, 50388-8, 50690-7, 51838-1, 51839-9, 53605-2, 53762-1, 53879-3, 53925-4, 53926-2, 53927-0, 55299-2, 55869-2, 55870-0, 56497-1, 57032-5, 59236-4, 59264-2, 59420-0, 61390-1, 61391-9, 61392-7, 61393-5, 61394-3, 61395-0, 61396-8, 61372-9, 61373-7, 61374-5, 61375-2, 61376-0, 61377-8, 61378-6, 61379-4, 61380-2, 61381-0, 61382-8, 61383-6, 61384-4, 61385-1, 61386-9, 61387-7, 61388-5, 61389-3, 63464-2, 64088-8, 64094-6, 69002-4, 71793-4, 71431-1 _____________ Current Procedural Terminology © 2011 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Chlamydia Screening in Women 97 Administrative Specification Denominator The eligible population. Numerator At least one chlamydia test during the measurement year. A woman is counted as having had a test if she had a claim/encounter with a service date during the measurement year with one or more of the codes in Table CHL-C. Table CHL-C: Codes to Identify Chlamydia Screening CPT 87110, 87270, 87320, 8749087492, 87810 LOINC 557-9, 560-3, 4993-2, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43406-8, 44806-8, 44807-6, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 50387-0, 53925-4, 53926-2 Exclusion (optional) Members who had a pregnancy test during the measurement year, followed within seven days (inclusive) by either a prescription for Accutane (isotretinoin) or an x-ray. This exclusion does not apply to members who qualify for the denominator based on services other than the pregnancy test alone. Refer to Tables CHL-D and CHL-E for codes to identify exclusions. Table CHL-D: Codes to Identify Exclusions Description Pregnancy test CPT 81025, 84702, 84703 0925 UB Revenue Diagnostic radiology 70010-76499 032x LOINC 2106-3, 2107-1, 2110-5, 2111-3, 2112-1, 2113-9, 2114-7, 2115-4, 2118-8, 2119-6, 19080-1, 19180-9, 20415-6, 20994-0, 21198-7, 25372-4, 25373-2, 346700, 45194-8, 55869-2, 55870-0, 56497-1 WITH Table CHL-E: Medications to Identify Exclusions Description Retinoid Prescription Isotretinoin Note: An NDC list for isotretinoin is available at www.ncqa.org. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 98 MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women (ECS) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added LOINC codes 21440-3, 30167-1, 38372-9, 49896-4 and 59420-0 to Table ECS-C. Deleted Table ECS-D: Categories by Age and Number of Pap Tests. Clarified that step 3 of the Appropriately Screened rate should not double-count women already identified in step 2. Added a step to the Not Screened rate, to exclude women who had a Pap test and HPV test in the measurement year or 4 years prior to the measurement year. Added ICD-9-CM Diagnosis code 752.43 to Table ECS-A. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed code V76.47 from Table ECS-A. Added a new category to Appropriately Screened: Age 30-65 with Pap test and HPV test in the measurement year or 4 years prior to the measurement year. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Stated that for Immunodeficiency, including genetic (congenital) immunodeficiency syndromes, look as far back as possible in the member’s history for possible exclusions. MODIFICATIONS FROM HEDIS This non-HEDIS measure is based on a measure used by Health Partners in Minnesota. Description Women 21 years of age and older who received cervical cancer screening in accordance with evidencebased standards. Three separate overall rates are calculated for this measure based on the same eligible population. The denominator represents the entire population of women; the three rates are mutually exclusive categories that represent all the possible scenarios of care for a woman. The goal of the measure is to move as many women as possible into the ―Appropriately Screened‖ category, where a higher rate is better. A lower rate is better for the ―Not Screened‖ and ―Screened Too Frequently‖ categories. The eligible population starts at 24 years of age to account for the look-back period. Rate 1, Appropriately Screened, will be the only measure recommended for public reporting and payment. Because of the threeyear look back period, 66-year-olds are excluded from the specifications. They fall into both the ―Appropriately Screened‖ and ―Screened Too Frequently‖ categories, depending on where their birthday falls during the measurement year and the timing of the Pap test. Rate 1: Appropriately Screened Women who were screened for cervical cancer according to evidence-based guidelines. A higher rate indicates better performance. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening 99 Rate 2: Not Screened Women who should have been screened for cervical cancer but were not, based on the available data. A lower rate indicates better performance. Additional outreach could be done to encourage these women to come in for a Pap test. Rate 3: Screened Too Frequently Women who received more cervical cancer screenings than necessary, according to evidence-based guidelines. A lower rate indicates better performance. This provides an educational opportunity to reach out to physicians to reinforce the most current evidence and guidelines, and to discuss potential overuse. Eligible Population Population Commercial HMO/POS. Age Women 24–65 years old and 67 years old and older as of December 31 of the measurement year. Continuous enrollment: ….for selfreporting POs ….for health plans Allowable gap The measurement year and the two years prior to the measurement year in the PO (parent level). The measurement year and the two years prior to the measurement in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date ….for selfreporting POs ….for health plans Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and a P4P plan as of December 31 of the measurement year. Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) as of December 31 of the measurement year. Benefits Medical. Event/ diagnosis None. November 30, 2012 Measurement Year 2012 P4P Manual 100 MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening Administrative Specification Report each of the three rates separately. Rate 1: Appropriately Screened Denominator The eligible population. Numerator The number of women who had the appropriate number of Pap tests according to evidence-based guidelines. Note: If two or more claims/encounters with qualifying numerator codes for Pap test occur within 120 days of each other, count only the first one. Step 1 Screening and hysterectomy. Use the codes in Table ECS-A and Table ECS-B to identify the number of women 24–65 years of age with hysterectomies who had no Pap tests subsequent to their hysterectomy in the measurement year or the two years prior to the measurement year. If the member had a hysterectomy prior to the last three years (look as far back as possible for a hysterectomy): She will be in the ―Appropriately Screened‖ category if she had no Pap tests in the last three years. If the member had a hysterectomy in the last three years: She will be in the ―Appropriately Screened‖ category if she had no Pap tests after her hysterectomy. A hysterectomy that occurs on the same day as a Pap test should be considered subsequent to the Pap test. Table ECS-A: Codes to Identify Hysterectomies Description Hysterectomy CPT ICD-9-CM Diagnosis ICD-9-CM Procedure 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 5855058554, 58570-58573, 58951, 58953, 58954, 58956, 59135 618.5, 752.43, V67.01, V88.01*, V88.03* 68.4-68.8 *Only use codes V88.01 and V88.03 in Table ECS-A if there is a corresponding date when the hysterectomy occurred. Table ECS-B: Codes to Identify Cervical Cancer Screening CPT 88141-88143, 88147, 88148, 88150, 88152-88155, 8816488167, 88174, 88175 HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 ICD-9-CM Procedure 91.46 UB Revenue 0923 LOINC 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5 Note: Count any cervical cancer screening methodology that includes collection and microscopic analysis of cervical cells. Do not count biopsies for this measure because they are used for diagnostic and therapeutic purposes and are not valid for primary cervical cancer screening. Do not count diagnostic Pap tests identified by CPT 88142 with ICD-9-CM 795.0. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening 101 Step 2 Pap test. For women 24–65 years as of December 31 of the measurement year who have not had a hysterectomy (Table ECS-A), identify the number of women who had a single Pap test in the measurement year or the two years prior to the measurement year. Step 3 Pap and HPV co-test. For women 30–65 years as of December 31 of the measurement year who have not had a hysterectomy (Table ECS-A) and were not identified in step 2, identify the number of women who had a single Pap test with an HPV test (Table ESCC) in the measurement year or four years prior to the measurement year. To meet the co-testing criteria, the codes must pertain to the same date of service. Step 4 Over 67 years. Identify the number of women 67 years and older as of December 31 of the measurement year who had no Pap tests in the measurement year Step 5 Add the numbers from steps 1–4 to obtain the numerator for Rate 1: Appropriately Screened. Table ECS-C: Codes to Identify HPV Test CPT 87620, 87621, 87622 LOINC 21440-3, 30167-1, 38372-9, 49896-4, 59420-0 Rate 2: Not Screened Denominator The eligible population. Numerator The number of women who did not receive a Pap test according to evidence based guidelines. Note: If two or more claims/encounters with qualifying numerator codes for Pap test occur within 120 days of each other, count only the first one. Step 1 Count the number of women 24–65 years as of December 31 of the measurement year who have not had a hysterectomy (Table ECS-A) and who had no Pap tests in the measurement year or the two years prior to the measurement year. Use the codes in Table ECS-B to identify Pap tests. Step 2 Exclude women 30-65 years who had a Pap test with an HPV test (women identified in Step 3 of the Appropriately Screened rate) in the measurement year or 4 years prior to the measurement year. Step 3 This is the numerator for Rate 2: Not Screened. Rate 3: Screened Too Frequently Denominator The eligible population. Numerator The number of women who received more Pap tests than necessary according to evidence-based guidelines. Note: If two or more claims/encounters with qualifying numerator codes for Pap test occur within 120 days of each other, count only the first one. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 102 MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening Step 1 Use the codes in Table ECS-B to identify the number of women 24–30 years and the number of women 31–65 years as of December 31 of the measurement year with hysterectomies (Table ECS-A) who had one or more Pap tests subsequent to their hysterectomy in the measurement year or the two years prior to the measurement year. If the member had a hysterectomy prior to the last three years (look as far back as possible for a hysterectomy): She will be in the ―Screened Too Frequently‖ category if she had one or more Pap tests in the last three years. If the member had a hysterectomy in the last three years: She will be in the ―Screened Too Frequently‖ category if she had one or more Pap tests after her hysterectomy. Step 2 For women ages 24–30 years and for women ages 31–65 years as of December 31 of the measurement year who have not had a hysterectomy, count the number of women who had two or more Pap tests in the measurement year or the two years prior to the measurement year. Step 3 Count the number of women ages 67 and older as of December 31 of the measurement year who had one or more Pap tests in the measurement year. Step 4 Add the numbers from steps 1–3 to obtain the numerator for Rate 3: Screened Too Frequently. Exclusions Exclude from the denominator members who have had one of the following: A diagnosis of dysplasia, human papilloma virus (HPV) codes or an abnormal Pap test in the past five years. A history of cervical cancer, DES exposure, HIV or Immunodeficiency, including genetic (congenital) immunodeficiency syndromes. Look as far back as possible in the member’s history. Exclusions must have occurred by December 31 of the measurement year. Use the codes in Table ECS-D to identify allowable exclusions. Table ECS-D: Codes to Identify Denominator Exclusions Description Dysplasia of cervix Nonspecific abnormal Pap test Cervical cancer Diethylstilbestrol (DES) exposure HIV HPV Immunodeficiency, including genetic (congenital) immunodeficiency syndromes Measurement Year 2012 P4P Manual ICD-9-CM Diagnosis 622.1 795.0, 795.1 180, 233.1, V10.41 760.76 042, V08, 079.53 079.4, 795.05, 795.15 279 November 30, 2012 MY 2012 P4P Clinical Specifications: Breast Cancer Screening 103 Breast Cancer Screening (BCS) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Modified age stratifications for for reporting. Report ages 42 to 69 for the Medicare product line; report ages 52 to 69 and 70 to 74 separately for the commercial product line. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Added CPT modifier codes RT and LT to Table BCS-B and revised the optional exclusion for bilateral mastectomy to include instances where a mastectomy is performed on the right side and the left side of the body on the same date of service. Added two new age bands (40-49 years and 70-74 years) for internal reporting, and the requirement to report three age stratifications and an overall rate. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS HEDIS collects the percentage of women 40-69 years of age. Description Commercial product line: The percentage of women 50–69 years of age who had a mammogram to screen for breast cancer. The eligible population starts at 52 years of age to account for the look-back period. In alignment with USPSTF recommendations, P4P will also collect the 70–74 years age band for internal reporting only. Medicare product line: Breast Cancer Screening is the same measure as the CMS Stars Measure Breast Cancer Screening. The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer. The eligible population starts at 42 years of age to account for the look-back period. Eligible Population Product lines Commercial HMO/POS, Medicare (report each product line separately). Ages Women 42–74 years as of December 31 of the measurement year. Report one age stratification for Medicare and two age stratifications for commercial. 42 to 69 years–Medicare product line 52 to 69 years–commercial product line 70 to 74 years–commercial product line __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 104 MY 2012 P4P Clinical Specifications: Breast Cancer Screening Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement year and the year prior to the measurement year in the PO (parent level). The measurement year and the year prior to the measurement year in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. …for health plans Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefit Medical. Event/diagnosis None. Administrative Specification Denominator The eligible population. Numerator One or more mammograms during the measurement year or the year prior to the measurement year. A woman had a mammogram if a submitted claim/encounter contains any one of the codes in Table BCS-A. Table BCS-A: Codes to Identify Breast Cancer Screening 40B CPT 77055-77057 HCPCS G0202, G0204, G0206 ICD-9-CM Procedure 87.36, 87.37 UB Revenue 0401, 0403 Exclusion (optional) Women who had a bilateral mastectomy. Look for evidence of a bilateral mastectomy as far back as possible in the member’s history through December 31 of the measurement year. Refer to Table BCS-B for codes to identify exclusions. Any of the following meet criteria for bilateral mastectomy: A bilateral mastectomy code. A unilateral mastectomy code with a bilateral modifier. Two unilateral mastectomy codes on different dates of service. A unilateral mastectomy code with a right side modifier and a unilateral mastectomy code with a left side modifier (may be on the same date of service). __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Breast Cancer Screening 105 Table BCS-B: Codes to Identify Exclusions Description Bilateral mastectomy Unilateral mastectomy Bilateral modifier (a bilateral procedure performed during the same operative session) Right side modifier Left side modifier CPT 19180, 19200, 19220, 19240, 19303-19307 50, 09950 ICD-9-CM Procedure 85.42, 85.44, 85.46, 85.48 85.41, 85.43, 85.45, 85.47 RT LT Note: This measure evaluates primary screening. Do not count biopsies, breast ultrasounds or MRIs because they are not appropriate methods for primary breast cancer screening. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 106 MY 2012 P4P Clinical Specifications: Colorectal Cancer Screening Colorectal Cancer Screening (COL) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description Colorectal Cancer Screening is the same measure as the CMS Stars measure Colorectal Cancer Screening. The percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer. Eligible Population Product lines Commercial HMO/POS, Medicare (report each product line separately). Ages 51–75 years as of December 31 of the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap The measurement year and the year prior to the measurement year in the PO (parent level). The measurement year and the year prior to the measurement year in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. …for health plans Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Benefit Medical. Event/diagnosis None. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Colorectal Cancer Screening 107 Administrative Specification Denominator The eligible population. Numerator One or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the four criteria below. 1. Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the required number of samples was returned. 2. Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. 3. Colonoscopy during the measurement year or the nine years prior to the measurement year. 4. A submitted claim/encounter with any code in Table COL-A. Table COL-A: Codes to Identify Colorectal Cancer Screening ICD-9-CM Procedure Description FOBT CPT 82270, 82274 HCPCS G0328 Flexible sigmoidoscopy Colonoscopy 45330-45335, 45337-45342, 45345 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 G0104 45.24 G0105, G0121 45.22, 45.23, 45.25, 45.42, 45.43 LOINC 2335-8, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2 Exclusion (optional) Members with a diagnosis of colorectal cancer or total colectomy. Look for evidence of colorectal cancer or total colectomy as far back as possible in the member’s history through the end of the continuous enrollment period. Refer to Table COL-B for codes to identify exclusions. Table COL-B: Codes to Identify Exclusions 3 Description Colorectal cancer Total colectomy CPT HCPCS G0213-G0215, G0231 ICD-9-CM Diagnosis 153, 154.0, 154.1, 197.5, V10.05 ICD-9-CM Procedure 45.8 44150-44153, 4415544158, 44210-44212 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 108 MY 2012 P4P Clinical Specifications: Adult BMI Assessment Adult BMI Assessment (ABA) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Deleted obsolete HCPCS code G0344 from Table ABA-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 Medicare measure set. MODIFICATIONS FROM HEDIS Adapted for Medicare Advantage product lines only. Description Adult BMI Assessment is the same measure as the CMS Stars measure Adult BMI Assessment. The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. Definitions BMI Body mass index. A statistical measure of the weight of a person scaled according to height. BMI percentile The percentile ranking based on the Centers for Disease Control and Prevention’s (CDC) BMI-for-age growth charts, which indicates the relative position of the patient’s BMI number among those of the same sex and age. Eligible Population Product lines Medicare. Ages 18 years as of January 1 of the year prior to the measurement year to 74 years as of December 31 of the measurement year. Continuous enrollment ...for selfreporting POs …for health plans Allowable gap The measurement year in the PO (parent level). The measurement year in the health plan and PO (parent level). No more than one gap in enrollment of up to 45 days during the measurement year. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Adult BMI Assessment 109 Anchor date ...for selfreporting POs December 31 of the measurement year in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. …for health plans December 31 of the measurement year in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefit Medical. Event/diagnosis Members who had an outpatient visit (Table ABA-A) during the measurement year or the year prior to the measurement year. Table ABA-A: Codes to Identify Outpatient Visits CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 9934799350, 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 HCPCS G0402 UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 Administrative Specification Denominator The eligible population. Numerator BMI (Table ABA-B) during the measurement year or the year prior to the measurement year. Table ABA-B: Codes to Identify BMI ICD-9-CM Diagnosis V85.0-V85.5 Exclusions (optional) Members who have a diagnosis of pregnancy (Table ABA-C) during the measurement year or the year prior to the measurement year. Table ABA-C: Codes to Identify Exclusions Description Pregnancy ICD-9-CM Diagnosis 630-679, V22, V23, V28 _____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 110 MY 2012 P4P Clinical Specifications: Glaucoma Screening in Older Adults Glaucoma Screening in Older Adults (GSO) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. Deleted obsolete CPT code 92135 from Table GSO-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 Medicare measure set. MODIFICATIONS FROM HEDIS None. Description Glaucoma Screening in Older Adults is the same measure as the CMS Stars Measure Glaucoma Testing. The percentage of Medicare members 65 years of age and older who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. Eligible Population Product line Medicare. Ages 67 years of age and older as of December 31 of the measurement year. Continuous enrollment ...for selfreporting POs The measurement year and the year prior to the measurement year in the PO (parent level). …for health plans The measurement year and the year prior to the measurement year in the health plan and PO (parent level). Allowable gap No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date ...for selfreporting POs …for health plans December 31 of the measurement year in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. December 31 of the measurement year in the health plan and the PO (parent level, or, for eligible POs, subgroup level). ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Glaucoma Screening in Older Adults Benefit Medical. Event/ diagnosis None. 111 Administrative Specification Denominator The eligible population. Numerator One or more eye exams for glaucoma by an eye care professional (i.e., ophthalmologist, optometrist) during the measurement year or the year prior to the measurement year. A member is considered to have had an eye exam for glaucoma if a submitted claim/encounter contains any code in Table GSO-A. Table GSO-A: Codes to Identify Glaucoma Screening Eye Exams CPT HCPCS 92002, 92004, 92012, 92014, 92081-92083, 92100, 92120, 92130, 92140, 99202-99205, 99213-99215, 99242-99245 G0117, G0118, S0620, S0621 Exclusion (optional) Members who had a prior diagnosis of glaucoma or glaucoma suspect. Look for evidence of glaucoma or glaucoma suspect as far back as possible in the member’s history through December 31 of the measurement year. Refer to Table GSO-B for codes to identify exclusions. Table GSO-B: Codes to Identify Exclusions Description Glaucoma suspect Glaucoma ICD-9-CM Diagnosis 365.0 365.1-365.9, 377.14 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 112 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio Asthma Medication Ratio (AMR) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added two overall age bands for reporting, 5-50 years and 5-64 years. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added indacaterol to Table AMR-C. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Clarified medication dispensing events for multiple prescriptions. Created separate definitions for ―inhaler‖ and ―injection.‖ Clarified that members must have a ratio of 0.50 or greater during the measurement year. Added that four outpatient visit types listed in bullet three under step one, must be on different dates of service. In step 3 under required exclusion changed table reference ARM-D to AMR-E in second bullet. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Changed upper age limit band from 50 to 64, modified age bands as a result, adding 19-50 and 51-64, report four age stratifications and a total rate. Modified the dispensing event criteria for inhalers so that each individual inhaler canister counts as one dispensing event. Instead of a 90-days supply counting as one dispensing event it now counts as three dispensing events. Modified multiple prescriptions dispensed on the same day criteria so that multiple prescriptions for the same medication dispensed on the same day, should be counted individually. Added Table AMR-C to identify asthma medication. Removed note after Step 2 to exclude members from the eligible population who had no reliever and no controller medications. Changed exclusions from optional to a required and added it as a third step under the Eligible Population section. Under Ratio calculation for persistent asthmatics, restated the measure denominator and numerator. Under Ratio calculation for persistent asthmatics, clarified required steps 3-5. Renamed former Table AMR-C: Asthma Medications to Table AMR-E: Asthma Controller and Reliever Medications. MODIFICATIONS FROM HEDIS None. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio 113 Description The percentage of members 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medication of 0.50 or greater during the measurement year. This measure calculates an unweighted medication ratio of units of controller medications over units of controller medications plus units of short acting beta-agonists (SABA)/reliever medications for persistent asthmatics. Units of Controller _______________________________ Units of Controller+ Units of Reliever Patients with a ratio of 0.50 or greater experience significantly fewer asthma exacerbations, defined as either ED visits, with asthma listed as the primary diagnosis, or an oral corticosteroid dispensing event determined from medical and pharmacy claims. The intent is that patients have both controllers and relievers in their regimens, instead of relievers alone. Oral medication dispensing event An oral medication dispensing event is one prescription of an amount lasting 30 days or less. To calculate dispensing events for prescriptions longer than 30 days, divide the days supply by 30 and round down to convert. For example, a 100-day prescription is equal to three dispensing events (100/30 = 3.33, rounded down to 3). The organization should allocate the dispensing events to the appropriate year based on the date when the prescription is filled. Multiple prescriptions for different medications dispensed on the same day should be assessed separately. If multiple prescriptions for the same medication are dispensed on the same day, sum the days supply and divide by 30. Use the drug ID to determine if the prescriptions are the same or different. Two prescriptions for different medications dispensed on the same day, each with a 60-day supply, equals four dispensing events (two prescriptions with two dispensing events each). Two prescriptions for different medications dispensed on the same day, each with a 15-day supply, equals two dispensing events (two prescriptions with one dispensing event each). Two prescriptions for the same medication dispensed on the same day, each with a 15-day supply, equals one dispensing event (sum the days supply for a total of 30 days) Two prescriptions for the same medication dispensed on the same day, each with a 60-day supply, equals four dispensing events (sum the days supply for a total of 120 days). Inhaler dispensing event Each inhaler (i.e. canister) counts as one dispensing event. Multiple dispensing events of the same or different medication are assessed separately (even if medications were filled on the same date of service). The organization should allocate the dispensing events to the appropriate year based on the date when the prescription is filled. Injection dispensing event Injections count as one dispensing event. Multiple dispensing events of the same or different medication are assessed separately. The organization should allocate the dispensing events to the appropriate year based on the date when the prescription is filled. November 30, 2012 Measurement Year 2012 P4P Manual 114 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio Eligible Population for Persistent Asthmatics Product lines Commercial HMO/POS. Ages 5–64 years by December 31 of the measurement year. Report four age stratifications and two total rates. 5–11 years. 51–64 years. 12–18 years. Total 1: 5-50 years. 19–50 years. Total 2: 5-64 years. The two total rates are the sum of their respective age stratifications. Continuous enrollment …for selfreporting POs The measurement year and the year prior to the measurement year in the PO (parent level) …for health plans The measurement year and the year prior to the measurement year in the health plan and in the PO (parent level). Allowable gap No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs …for health plans Benefits Event/ diagnosis Step 1 Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on December 31 of the measurement year. Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on December 31 of the measurement year. Medical during the measurement year and the year prior to the measurement year. Pharmacy during the measurement year. Follow the steps below to identify the eligible population for the measure. Identify members as having persistent asthma who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. At least one ED visit (Table AMR-B) with asthma as the principal diagnosis (Table AMR-A). At least one acute inpatient discharge (Table AMR-B) with asthma as the principal diagnosis (Table AMR-A). At least four outpatient asthma visits (Table AMR-B) on different dates of service, with asthma as one of the listed diagnoses (Table AMR-A) and at least two asthma medication dispensing events (Table AMR-C). At least four asthma medication dispensing events (Table AMR-C). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio 115 Table AMR-A: Codes to Identify Asthma Description Asthma ICD-9-CM Diagnosis 493.0, 493.1, 493.8, 493.9 Table AMR-B: Codes to Identify Visit Type Description Outpatient CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99382-99386, 99392-99396, 99401-99404, 99411, 99412, 99420, 99429 99221-99223, 99231-99233, 99238, 99239, 99251-99255, 99291 Acute inpatient ED 99281-99285 UB Revenue 051x, 0520-0523, 0526-0529, 057x- 059x, 0982, 0983 010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x, 021x, 072x, 0987 045x, 0981 Table AMR-C: Asthma Medications Description Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Long-acting, inhaled beta-2 agonists Mast cell stabilizers Methylxanthines Short-acting, inhaled beta-2 agonists Dyphylline-guaifenesin Omalizumab Budesonide-formoterol Beclomethasone Budesonide Ciclesonide Montelukast Aformoterol Formoterol Cromolyn Aminophylline Dyphylline Albuterol Levalbuterol Prescriptions Guaifenesin-theophylline Fluticasone-salmeterol Flunisolide Fluticasone CFC free Mometasone Zafirlukast Indacaterol Salmeterol Nedocromil Oxtriphylline Theophylline Metaproterenol Pirbuterol Potassium iodide-theophylline Mometasone-formoterol Triamcinolone Zileuton Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). Step 2 A member identified as having persistent asthma because of at least four asthma medication dispensing events, where leukotriene modifiers were the sole asthma medication dispensed in that year, must also have at least one diagnosis of asthma (Table AMR-A) in any setting, in the same year as the leukotriene modifier (i.e., the measurement year or the year prior to the measurement year). ______________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 116 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio Step 3: Required exclusions Exclude members who had at least one encounter in any setting, with any code to identify a diagnosis of emphysema, COPD, cystic fibrosis or acute respiratory failure (Table AMR-D). Look as far back as possible in the member’s history through December 31 of the measurement year. Exclude members who have no asthma controller or reliever medications (Table AMR-E) dispensed during the measurement year. Table AMR-D Codes to Identify Required Exclusions Description Emphysema COPD Cystic fibrosis Acute respiratory failure ICD-9-CM Diagnosis 492, 506.4, 518.1, 518.2 491.2, 493.2, 496, 506.4 277.0 518.81 Ratio Calculation for Persistent Asthmatics Denominator The eligible population. Numerator The number of members who have a medication ratio of 0.50 or greater during the measurement year. Follow the steps below to determine the number of numeratorcompliant members. Step 1 For each member, count the units of controller medications (Table AMR-E) dispensed during the measurement year. Each dispensing event is one unit. Step 2 For each member, count the units of reliever medications (Table AMR-E) dispensed during the measurement year. Each dispensing event is one unit. Step 3 For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma medications. Step 4 For each member, calculate the ratio of controller medications to total asthma medications using the following formula. Units of Controller Medications (step 1) _______________________________ Units of Total Medications (step 3) Step 5: Calculate performance rate Sum the total number of members who have a ratio of 0.50 or greater in step 4. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Asthma Medication Ratio 117 Table AMR-E: Asthma Controller and Reliever Medications Type Description Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Asthma controller medications Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Asthma reliever medications Short-acting, inhaled beta-2 agonists Dyphyllineguaifenesin Omalizumab Budesonideformoterol Beclomethasone Budesonide Ciclesonide Montelukast Cromolyn Aminophylline Dyphylline Albuterol Levalbuterol Prescriptions Guaifenesintheophylline Potassium iodidetheophylline Bluticasonesalmeterol Flunisolide Fluticasone CFC free Mometasoneformoterol Mometasone Triamcinolone Zafirlukast Nedocromil Oxtriphylline Theophylline Metaproterenol Pirbuterol Zileuton Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). November 30, 2012 Measurement Year 2012 P4P Manual 118 MY 2012 P4P Clinical Specifications: Appropriate Testing for Children With Pharyngitis Appropriate Testing for Children With Pharyngitis (CWP) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Removed gatifloxacin, lomefloxacin and sparfloxacin from Table CWP-C. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed cephradine and erythromycin estolate from Table CWP-C. Added cefditoren to Table CWP-C. Added LOINC code 68954-7 to Table CWP-D. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description The percentage of children 2–18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Definitions Intake Period A 12-month window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The Intake Period captures eligible episodes of treatment. Episode Date The date of service for any outpatient or ED visit (Table CWP-B) during the Intake Period with only a diagnosis of pharyngitis (Table CWP-A). Exclude claims/encounters with more than one diagnosis. IESD Index Episode Start Date. The earliest Episode Date during the Intake Period that meets all of the following criteria. Linked to a dispensed antibiotic prescription on or during the three days after the Episode Date. A 30-day Negative Medication History prior to the Episode Date. The member was continuously enrolled during the 30 days prior to the Episode date through 3 days after the Episode Date. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Appropriate Testing for Children With Pharyngitis Negative Medication History 119 To qualify for Negative Medication History, the following criteria must be met. A period of 30 days prior to the Episode Date when the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug (Table CWP-C). No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date (Table CWP-C). A prescription is considered active if the ―days supply‖ indicated on the date the member filled the prescription is the number of days or more between the date the prescription was filled and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period. Eligible Population Product lines Commercial HMO/POS. Ages Children 2 years as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year. Continuous enrollment: ….for selfreporting POs ….for health plans Allowable gap 30 days prior to the Episode Date through 3 days after the Episode Date in the PO (parent level). 30 days prior to the Episode Date through 3 days after the Episode Date in the health plan and in the PO (parent level). No gaps in enrollment during the continuous enrollment period. Anchor date: ….for selfreporting POs Episode Date. ….for health plans Episode Date. Benefits Medical and pharmacy. Event/diagnosis Outpatient or ED visit with only a diagnosis of pharyngitis and a dispensed antibiotic for that episode of care during the Intake Period. Follow the steps below to identify the eligible population. Step 1 Identify all members who had an outpatient or ED visit (Table CWP-B) with only a diagnosis of pharyngitis (Table CWP-A). Exclude claims/encounters with more than one diagnosis. Table CWP-A: Codes to Identify Pharyngitis Description Acute pharyngitis Acute tonsillitis Streptococcal sore throat November 30, 2012 ICD-9-CM Diagnosis 462 463 034.0 Measurement Year 2012 P4P Manual 120 MY 2012 P4P Clinical Specifications: Appropriate Testing for Children With Pharyngitis Table CWP-B: Codes to Identify Visit Type Description Outpatient ED* CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 9938299385, 99392-99395, 99401-99404, 99411, 99412, 99420, 99429 99281-99285 UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 045x, 0981 *Do not include ED visits that result in an inpatient admission. Step 2 Determine all pharyngitis Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a diagnosis of pharyngitis. Step 3 Determine if antibiotics (Table CWP-C) were dispensed for any of the Episode Dates. For each Episode Date with a qualifying diagnosis, determine if antibiotics were dispensed on or up to three days after. Exclude Episode Dates if the member did not receive antibiotics on or three days after the Episode Date. Table CWP-C: Antibiotic Medications Description Aminopenicillins Beta-lactamase inhibitors First-generation cephalosporins Folate antagonist Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Penicillinase-resistant penicillins Quinolones Second-generation cephalosporins Sulfonamides Tetracyclines Third-generation cephalosporins Amoxicillin Amoxicillin-clavulanate Cefadroxil Cefazolin Trimethoprim Clindamycin Azithromycin Clarithromycin Erythromycin Erythromycin-sulfisoxazole Penicillin G potassium Dicloxacillin Ciprofloxacin Levofloxacin Cefaclor Cefprozil Sulfamethoxazole-trimethoprim Doxycycline Minocycline Cefdinir Cefditoren Prescription Ampicillin Cephalexin Erythromycin ethylsuccinate Erythromycin lactobionate Erythromycin stearate Penicillin G sodium Penicillin V potassium Moxifloxacin Ofloxacin Cefuroxime Loracarbef Sulfisoxazole Tetracycline Cefixime Cefpodoxime Ceftibuten Ceftriaxone Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). Step 4 Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or where a prescription filled more than 30 days prior to the Episode Date was active on the Episode Date. Step 5 Calculate continuous enrollment. The member must be continuously enrolled without any gaps in coverage from 30 days prior to through 3 days after the Episode Date. Step 6 Select the IESD. This measure examines the earliest eligible episode per member. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Appropriate Testing for Children With Pharyngitis 121 Administrative Specification Denominator The eligible population. Numerator A group A streptococcus test (Table CWP-D) in the seven-day period from three days prior to the IESD through three days after the IESD. Table CWP-D: Codes to Identify Group A Streptococcus Tests CPT 87070, 87071, 87081, 87430, 87650-87652, 87880 LOINC 626-2, 5036-9, 6556-5, 6557-3, 6558-1, 6559-9, 11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 60489-2, 68954-7 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 122 MY 2012 P4P Clinical Specifications: Appropriate Treatment for Children With URI Appropriate Treatment for Children With Upper Respiratory Infection (URI) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Removed gatifloxacin, lomefloxacin and sparfloxacin from Table URI-D. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed cephradine and erythromycin estolate from Table URI-D. Added cefditoren to Table URI-D. Clarified that claims/encounters with only a diagnosis for URI should be identified in step 2 of the event/diagnosis criteria. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description The percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Submit the data for the measure as the direct rate not as the inverted calculation of numerator and denominator. After submission, NCQA reports the measure as an inverted rate [1-(numerator/eligible population]. A higher reported rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed). Definitions Intake Period A 12-month window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The Intake Period captures eligible episodes of treatment. Episode Date The date of service for any outpatient or ED visit (Table URI-B) during the Intake Period with only a diagnosis of URI (Table URI-A). Exclude claims/encounters with more than one diagnosis. IESD Index Episode Start Date. The earliest Episode Date during the Intake Period that meets all of the following criteria. A 30-day Negative Medication History prior to the Episode Date. A Negative Competing Diagnosis on or within 3 days after the Episode Date. The member was continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Appropriate Treatment for Children With URI Negative Medication History 123 To qualify for Negative Medication History, the following criteria must be met. A period of 30 days prior to the Episode Date during which time the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug. No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date (Table URI-D). A prescription is considered active if the ―days supply‖ indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period. Negative Competing Diagnosis The Episode Date and three days following the Episode Date during which the member had no claims/encounters with any competing diagnosis (Table URI-C). Eligible Population Product line Commercial HMO/POS. Ages Children 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap 30 days prior to the Episode Date through 3 days after the Episode Date in the PO (parent level). 30 days prior to the Episode Date through 3 days after the Episode Date in the health plan and in the PO (parent level). No gaps in enrollment during the continuous enrollment period. Anchor date …for selfreporting POs …for health plans Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on the Episode Date. Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level) on the Episode Date. Benefits Medical and pharmacy. Event/ diagnosis Follow the steps below to identify the eligible population. Step 1 Identify all members who had an outpatient or ED visit (Table URI-B) with only a diagnosis of URI (Table URI-A) during the Intake Period. Exclude claims/encounters with more than one diagnosis. November 30, 2012 Measurement Year 2012 P4P Manual 124 MY 2012 P4P Clinical Specifications: Appropriate Treatment for Children With URI Table URI-A: Codes to Identify URI Description Acute nasopharyngitis (common cold) URI ICD-9-CM Diagnosis 460 465 Table URI-B: Codes to Identify Visit Type Description Outpatient ED* CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 9938199385, 99391-99395, 99401-99404, 99411, 99412, 99420, 99429 99281-99285 UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 045x, 0981 *Do not include ED visits that result in an inpatient admission. Table URI-C: Codes to Identify Competing Diagnoses Description Intestinal infections Pertussis Bacterial infection unspecified Lyme disease and other arthropod-borne diseases Otitis media Acute sinusitis Acute pharyngitis Acute tonsillitis Chronic sinusitis Infections of the pharynx, larynx, tonsils, adenoids Prostatitis Cellulitis, mastoiditis, other bone infections Acute lymphadenitis Impetigo Skin staph infections Pneumonia Gonococcal infections and venereal diseases Syphilis Chlamydia Inflammatory diseases (female reproductive organs) Infections of the kidney Cystitis or UTI Acne ICD-9-CM Diagnosis 001–009 033 041.9 088 382 461 034.0, 462 463 473 464.1–464.3, 474, 478.21–478.24, 478.29, 478.71, 478.79, 478.9 601 383, 681, 682, 730 683 684 686 481–486 098, 099, V01.6, V02.7, V02.8 090-097 078.88, 079.88, 079.98 131, 614–616 590 595, 599.0 706.0, 706.1 __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Appropriate Treatment for Children With URI 125 Step 2 Determine all URI Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a URI diagnosis. Step 3 Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date (Table URI-D). Step 4 Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis (Table URI-C) on or 3 days after the Episode Date. Step 5 Calculate continuous enrollment. The member must be continuously enrolled without any gaps in coverage from 30 days prior to the Episode Date through 3 days after the Episode Date. Step 6 Select the IESD. This measure examines the earliest eligible episode per member. Administrative Specification Denominator The eligible population. Numerator Dispensed a prescription for antibiotic medication (Table URI-D) on or three days after the IESD. 39B Table URI-D: Antibiotic Medications Description Aminopenicillins Beta-lactamase inhibitors First generation cephalosporins Folate antagonist Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Penicillinase resistant penicillins Quinolones Second generation cephalosporins Sulfonamides Tetracyclines Third generation cephalosporins Prescriptions Ampicillin Amoxicillin Amoxicillin-clavulanate Cefadroxil Cefazolin Trimethoprim Clindamycin Azithromycin Clarithromycin Erythromycin Erythromycin ethylsuccinate Erythromycin-sulfisoxazole Penicillin G potassium Penicillin G sodium Dicloxacillin Ciprofloxacin Levofloxacin Cefaclor Cefprozil Sulfamethoxazoletrimethoprim Doxycycline Minocycline Cefdinir Cefixime Cefditoren Cephalexin Erythromycin lactobionate Erythromycin stearate Penicillin V potassium Moxifloxacin Ofloxacin Cefuroxime Loracarbef Sulfisoxazole Tetracycline Cefpodoxime Ceftibuten Ceftriaxone Note: NCQA provides a comprehensive list of medications and NDC codes on its Web site (www.ncqa.org). November 30, 2012 Measurement Year 2012 P4P Manual 126 MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis (AAB) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Removed gatifloxacin, lomefloxacin and sparfloxacin from Table AAB-E. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed rows ―5-aminosalicylates,‖ ―Amebicides‖ and ―Sulfamethoxazole-trimethoprim DS‖ from Table AAB-E. Removed neomycin, cephradine and cefoperazone from Table AAB-E. Added vancomycin, penicillin G benzathine, cefditoren and cefpodoxime to Table AAB-E. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS None. Description The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Submit the data for the measure as the direct rates not as the inverted calculation of numerator and denominator. After submission, NCQA reports the measure as an inverted rate [1–(numerator/eligible population)]. A higher reported rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed). Definitions Intake Period January 1–December 24 of the measurement year. The Intake Period captures eligible episodes of treatment. Episode Date The date of service for any outpatient or ED visit (Table AAB-B) during the Intake Period with any diagnosis of acute bronchitis (Table AAB-A). IESD Index Episode Start Date. The earliest Episode Date during the Intake Period that meets all of the following criteria. A 30-day Negative Medication History prior to the Episode Date (Table AAB-E). A 12-month Negative Comorbid Condition History prior to and including the Episode Date (Table AAB-C). A Negative Competing Diagnosis during the 30 days prior to the Episode Date through 7 days after the Episode Date (Table AAB-D). The member was continuously enrolled one year prior to the Episode Date through 7 days after the Episode Date. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment Negative Medication History 127 To qualify for Negative Medication History, the following criteria must be met. A period of 30 days prior to the Episode Date when the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug (Table AAB-E). No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date (Table AAB-E). A prescription is considered active if the ―days supply‖ indicated on the date the member filled the prescription is the number of days or more between the date the prescription was filled and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period. Negative Comorbid Condition History Twelve months prior to and including the Episode Date when the member had no claims/encounters containing either a principal or a secondary diagnosis for a comorbid condition (Table AAB-C). Negative Competing Diagnosis History Thirty days prior to the Episode Date through 7 days after the Episode Date (inclusive) when the member had no claims/encounters with any competing diagnosis (Table AAB-D). Eligible Population Product lines Commercial HMO/POS. Ages Adults 18 years as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year. Continuous enrollment ….for self-reporting POs One year prior to the Episode Date through 7 days after the Episode Date in the PO (parent level). ….for health plans One year prior to the Episode Date through 7 days after the Episode Date in the health plan and the PO (parent level). Allowable gap No more than one gap of 45 days is permitted from 365 days prior to the Episode Date through 7 days after the Episode Date. Anchor date: ….for self-reporting POs ….for health plans Episode Date in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. Episode Date in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefits Medical and pharmacy. Event/diagnosis Outpatient or ED visit with any diagnosis of acute bronchitis during the Intake Period. Follow the steps below to identify the eligible population. Step 1 November 30, 2012 Identify all members in the specified age range who had an outpatient or ED visit (Table AAB-B) during the Intake Period, with any diagnosis of acute bronchitis (Table AAB-A). Measurement Year 2012 P4P Manual 128 MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment Table AAB-A: Codes to Identify Acute Bronchitis Description Acute bronchitis ICD-9-CM Diagnosis 466.0 Table AAB-B: Codes to Identify Visit Types Description Outpatient ED* CPT 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99385, 99386, 99395, 99396, 99401-99404, 99411, 99412, 99420, 99429 99281-99285 UB Revenue 051x, 0520-0523, 0526-0529, 0982, 0983 045x, 0981 *Do not include ED visits that result in an inpatient admission. Step 2 Determine all acute bronchitis Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with a diagnosis of acute bronchitis. Step 3 Test for Negative Comorbid Condition History. Exclude Episode Dates for which the member had a claim/encounter with a diagnosis for a comorbid condition during the 12 months prior to or on the Episode Date (Table AAB-C). Table AAB-C: Codes to Identify Comorbid Conditions Description HIV disease; asymptomatic HIV Cystic fibrosis Disorders of the immune system Malignancy neoplasms Chronic bronchitis Emphysema Bronchiectasis Extrinsic allergic alveolitis Chronic airway obstruction, chronic obstructive asthma Pneumoconiosis and other lung disease due to external agents Other diseases of the respiratory system Tuberculosis ICD-9-CM Diagnosis 042, V08 277.0 279 140–209 491 492 494 495 493.2, 496 500–508 510–519 010–018 Step 4 Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date (Table AAB-E). Step 5 Test for Negative Competing Diagnosis History. Exclude Episode Dates where, during the period 30 days prior to the Episode Date through 7 days after the Episode Date (inclusive), the member had a claim/encounter with any competing diagnosis (Table AAB-D). __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment 129 Table AAB-D: Codes to Identify Competing Diagnoses Description Intestinal infections Pertussis Bacterial infection unspecified Lyme disease and other arthropod-borne diseases Otitis media Acute sinusitis Acute pharyngitis Acute tonsillitis Chronic sinusitis Infections of the pharynx, larynx, tonsils, adenoids Prostatitis Cellulitis, mastoiditis, other bone infections Acute lymphadenitis Impetigo Skin staph infections Pneumonia Gonococcal infections and venereal diseases Syphilis Chlamydia Inflammatory diseases (female reproductive organs) Infections of the kidney Cystitis or UTI Acne ICD-9-CM Diagnosis 001-009 033 041.9 088 382 461 034.0, 462 463 473 464.1-464.3, 474, 478.21-478.24, 478.29, 478.71, 478.79, 478.9 601 383, 681, 682, 730 683 684 686 481-486 098, 099, V01.6, V02.7, V02.8 090-097 078.88, 079.88, 079.98 131, 614-616 590 595, 599.0 706.0, 706.1 Step 6 Calculate continuous enrollment. The member must be continuously enrolled with no more than one gap from 365 days prior to the Episode Date through 7 days after the Episode Date. Step 7 Select the IESD. This measure examines one eligible episode per member. Administrative Specification Denominator The eligible population. Numerator Dispensed prescription for antibiotic medication (Table AAB-E) on or within three days after the IESD. November 30, 2012 Measurement Year 2012 P4P Manual 130 MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment Table AAB-E: Antibiotic Medications Description Aminoglycosides Aminopenicillins Antipseudomonal penicillins Beta-lactamase inhibitors First generation cephalosporins Fourth generation cephalosporins Ketolides Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Penicillinase resistant penicillins Quinolones Rifamycin derivatives Second generation cephalosporin Sulfonamides Tetracyclines Third generation cephalosporins Urinary anti-infectives Prescription Kanamycin Streptomycin Ampicillin Ticarcillin Piperacillintazobactam Amikacin Tobramycin Gentamicin Amoxicillin Piperacillin Amoxicillin-clavulanate Ticarcillin-clavulanate Ampicillin-sulbactam Cefadroxil Cephalexin Cefazolin Cefepime Telithromycin Clindamycin Lincomycin Azithromycin Erythromycin Erythromycin lactobionate Clarithromycin Erythromycin ethylsuccinate Erythromycin stearate Aztreonam Daptomycin Metronidazole Chloramphenicol Erythromycin-sulfisoxazole Vancomycin Dalfopristin-quinupristin Linezolid Penicillin G benzathine Penicillin G sodium Penicillin G potassium Penicillin G benzathinePenicillin V potassium procaine Penicillin G procaine Dicloxacillin Nafcillin Oxacillin Ciprofloxacin Levofloxacin Norfloxacin Gemifloxacin Moxifloxacin Ofloxacin Rifampin Cefaclor Cefoxitin Cefuroxime Cefotetan Cefprozil Loracarbef Sulfadiazine Sulfisoxazole Sulfamethoxazole-trimethoprim Doxycycline Minocycline Tetracycline Cefdinir Cefotaxime Ceftibuten Cefditoren Cefpodoxime Ceftriaxone Cefixime Ceftazidime Fosfomycin Nitrofurantoin macrocrystals-monohydrate Nitrofurantoin Trimethoprim Nitrofurantoin macro-crystals Note: NCQA provides a comprehensive list of medications and NDC codes its Web site (www.ncqa.org). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions 131 All-Cause Readmissions (PCR) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added text stating that PCR is a mandatory testing measure for the commercial product line for MY 2012 and part of the measure set for the Medicare product line for MY 2012. Added modification from HEDIS; age 18-64 age band not reported for Medicare. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Removed Medicare age band 18–64. Added text stating how the measure is labeled by CMS. Added the commercial product line to the measure. Added PCR-Comm-DischCC-Weight, PCR-Comm-ComorbHCC-Weight and PCR-Comm-OtherWeights to the Risk Adjustment Tables. Clarified the variance calculation in step 8 of the Risk Adjustment Weighting section. Added the variance calculation to Sample Table: PCR—Risk Adjustment Weighting. Clarified how to calculate the average adjusted probability in step 1 in the Reporting: Risk Adjustment section. Revised the rounding requirements in steps 2 and 4 in the Reporting: Risk Adjustment section. Added a Note section and a note that Risk Assessment Protocols may not be used. Added the observed-to-expected ratio and lower and upper confidence interval calculations to the reporting tables. Changed Table PCR-A-2/3 to PCR-A-2. Clarified that Table PCR-A-2 is for the commercial product line. Clarified that Table PCR-B-3 is for the Medicare product line. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 P4P quality and Medicare measure sets. MODIFICATIONS FROM HEDIS Age 18-64 age band not reported for Medicare NCQA refers to this measure as Plan All-Cause Readmissions. Description All-Cause Readmissions is the same measure as the CMS Stars measure Plan All-Cause Readmissions. For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories: 1. Count of Index Hospital Stays (IHS) (denominator). 2. Count of 30-Day Readmissions (numerator). 3. Average Adjusted Probability of Readmission. November 30, 2012 Measurement Year 2012 P4P Manual 132 MY 2012 P4P Clinical Specifications: All-Cause Readmissions POs are not expected to run this measure. PCR is a mandatory testing measure for the commercial product line for MY 2012 and part of the measure set for the Medicare product line for MY 2012. Note: For commercial, only members 18–64 years of age are reported. For Medicare, only members 65 years of age and older are reported. Definitions IHS Index hospital stay. An acute inpatient stay with a discharge on or between January 1 and December 1 of the measurement year. Exclude stays that meet the exclusion criteria in the denominator section. Index Admission Date The IHS admission date. Index Discharge Date The IHS discharge date. The index discharge date must occur on or between January 1 and December 1 of the measurement year. Index Readmission Stay An acute inpatient stay for any diagnosis with an admission date within 30 days of a previous Index Discharge Date. Index Readmission Date The admission date associated with the Index Readmission Stay. Classification Period 365 days prior to and including an Index Discharge Date. Risk Adjustment Tables Table HCC-Surg PCR-DischCC CC-Comorbid HCC –Rank HCC-Comb PCR-MA-DischCC-Weight-65plus PCR-Comm-DischCC-Weight PCR-MA-ComorbHCC-Weight65plus PCR-Comm-ComorbHCC-Weight PCR-MA-OtherWeights-65plus PCR-Comm-OtherWeights Table Description Surgery codes for Risk Adjustment Determination Discharge Clinical Condition category codes for Risk Adjustment Determination Comorbid Clinical Condition category codes for Risk Adjustment Determination step 2 HCC rankings for Risk Adjustment Determination step 3 Combination HCCs for Risk Adjustment Determination step 5 MA and SNP primary discharge weights for Risk Adjustment Weighting step 2 for ages 65 and older Commercial primary discharge weights for Risk Adjustment Weighting step 2 MA and SNP comorbidity weights for Risk Adjustment Weighting step 3 for ages 65 and older Commercial comorbidity weights for Risk Adjustment Weighting step 3 MA and SNP base risk, surgery, age and gender weights for Risk Adjustment Weighting steps 1, 4, 5 for ages 65 and older Commercial base risk, surgery, age and gender weights for Risk Adjustment Weighting steps 1, 4, 5 Note: The Risk Adjustment tables are posted to www.ncqa.org. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions 133 Eligible Population Product line Commercial, Medicare (report each product line separately). Ages For commercial, ages 18–64 as of the Index Discharge Date. For Medicare, ages 65 and older as of the Index Discharge Date. Continuous enrollment 365 days prior to the Index Discharge Date through 30 days after the Index Discharge Date in the health plan and PO (parent level). Allowable gap No more than one gap in enrollment of up to 45 days during the 365 days prior to the Index Discharge Date and no gap during the 30 days following the Index Discharge date. Anchor date Index Discharge Date for the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefit Medical. Event/ diagnosis An acute inpatient discharge on or between January 1 and December 1 of the measurement year. The denominator for this measure is based on discharges, not members. Include all acute inpatient discharges for members who had one or more discharges on or between January 1 and December 1 of the measurement year. The organization should follow the steps below to identify acute inpatient stays. Administrative Specification Denominator Step 1 The eligible population. Identify all acute inpatient stays with a discharge date on or between January 1 and December 1 of the measurement year. Include acute admissions to behavioral healthcare facilities. Exclude nonacute inpatient rehabilitation services, including nonacute inpatient stays at rehabilitation facilities. Step 2 Acute-to-acute transfers: Keep the original admission date as the Index Admission Date, but use the transfer’s discharge date as the Index Discharge Date. Step 3 Exclude hospital stays where the Index Admission Date is the same as the Index Discharge Date. Step 4 Exclude any acute inpatient stay with a discharge date in the 30 days prior to the Index Admission Date. Step 5 Exclude stays for the following reasons. Inpatient stays with discharges for death. Acute inpatient discharge with a principal diagnosis for pregnancy or for any other condition originating in the perinatal period in Table PCR-A. November 30, 2012 Measurement Year 2012 P4P Manual 134 MY 2012 P4P Clinical Specifications: All-Cause Readmissions Table PCR-A: Codes to Identify Maternity Related Inpatient Discharges Description Pregnancy Conditions originating in the perinatal period ICD-9-CM Diagnosis 630-679, V22, V23, V28 760-779, V21, V29-V39 Step 6 Calculate continuous enrollment. Step 7 Assign each acute inpatient stay to one age and gender category. Refer to Tables PCR-A-2 and PCR-B-3. Risk Adjustment Determination For each IHS, use the following steps to identify risk adjustment categories based on presence of surgeries, discharge condition, comorbidity, age and gender. Surgeries Determine if the member underwent surgery during the inpatient stay. Download the list of codes from the NCQA Web site (Table HCC—Surg) and use it to identify surgeries. Consider an IHS to include a surgery if at least one procedure code in Table HCC— Surg is present from any provider between the admission and discharge dates. Discharge condition Assign a discharge Clinical Condition (CC) category code to the IHS based on its primary discharge diagnosis, using Table PCR—DischCC. For acute-to-acute transfers, use the transfer’s primary discharge diagnosis. Exclude diagnoses that cannot be mapped to Table PCR—DischCC. Comorbidities Step 1 Identify all diagnoses for face-to-face encounters (Table PCR-B) during the classification period. Exclude the primary discharge diagnosis on the IHS. Table PCR-B: Codes to Identify Visit Type Description Outpatient Nonacute inpatient Acute inpatient ED CPT 92002, 92004, 92012, 92014, 98925-98929, 9894098942, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 9938499387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291 99281-99285 Step 2 UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 082x085x, 088x, 0982, 0983 0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x, 1001, 1002 010x, 0110-0114, 0119, 0120-0124, 0129, 01300134, 0139, 0140-0144, 0149, 0150-0154, 0159, 016x, 020x, 021x, 072x, 080x, 0987 045x, 0981 Assign each diagnosis to one comorbid Clinical Condition (CC) category using Table CC—Comorbid. Exclude all diagnoses that cannot be assigned to a comorbid CC category. For members with no qualifying diagnoses from face-to-face encounters, skip to Risk Adjustment Weighting. All digits must match exactly when mapping diagnosis codes to the comorbid CCs. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions Step 3 135 Determine HCCs for each comorbid CC identified. Refer to Table HCC—Rank. For each stay’s comorbid CC list, match the comorbid CC code to the comorbid CC code in the table, and assign: The ranking group. The rank. The HCC. For comorbid CCs that do not match to Table HCC—Rank, use the comorbid CC as the HCC and assign a rank of 1. Note: One comorbid CC can map to multiple HCCs; each HCC can have one or more comorbid CCs. Step 4 Assess each ranking group separately and select only the highest ranked HCC in each ranking group using the Rank column (1 is the highest rank possible). Drop all other HCCs in each ranking group, and de-duplicate the HCC list if necessary. Example Assume a stay with the following comorbid CCs: CC-15, CC-19 and CC-80 (assume no other CCs). CC-80 does not have a map to the ranking table and becomes HCC-80. HCC-15 is part of Ranking Group 1 and HCC-19 is part of Ranking Groups Diabetes 1– Diabetes 4. Because CC-15 is ranked higher than CC-19 in Ranking Group Diabetes 1, the comorbidity is assigned as HCC-15 for Ranking Group 1. Because CC-19 is ranked higher in Ranking Groups Diabetes 2-4, the comorbidity is assigned as HCC-19 for these ranking groups. The final comorbidities for this discharge include HCC-15, HCC-19 and HCC-80. November 30, 2012 Measurement Year 2012 P4P Manual 136 MY 2012 P4P Clinical Specifications: All-Cause Readmissions Example: Table HCC—Rank Ranking Group CC Description Rank HCC NA HCC-80 NA CC-80 Congestive Heart Failure Diabetes 1 CC-15 Diabetes With Renal or Peripheral Circulatory Manifestation Diabetes With Neurologic or Other Specified Manifestation Diabetes With Acute Complications 1 HCC-15 2 HCC-16 3 HCC-17 Diabetes With Ophthalmologic or Unspecified Manifestation Diabetes Without Complications 4 HCC-18 5 HCC-19 Diabetes With Neurologic or Other Specified Manifestation Diabetes With Acute Complications 1 HCC-16 2 HCC-17 3 HCC-18 CC-19 Diabetes With Ophthalmologic or Unspecified Manifestation Diabetes Without Complication 4 HCC-19 CC-17 Diabetes With Acute Complications 1 HCC-17 CC-18 Diabetes With Ophthalmologic or Unspecified Manifestation Diabetes Without Complication 2 HCC-18 3 HCC-19 Diabetes With Ophthalmologic or Unspecified Manifestation Diabetes Without Complication 1 HCC-18 2 HCC-19 CC-16 CC-17 CC-18 CC-19 Diabetes 2 CC-16 CC-17 CC-18 Diabetes 3 CC-19 CC-18 Diabetes 4 CC-19 Step 5 Identify combination HCCs listed in Table HCC—Comb. Some combinations suggest a greater amount of risk when observed together. For example, when diabetes and CHF are present, an increased amount of risk is evident. Additional HCCs are selected to account for these relationships. Compare each stay’s list of unique HCCs to those in the HCC column in Table HCC—Comb and assign any additional HCC conditions. For fully nested combinations (e.g., the diabetes/CHF combinations is nested in the diabetes/ CHF/renal combination), use only the more comprehensive pattern. In this example, only the diabetes/CHF/renal combination is counted. For overlapping combinations (e.g., the CHF, COPD combination overlaps with the CHR/ renal/diabetes combination), use both sets of combinations. In this example, both CHF/COPD and CHF/renal/diabetes combinations are counted. Based on the combinations, a member can have none, one or more of these added HCCs. Example For a stay with comorbidities HCC-15, HCC-19 and HCC-80 (assume no other HCCs), assign HCC-901 in addition to HCC-15, HCC-19 and HCC-80. This does not replace HCC-15, HCC-19 or HCC-80. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions 137 Example: Table HCC-Comb Comorbid HCC HCC-15 HCC-16 HCC-17 HCC-18 HCC-19 Combination: Diabetes and CHF Comorbid HCC Comorbid HCC HCC-80 NA HCC-80 NA HCC-80 NA HCC-80 NA HCC-80 NA Combination HCC HCC-901 HCC-901 HCC-901 HCC-901 HCC-901 Risk Adjustment Weighting For each IHS, use the following steps to identify risk adjustment weights based on presence of surgeries, discharge condition, comorbidity, age and gender. Note: The final weights table will be released on November 15, 2012. Step 1 For each IHS with a surgery, link the surgery weight. For Medicare product lines ages 65 and older: Use Table PCR-MA-OtherWeights-65plus. For commercial product lines: Use Table PCR-Comm-OtherWeights. Step 2 For each IHS with a discharge CC Category, link the primary discharge weights. For Medicare product lines ages 65 and older: Use Table PCR-MA-DischCC-Weight65plus. For commercial product lines: Use Table PCR-Comm-DischCC-Weight. Step 3 For each IHS with a comorbidity HCC Category, link the weights. For Medicare product lines ages 65 and older: Use Table PCR-MA-ComorbHCC-Weight65plus. For commercial product lines: Use Table PCR-Comm-ComorbHCC-Weight. Step 4 Link the age and gender weights for each IHS. For Medicare product lines ages 65 and older: Use Table PCR-MA-OtherWeights-65plus. For commercial product lines: Use Table PCR-Comm-OtherWeights. Step 5 Identify the base risk weight. For Medicare product lines ages 65 and older: Use Table PCR-MA-OtherWeights-65plus. For commercial product lines: Use Table PCR-Comm-OtherWeights to determine the base risk weight. Step 6 Sum all weights associated with the IHS (i.e., presence of surgery, primary discharge diagnosis, comorbidities, age, gender and base risk weight). November 30, 2012 Measurement Year 2012 P4P Manual 138 MY 2012 P4P Clinical Specifications: All-Cause Readmissions Step 7 Use the formula below to calculate the adjusted probability of a readmission based on the sum of the weights for each IHS. Adjusted probability of readmission = e( WeightsForIHS ) 1 e( WeightsForIHS ) OR Adjusted probability of readmission = [exp (sum of weights for IHS )] / [ 1 + exp (sum of weights for IHS) ] Note: ―Exp‖ refers to the exponential or antilog function. Step 8 Use the formula below and the adjusted probability of readmission calculated in step 7 to calculate the variance for each IHS. Variance = adjusted probability of readmission x (1—adjusted probability of readmission) Example: If the adjusted probability of readmission is 0.1518450741 for an IHS, then the variance is 0.1518450741 x 0.8481549259 = 0.1287881476. Note: The variance is calculated at the IHS level. Organizations must sum the variances for each age/gender and total category when populating the Total Variance cells in the reporting tables. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions 139 Sample Table: PCR—Risk Adjustment Weighting Gender Age and Gender Weight Discharge CC Member ID* Admass. Counter Base Risk Weight 1250 1 -1.08883 67 Female 0.1000 -0.2800 250.4 15 0.0700 4010 1 -1.08883 50 Male 0.1200 NA 007.4 5 0.0300 4010 2 -1.08883 50 Male 0.1200 NA 298.00 77 0.0600 Age Surgical Weight ICD-9 Diagnosis Code Category Weight HCC-PCR Category 20 Weight 0.1400 25 0.2000 NA 5 NA 0.0100 47 0.3300 Sum of Weights Adjusted Probability Variance -0.8600 0.2976 0.2090 -0.9400 0.2811 0.2021 -0.5700 0.3615 0.2308 *Each Member ID field with a value represents a unique IHS. Numerator At least one acute readmission for any diagnosis within 30 days of the Index Discharge Date. Step 1 Identify all acute inpatient stays with an admission date on or between January 2 and December 31 of the measurement year. Step 2 Acute-to-acute transfers: Keep the original admission date as the Index Admission Date, but use the transfer’s discharge date as the Index Discharge Date. Step 3 Exclude acute inpatient hospital discharges with a principal diagnosis using the codes listed in Table PCR-A. Step 4 For each IHS, determine if any acute inpatient stays have an admission date within 30 days after the Index Discharge Date. November 30, 2012 Measurement Year 2012 P4P Manual 140 MY 2012 P4P Clinical Specifications: All-Cause Readmissions Reporting: Denominator Count the number of IHS for each age, gender and total combination and enter these values into the reporting table. Reporting: Risk Adjustment Step 1 Calculate the average adjusted probability for IHS, for each age, gender and total combination and the overall total. Organizations must calculate the probability of readmission for each hospital stay within the applicable age and gender group to calculate the average (which is reported to IHA). For the total age/gender category, the probability of readmission for all hospital stays in the age/ gender categories must be averaged together; organizations cannot take the average of the average adjusted probabilities reported for each age/gender. Step 2 Enter these values into the reporting table and round to 4 decimal places. Note: Do not take the average of the cells in the reporting table. Example For the ―18–44‖ age category: Identify all IHS by 18–44 year-old males and calculate the average adjusted probability. Identify all IHS by 18–44 year-old females and calculate the average adjusted probability. Identify all IHS by all 18–44 year-olds and calculate the average adjusted probability. Repeat for each subsequent group. Step 3 Calculate the total (sum) variance for each age, gender and total combination and the overall total. Step 4 Enter these values into the reporting table and round to 4 decimal places. Reporting: Numerator Count the number of IHS with a readmission within 30 days for each age, gender and total combination and enter these values into the reporting table. Note Organizations may not use Risk Assessment Protocols to supplement diagnoses for calculation of the risk adjustment scores for this measure. The PCR measurement model was developed and tested using only claims-based diagnoses and diagnoses from additional data sources would affect the validity of the models as they are currently implemented in the specification. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: All-Cause Readmissions 141 Table PCR-A-2: Plan All-Cause Readmission Rates by Age, Gender and Risk Adjustment (for the Commercial product line) Age 1844 4554 5564 Total Sex Male Female Total: Male Female Total: Male Female Total: Male Female Total: Count of Index Stays (Denominator) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Count of 30-Day Readmissions (Numerator) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Observed Readmission (Num/Den) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Average Adjusted Probability __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Total Variance ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ O/E Ratio (Observed Readmission/Average Adjusted Probability) Lower Confidence Interval (O/E Ratio) Upper Confidence Interval (O/E Ratio) Table PCR-B-3: Plan All-Cause Readmission Rates by Age, Gender and Risk Adjustment (for the Medicare product line) 85+ Sex Male Female Total: Male Female Total: Male Female Total Total: Male Female Age 65-74 75-84 Total: Count of Index Stays (Denominator) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ November 30, 2012 Count of 30-Day Readmissions (Numerator) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Observed Readmission (Num/Den) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Average Adjusted Probability ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Total Variance ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ O/E Ratio (Observed Readmission/Average Adjusted Probability) Lower Confidence Interval (O/E Ratio) Upper Confidence Interval (O/E Ratio) Measurement Year 2012 P4P Manual Meaningful Use of Health IT For P4P MY 2012 Self-Reporting POs MY 2012 P4P Meaningful Use of Health IT: Overview 143 Overview MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 PO Reporting Structure, including whether the PO reports based on PCPs or EPs and the total number of PCPs or EPs in each PO, moved to the beginning of the MUHIT survey, rather than in the required submission of every measure. Added number of PCPs or EPs excluded from the measure to the required submission for all applicable measures. Removed ―assign points‖ from the required submission for Measures 1—20. Added submission requirements and examples for each of the three conditions in Measure 21. Clarified that a PO must be able to track the care management activities performed by a vendor for Measure 21. Removed reference to CMS requirements for the time frame in which PCPs or EPs must have functional EHRs in place. Attestation of Accuracy moved to the end of the MUHIT survey, rather than in the required submission of every measure. Requirement to attach documentation to support submitted numbers, including measure threshold if applicable, added to required submissions in the MUHIT survey. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 A PO must report either by PCP or EP, not a combination of the two. Added language clarifying the Meaningful Use of Health IT audit process. Stated that health plans do not submit data for the Meaningful Use of Health IT domain; POs voluntarily self-report this domain. Added information on the survey tool and submission requirements for POs. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 POs report performance based on either: (1) the percentage of primary care practitioners (PCP) who meet the intent of the measure, or (2) the percentage of eligible professionals (EPs) as defined by CMS. Defined primary care practitioners (PCP). Removed the option to report based on the number of patients assigned to PCPs who meet the intent of the measure. Removed the option to report based on EHRs that are not ONC-ATCB certified software. Clarified the audit requirement for each measure. Removed Measure 16, generate patient lists by specific conditions. Removed Measure 17, send patient reminders per patient preference for preventive/follow-up care. Added Measures 16–20, report any five CMS/ONC menu set measures. Renumbered Measure 18 to Measure 21. November 30, 2012 Measurement Year 2012 P4P Manual 144 MY 2012 P4P Meaningful Use of Health IT: Overview Description In MY 2011, the ―IT-Enabled Systemness‖ domain was renamed ―Meaningful Use of Health IT‖ (MUHIT). The original Systemness Domain had been in place for four years, and the P4P committees agreed it was time to evolve. During this same time period, the Centers for Medicaid & Medicare Services (CMS) committed to dedicate resources to support the adoption and use of electronic health records (EHR). In addition to the adoption of EHRs, CMS supports the implementation of ―meaningful use‖ measures designed to improve clinical outcomes by leveraging technology. To allow flexibility, CMS and ONC established both a ―core‖ and ―menu‖ set of objectives. To qualify as a meaningful EHR user, an eligible professional (EP) must successfully meet the requirement for each objective in the core set and must meet five objectives in the menu set. To align with previous IHA requirements and new CMS criteria, P4P provides the option to report either by PCP or EP. A PO must report either by PCP or EP, not by a combination of the two. To support the continued implementation of technology and eliminate redundancy, the P4P committees recommended aligning with the CMS and ONC meaningful use measures. Promoting health IT adoption and use will also allow the future addition of measures that require clinically enriched data. Only ONC-ATCB software is considered compliant with MUHIT criteria Although alignment with national standards is valuable, the committees agreed that it is important to maintain components of the original Systemness standards that exceed the new national standards. Care management for diabetes, depression and one other condition is not represented in the CMS/ONC measures of meaningful use. The P4P committees recommended that the Chronic Care Management measure also be retained as part of MUHIT. Health plans do not submit data for the MUHIT domain; POs voluntarily self-report this domain. Who We Measure CMS and ONC requirements for meaningful use were developed at the EP level. POs report performance based on the percentage of primary care practitioners (PCP) or on the percentage of EPs who meet the intent of the measure. P4P defines PCPs as ―physicians or nonphysicians (e.g., physician assistants, nurse practitioners) who offer primary care services.‖ POs that are reporting based on EPs may choose either Medicare-only EPs or Medicaid-only EPs as defined by CMS. For a list of who qualifies as an EP under the two programs, refer to: http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/15_Eligibility.asp. Domain Structure Point allocation There are 21 measures, for a total of 115 possible points; the maximum P4P score for this domain is 30. Overall P4P scores are calculated by applying a weight of .26 to the total number of points earned. POs must successfully meet the criteria for all measures using ONC-ATCB certified software. For example, if a PO earned 60 points, its overall calculated P4P score would be 16. Scores are rounded to the nearest whole number. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Overview 145 Table 1. MUHIT Points for ONC-ATCB Certified Software Percentage of PCPs or EPs Who Meet the Intent of the Measure 1–24 25–49 50–74 75+ Points per Measure 1 3 4 5 Time frame PCPs or EPs who meet the intent of the measure must have functional EHRs in place 90 days before the end of the measurement year (i.e., EHRs must be functional and in use by October 1, 2012). Duration of scores Points earned for the MUHIT Survey are valid for one year. POs must resubmit a scoring tool every year. Submitting the survey POs must: Submit PO level results using a scoring tool provided by NCQA. Submit an attestation of accuracy for the entire survey submission. Attach documentation for each measure, including documentation that thresholds for individual measures are being met, where applicable. For example, a dashboard report generated by the EHR that includes measure thresholds would suffice. Submit accurate PO level results, not results that are inferred based on a sample. Submit the total number of PCPs/EPs in the PO, not only those that are using EHRs. Computing the Results PCPs or EPs who meet the CMS and ONC meaningful use regulations will count toward the PO thresholds for the same measures in MUHIT. POs should calculate a score for all PCPs or EPs across their organization and self-score accordingly. An attestation of accuracy will be required for the entire survey submission. For Measure 21, NCQA decides whether a PO has met the standard requirements. Decisions are based on a numeric score. NCQA will audit 5 percent of submissions. Documentation to support the numbers submitted must be available for the audit. Specifically: If a PO is selected for an audit, all documentation must be provided within two weeks of the request. An onsite audit may be required. Selected POs must attend two phone meetings to discuss the audit, to understand the instructions and requirements and to review the audit findings. If the PO chooses not to provide audit documentation, scores for all MUHIT measures will be changed to zero. If the submitted MUHIT scores are found to be inaccurate after the audit, scores will be adjusted according to the documentation received, with the possibility that scores for all MUHIT measures will be changed to zero if egregious errors are found in the submission. All changes to scores will be open to the P4P appeal process. November 30, 2012 Measurement Year 2012 P4P Manual 146 MY 2012 P4P Meaningful Use of Health IT: Overview Administrative Policies Organization obligations By submitting the MUHIT Survey for the P4P program, the applicant agrees to the following: To release to NCQA the information that NCQA deems pertinent. To hold NCQA, its directors, officers, employees, agents and representatives harmless from any claims related to: 1. Third-party claims for PO or injury by physician organization. 2. The PO’s failure to achieve desired results under the MUHIT Survey. 3. Payment and network decisions made by third parties based on the MUHIT measures under the P4P program. The score for the MUHIT Survey administered by NCQA does not constitute a warranty or any other representation by NCQA to any third parties (including, but not limited to, employers, consumers or payers) regarding the quality or nature of the health-related services provided or arranged for by the PO. Any information created as a part of the NCQA MUHIT Survey of the PO shall be kept confidential, except as indicated in the Guidelines for NCQA P4P Audit Review Advertising and Marketing, in the MY 2012 P4P Manual. The MUHIT Survey score is not a replacement for an applicant’s evaluation, assessment and monitoring of its own services and programs. The applicant will not misrepresent its MUHIT Survey score or suggest that it participated in the MUHIT Survey when such representation is not accurate. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Overview 147 Measures in Meaningful Use of Health IT Meaningful Use Objective Meaningful Use 1. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines 2. Implement drug-drug and drug-allergy interaction checks 3. Maintain an up-to date problem list of current and active diagnoses 4. Generate and transmit permissible prescriptions electronically (eRx) 5. Maintain active medication list 6. Maintain active medication allergy list 7. Record all of the following demographics: A. Preferred language B. Gender C. Race D. Ethnicity E. Date of birth 8. Record and chart changes in the following vital signs: A. Height B. Weight C. Blood pressure D. Calculate and display body mass index (BMI) E. Plot and display growth charts for children 2–20 years, including BMI 9. Record smoking status for patients 13 years old or older 10. Report ambulatory clinical quality measures to CMS or, in the case of Medicaid EPs, the states 11. Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule 12. Provide patients with an electronic copy of their health information 13. Provide clinical summaries for patients for each office visit 14. Capability to exchange key clinical information 15. Protect electronic health information created or maintained by the certified EHR technology 16. Any one CMS/ONC menu set measure 17. Any one CMS/ONC menu set measure 18. Any one CMS/ONC menu set measure 19. Any one CMS/ONC menu set measure 20. Any one CMS/ONC menu set measure Chronic Care Management* 21. Chronic care management for diabetes, depression and one other clinically important condition Total possible points Points 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 15 115 *Chronic care management measures were carried over from the IT-enabled Systemness domain, to address an area not covered by the Meaningful Use measures. November 30, 2012 Measurement Year 2012 P4P Manual 148 MY 2012 P4P Meaningful Use of Health IT: PO Reporting Structure PO Reporting Structure PO Denominator A PO must report either by PCP or EP, not a combination of the two. 1. Does your PO plan to submit based on the number of PCPs or EPs? 2. What is the total number of PCPs or EPs in your PO?* (Submit the total number of PCPs or EPs in the PO, not only those that are using EHRs). *Respond to this question and all subsequent questions, based on how you responded to question 1 above (e.g. If your PO selected PCP in question 1, base all other responses on the number of PCPs in your PO.). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 1 149 Measure 1: Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Intent Objective The organization’s Primary Care Practitioners (PCP) or Eligible Professionals (EP) use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. Measure More than 30 percent of all unique patients with at least one medication in their medication list seen by the organization’s PCPs or EPs have at least one medication order entered using CPOE. Exclusions Any PCP or EP who writes fewer than 100 prescriptions during the reporting period. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs, who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPS who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 150 MY 2012 P4P Meaningful Use of Health IT: Measure 2 Measure 2: Implement drug-drug and drug-allergy interaction checks Intent Objective The organization’s PCPs or EPs implemented drug-drug and drug-allergy interaction checks. Measure The organization’s PCPs or EPs have enabled this functionality for the entire EHR reporting period. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 3 151 Measure 3: Maintain an up-to-date problem list of current and active diagnoses Intent Objective The organization’s PCPs or EPs maintain an up-to-date problem list of current and active diagnoses. Measure More than 80 percent of all unique patients seen by the organization’s PCPs or EPs have at least one entry or an indication that no problems are known for the patient recorded as structured data. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 152 MY 2012 P4P Meaningful Use of Health IT: Measure 4 Measure 4: Generate and transmit permissible prescriptions electronically (eRx) Intent Objective The organization’s PCPs or EPs generate and transmit permissible prescriptions electronically (eRx). Measure More than 40 percent of all permissible prescriptions written by the organization’s PCPs or EPs are transmitted electronically using certified EHR technology. Exclusions Any PCP or EP who writes fewer than 100 prescriptions during the reporting period. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 5 153 Measure 5: Maintain active medication list Intent Objective The organization’s PCPs or EPs maintain active medication list. Measure More than 80 percent of all unique patients seen by the organization’s PCPs or EPs have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 154 MY 2012 P4P Meaningful Use of Health IT: Measure 6 Measure 6: Maintain active medication allergy list Intent Objective The organization’s PCPs or EPs maintain active medication allergy list. Measure More than 80 percent of all unique patients seen by the organization’s PCPs or EPs have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 7 155 Measure 7: Record demographics Intent Objective The organization’s PCPs or EPs record all of the following demographics: A. Preferred language. B. Gender. C. Race. D. Ethnicity. E. Date of birth. Measure More than 50 percentage of all unique patients seen by the organization’s PCPs or EPs have demographics recorded as structured data. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 156 MY 2012 P4P Meaningful Use of Health IT: Measure 8 Measure 8: Record and chart changes in vital signs Intent Objective The organization’s PCPs or EPs record and chart changes in the following vital signs: A. Height. B. Weight. C. Blood Pressure. D. Calculate and display body mass index (BMI). E. Plot and display growth charts for children 2-20 years, including BMI. Measure For more than 50 percent of all unique patients age 2 and over seen by the organization’s PCPs or EPs, height, weight and blood pressure are recorded as structured data. Exclusions Any PCP or EP who either sees no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information. 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 9 157 Measure 9: Record smoking status Intent Objective The organization’s PCPs or EPs record smoking status for patients 13 years old or older. Measure More than 50 percent of all unique patients 13 years old or older seen by the organization’s PCPs or EPs have smoking status recorded as structured data. Exclusions Any PCP or EP who sees no patients 13 years or older. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 158 MY 2012 P4P Meaningful Use of Health IT: Measure 10 Measure 10: Report ambulatory clinical quality measures Intent Objective The organization’s PCPs or EPs report ambulatory clinical quality measures to CMS. Measure Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 11 159 Measure 11: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule Intent Objective The organization’s PCPs or EPs implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. Measure Implement one clinical decision support rule. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 160 MY 2012 P4P Meaningful Use of Health IT: Measure 12 Measure 12: Provide patients with an electronic copy of their health information Intent Objective The organization’s PCPs or EPs provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request. Measure More than 50 percent of all patients who request an electronic copy of their health information are provided it within three business days. Exclusions Any PCP or EP that has no requests from patients or their agents for an electronic copy of patient health information during the reporting period. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 13 161 Measure 13: Provide clinical summaries for patients for each office visit Intent Objective The organization’s PCPs or EPs provide clinical summaries for patients for each office visit. Measure Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days. Exclusions Any PCP or EP who has no office visits during the reporting period. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 162 MY 2012 P4P Meaningful Use of Health IT: Measure 14 Measure 14: Capability to exchange key clinical information Intent Objective The organization’s PCPs or EPs have the capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically. Measure Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 15 163 Measure 15: Protect electronic health information created or maintained by the certified EHR technology Intent Objective The organization’s PCPs or EPs protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process. Exclusions No exclusion. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 164 MY 2012 P4P Meaningful Use of Health IT: Measures 16-20 Menu Set Items Measures 16–20: CMS menu set items Intent For measures 16–20, choose from among the 10 CMS menu set items in Table MUHIT-A. Table MUHIT-A. CMS Menu Set Items CMS Menu Set Item A. Drug Formulary Checks Item Objective Measure Exclusion B. Clinical Lab Test Results Objective Measure Exclusion C. Patient Lists Objective D. Patient Reminders Measure Exclusion Objective Measure Exclusion E. Patient Electronic Access Objective Measure Exclusion F. Patientspecific Education Resources Objective Measure Exclusion Description Implement drug formulary checks. The PCP or EP has enabled this functionality and has access to at least one internal or external formulary for the entire EHR reporting period. Any PCP or EP who writes fewer than 100 prescriptions during the EHR reporting period. Incorporate clinical lab test results into EHR as structured data. More than 40 percent of all clinical lab test results ordered by the PCP or EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data. Any PCP or EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one report listing patients of the PCP or EP with a specific condition. No exclusion. Send reminders to patients per patient preference for preventive/follow-up care. More than 20 percent of all patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period. Any PCP or EP who has no patients 65 years old or older or 5 years old or younger with records maintained using certified EHR technology. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the PCP or EP. At least 10 percent of all unique patients seen by the PCP or EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP’s discretion to withhold certain information. Any PCP or EP that neither orders nor creates lab tests or information that would be contained in the problem list, medication list, medication allergy list (or other information as listed at 45 CFR 170.304(g)) during the EHR reporting period. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. More than 10 percent of all unique patients seen by the PCP or EP are provided patient-specific education resources. No exclusion. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measures 16-20 Menu Set Items 165 Table MUHIT-A. CMS Menu Set Items (continued) CMS Menu Set Item G. Medication Reconciliation Item Objective Measure Exclusion H. Transition of Care Summary Objective Measure Exclusion I. Immunization Registries Data Submission Objective Measure Exclusion J. Syndromic Surveillance Data Submission Objective Measure Exclusion November 30, 2012 Description The PCP or EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The PCP or EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. A PCP or EP who was not the recipient of any transitions of care during the EHR reporting period. The PCP or EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. The PCP or EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. A PCP or EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice. Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the PCP or EP submits such information has the capacity to receive the information electronically). A PCP or EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice. Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which a PCP or EP submits such information has the capacity to receive the information electronically). A PCP or EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically. Measurement Year 2012 P4P Manual 166 MY 2012 P4P Meaningful Use of Health IT: Measure 16 Measure 16: Select one of the CMS menu set items Intent Objective Select one of the menu set items from Table MUHIT-A. Organizations must meet the objective, measure and exclusion requirements. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 17 167 Measure 17: Select one of the CMS menu set items Intent Objective Select one menu set item from Table MUHIT-A. Organizations must meet the objective, measure and exclusion requirements. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information. 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 168 MY 2012 P4P Meaningful Use of Health IT: Measure 18 Measure 18: Select one of the CMS menu set items Intent Objective Select one menu set item from Table MUHIT-A. Organizations must meet the objective, measure and exclusion requirements. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 19 169 Measure 19: Select one of the CMS menu set items Intent Objective Select one menu set item from Table MUHIT-A. Organizations must meet the objective, measure and exclusion requirements. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. November 30, 2012 Measurement Year 2012 P4P Manual 170 MY 2012 P4P Meaningful Use of Health IT: Measure 20 Measure 20: Select one of the CMS menu set items Intent Objective Select one menu set item from Table MUHIT-A. Organizations must meet the objective, measure and exclusion requirements. Scoring Scoring is determined by the percentage of the organization’s PCPs or EPs who meet the intent of the measure. Percentage of PCPs or EPs Meeting the Intent of the Measure 1–24 25–49 50–74 75+ Required submission Points per Measure for ONC-ATCB Certified Software 1 3 4 5 Record the following information 1. Number of PCPs or EPs who meet the intent of the measure. 2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable. 3. Attach documentation to support submitted numbers, including measure threshold, if applicable. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 21 171 Measure 21: Chronic care management Intent For members in the patient population who are identified with diabetes, depression or one other clinically important condition, the organization and its physicians have IT systems that support care management processes for at least 50 percent of the eligible commercial HMO/POS members and perform the following. 1. Identify, stratify by risk level and engage patients in care management processes. 2. Inform physicians about the conditions of their individual patients using electronic data. 3. Provide regular patient contact outside of the office setting. 4. Support patient self-management. Scoring for Diabetes Scoring for Depression Scoring for Other Condition Explanation The organization conducts all four items for diabetes. Yes No The organization conducts all four items for depression. (May be addressed as comorbidity of another chronic condition.) Yes No The organization conducts all four items for one other clinically important condition. Yes No Points 5 0 Points 5 0 Points 5 0 This is the core of population-based care management, where the organization reaches out to provide assistance and follow-up to populations with, or at risk for, established medical conditions. This is not utilization management or case management, because it focuses on preventing exacerbations and improving health status, rather than on directing utilization. Definitions Care management Provides population-based, supportive and ongoing care for patients and requires a continuous relationship with patients and interaction through multiple media. Care management incorporates disease management, a system of coordinated health care interventions and communication for populations with conditions in which patient selfcare efforts are significant. Disease management includes the following. Population identification processes. Evidence-based practice guidelines. Collaborative practice models to include physician and support-service providers. Patient self-management education (may include primary prevention, behavior modification programs and compliance/surveillance). Process and outcomes measurement, evaluation and management. Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers and practice profiling). November 30, 2012 Measurement Year 2012 P4P Manual 172 MY 2012 P4P Meaningful Use of Health IT: Measure 21 Participation Including the patient in a population for which the organization consistently provides care management to improve health status. Details The organization may take responsibility for some or all of the four items, may work with health plan programs that provide care management or may assign physician practices to provide the functions. In this last case, the organization should show evidence of how it directs practices’ actions. Examples Diabetes Stratify diabetic patients into a high level of interaction because they have high blood pressure. The medical group has the patient educator contact the patients, train them to monitor their own blood pressure and follow up with them on the results. The patient educator works with the patients by phone, e-mail and occasionally in person, to help patients stay on their medication and change their lifestyle habits to lower blood pressure. Depression Stratify patients according to their results on PHQ 9. The group regularly follows those at highest risk, either by regular contact with the behavioral healthcare provider, or if the medical group itself is treating the problem, by checking in with the patient to determine if treatment is helping. All Use electronic data to inform practitioners about the conditions of individual patients (e.g., provide a registry or report showing a history of HbA1c levels, LDL levels and blood pressure readings). Provide regular patient contact outside of the office setting (e.g., a phone call or e-mail to confirm that a patient filled a prescription or understood the treatment plan, patient-initiated or provider-initiated e-communication, electronic patient reminders, pre-visit reminder or preparation, electronic after-visit summaries). Support patient self-management (e.g., provide patients with online/interactive tracking tools, educational DVDs, shared decision-making tools, remote devices, referrals to online or community-based resources for exercise or diet instruction). Required submission The care management process can be operated by the organization or by an external organization (e.g., a health plan or disease management vendor), but the PO must be able track the activities of that vendor. For example, if a vendor is conducting care management activities for patients with depression, the PO must be able to track which members are being served and what care management activities are taking place. The care management process must be in place for at least 50% of the commercial HMO/POS members with the given condition. The below information is collected to document that this 50% threshold is met. Diabetes Record the following information for diabetes: Number of patients with diabetes: __________ Number of patients identified by risk stratification level: __________ (Example: If a PO has 100 diabetic members, and 75 of those members can be stratified into different risk categories, enter 75 for this number. Include all diabetic members who can be stratified by risk, not only those who fall into the highest risk category). Number of patients with diabetes to whom the care management process is available: __________ (Note: Include the number of diabetic members to whom the care management process is offered, not only those who participate). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Meaningful Use of Health IT: Measure 21 Number of patients engaged in your care management process: 173 __________ Note: Documentation to support submitted numbers must be available if selected for audit. Depression Record the following information for depression: Number of patients with depression: __________ Number of patients identified by risk stratification level: __________ (Example: If a PO has 100 members with depression, and 75 of those members can be stratified into different risk categories, enter 75 for this number. Include all members with depression who can be stratified by risk, not only those who fall into the highest risk category). Number of patients with condition to whom the care management process is available: __________ (Note: Include the number of members with depression to whom the care management process is offered, not only those who participate). Number of patients engaged in your care management process: __________ Note: Documentation to support submitted numbers must be available if selected for audit. One other clinically important condition Record the following information for the condition: Number of patients with condition: __________ Number of patients identified by risk stratification level: __________ (Example: If a PO has 100 members with the condition, and 75 of those members can be stratified into different risk categories, enter 75 for this number. Include all members with the condition who can be stratified by risk, not only those who fall into the highest risk category). Number of patients with condition to whom the care management process is available: __________ (Note: Include the number of members with the condition to whom the care management process is offered, not only those who participate). Number of patients engaged in your care management process: __________ Note: Documentation to support submitted numbers must be available if selected for audit. November 30, 2012 Measurement Year 2012 P4P Manual 174 MY 2012 P4P Meaningful Use of Health IT: Attestation of Accuracy Attestation of Accuracy Intent POs must submit accurate PO level results, not results that are inferred based on a sample. 1. Do you attest to the accuracy of all of your responses to MY 2012 MUHIT survey? Measurement Year 2012 P4P Manual November 30, 2012 Patient Experience Domain For P4P MY 2012 Self-Reporting POs 176 MY 2012 P4P Patient Experience Domain: Overview Overview MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Clarified that the Overall Rating of Care composite is made of the Rating of PCP and Rating of All Healthcare measures. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Clarified that health plans do not submit data for the Patient Experience domain; POs voluntarily self-report this domain. Starting in MY 2012, the survey used to collect data for the Patient Experience Domain, will be the national standard CAHPS Clinician & Group (CG-CAHPS) Patient Experience Survey endorsed by the National Quality Forum (NQF). Added information about an e-mail version of the survey. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. Description This section includes the P4P guidelines and specifications for POs that participate in the Patient Experience domain for MY 2012. Health plans do not submit data for the Patient Experience domain; POs voluntarily self report this domain. P4P uses the Patient Assessment Survey (PAS) to assess PO performance. Since 2001, the California Cooperative Healthcare Reporting Initiative (CCHRI), a statewide collaborative of health plans, POs and purchasers, has conducted an annual survey to assess patient experience with the care delivered by the patient’s PO. The PAS is conducted under the auspices of the CCHRI, with guidance provided by the CCHRI PAS Project Committee—composed of representatives of each participating health plan and 10 physician organizations—and the CCHRI Executive Committee. Each P4P measurement year, a subset of questions from the PAS survey is selected for inclusion in the Patient Experience domain. Survey instrument Starting in MY 2012, the PAS will be the national standard CG-CAHPS Patient Experience survey, which has been endorsed by the National Quality Forum. It was developed by the Agency for Healthcare Research and Quality (AHRQ) and its research partners in the CAHPS consortium. The survey has both PCP and specialist versions of the survey, which overlap substantially. Participation For MY 2012, CCHRI will invite all POs that operate in California and serve commercially insured HMO and POS patients to participate in PAS. Invitations will be distributed electronically by early September, and POs will be required to register formally by September 28, 2012. Registration will be online; registration forms can be found at http://www.cchri.org/pas_registration. POs that do not receive an e-mail invitation by September 7, 2012, should contact Ariel Klein by e-mail at [email protected] or by phone at 415-615-6305. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Patient Experience Domain: Overview 177 During the registration process, POs will be given information on various survey options and the associated fees. POs will be required to provide up-to-date contact information and data on member enrollment, geographic locations served and other PO characteristics, and must agree to the terms outlined in the CCHRI PAS Participation Agreement. POs will have the option to download and sign off on the terms outlined in the Business Associate Agreement with the survey vendor for the project, the Center for the Study of Services (CSS). In addition to participating in the PAS Physician Group Survey, POs may elect supplemental survey options including: Surveys of distinct subunits or practice sites of the PO as separate reporting units, each with a unique sample of 900 patients. Alternative-language surveys, in which POs ―double-stuff‖ patient survey packages with a survey translated into one of three alternative languages (i.e., Spanish, Chinese or Vietnamese). Doublestuffing facilitates responses by patient populations that may not be fluent in English. Doctor surveys, in which POs conduct additional surveys at the physician level using the PAS survey instrument, processes and methods. This supplemental project is designed to facilitate quality improvement. Pediatricians may be included in the survey process. PO Requirements In addition to formal registration, POs must adhere to the following requirements. Meet deadlines that will be specified during the registration process. Failure to meet deadlines will result in forfeiture of the PO’s participation in the PAS project and eligibility for P4P bonus dollars associated with PAS performance measures. Sign up for the PAS at the same reporting level at which the PO will be reported for P4P. All P4P domains must be reported at the same level. The data aggregator cannot separate subgroup results and can no longer roll up PAS scores. Sign off on the PAS Participation Agreement at the time of registration. Submit (or confirm) the PO logo and executive (i.e., medical director) signature, which will be printed on the survey cover letter and instrument. POs will be given instructions for submitting these items after registration. Provide accurate information on the PO’s coding practices and provider specialties, as requested in an online survey to be hosted by the survey vendor. POs will be given instructions for providing this information after registration. Submit data files on all eligible patients, patient visits and providers, from which the patient sample will be drawn. POs will be given a set of data specifications that define the layout of the files and the information required within each field. All data submissions must meet the data quality criteria identified by PAS. Failure to meet the defined criteria will result in forfeiture of participation in PAS. Pay participation fees associated with the survey options elected by the PO. Fees are listed on the registration site. November 30, 2012 Measurement Year 2012 P4P Manual 178 MY 2012 P4P Patient Experience Domain: Overview Performance Areas The following key performance areas are assessed in P4P. Doctor-Patient Interaction Composite for PCPs. Doctor-Patient Interaction Composite for Specialists. Coordination of Care Composite. Timely Care and Service Composite for PCPs. Timely Care and Service Composite for Specialists. Overall Rating of Care Composite. This composite is calculated by NCQA, and is made up of the following two measures: – Rating of PCP. – Rating of All Healthcare. Office Staff Composite. Health Promotion Composite (based on a two year roll-up). P4P Measurement Year 2012 Patient Experience Questions From 2013 PAS Performance Area Doctor-Patient Interaction Composite Coordination of Care Composite Primary Care Version In the last 12 months, how often did this doctor listen carefully to you? (Q17) In the last 12 months, how often did this doctor explain things in a way that was easy to understand? (Q16) In the last 12 months, how often did this doctor spend enough time with you? (Q22) In the last 12 months, how often did this doctor show respect for what you had to say? (Q21) In the last 12 months, how often did this doctor give you easy to understand information about taking care of these health problems or concerns? (Q19) In the last 12 months, how often did this doctor seem to know the important information about your medical history? (Q20) In the last 12 months, when this doctor ordered a blood test, x-ray or other test for you, how often did someone from the doctor’s office follow up to give you those results? (Q29) In the last 12 months, how often did this doctor seem informed and up-to-date about the care you got from specialists? Q27) Measurement Year 2012 P4P Manual Specialist Version In the last 12 months, how often did this doctor listen carefully to you? (Q15) In the last 12 months, how often did this doctor explain things in a way that was easy to understand? (Q14) In the last 12 months, how often did this doctor spend enough time with you? (Q20) In the last 12 months, how often did this doctor show respect for what you had to say? (Q19) In the last 12 months, how often did this doctor give you easy to understand information about taking care of these health problems or concerns? (Q17) In the last 12 months, how often did this doctor seem to know the important information about your medical history? (Q18) In the last 12 months, when this doctor ordered a blood test, x-ray or other test for you, how often did someone from the doctor’s office follow up to give you those results? (Q26) In the last 12 months, how often did this doctor seem informed and up-to-date about the care you got from specialists? (Q24) Weighting 2.5% for PCP 2.5% for specialist 2.5% November 30, 2012 MY 2012 P4P Patient Experience Domain: Overview Performance Area Timely Care and Service Composite Primary Care Version (PAS) Measurement Year 2012/2013 Payout In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed? (Q5) In the last 12 months, when you phoned this doctor’s office during regular hours, how often did you get an answer to your medical questions that same day? (Q9) In the last 12 months, when you made an appointment for a check-up or routine care with this doctor, how often did you get an appointment as soon as you thought you needed? (Q7) In the last 12 months, when you phoned this doctor’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? (Q11) Specialist Version (PAS) Measurement Year 2012/2013Payout In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed? (Q5) In the last 12 months, when you phoned this doctor’s office during regular hours, how often did you get an answer to your medical questions that same day? (Q7) 179 Weighting 2.5% for PCP 2.5% for specialist In the last 12 months, when you phoned this doctor’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? (Q9) Wait time includes time spent in the waiting Wait time includes time spent in the waiting room and exam room. In the last 12 months, room and exam room. In the last 12 months, how often did you see this doctor within 15 how often did you see this doctor within 15 minutes of your appointment time? (Q12) minutes of your appointment time? (Q10) 2.5% Overall Ratings What number would you use to rate this What number would you use to rate this of Care doctor? (0-10 scale) (Q32) doctor? (0-10 scale) (Q29) Composite What number would you use to rate all your What number would you use to rate all your health care from all doctors and other health health care from all doctors and other health providers that you have seen in the last 12 providers that you have seen in the last 12 months? (0-10 scale) (Q38) months? (0-10 scale) (Q35) 2.5% Office Staff In the last 12 months, how often were clerks In the last 12 months, how often were clerks Composite and receptionists at this doctor’s office as and receptionists at this doctor’s office as helpful as you thought they should be? (Q36) helpful as you thought they should be? (Q33) In the last 12 months, how often did clerks and receptionists at this doctor’s office treat In the last 12 months, how often did clerks you with courtesy and respect? (Q37) and receptionists at this doctor’s office treat you with courtesy and respect? (Q34) 2.5% Health In the last 12 months, did you and this doctor In the last 12 months, did you and this Promotion talk about a healthy diet and healthy eating doctor talk about a healthy diet and healthy Composite habits? (Q30) eating habits? (Q27) In the last 12 months, did you and this doctor In the last 12 months, did you and this talk about the exercise or physical activity doctor talk about the exercise or physical you get? (Q31) activity you get? (Q28) Note: The total weight for the Patient Experience Domain is 20 percent. There are eight composites, each weighted 2.5 percent: Doctor-Patient Communication for PCPs, Doctor-Patient Communication for Specialists, Coordination of Care, Timely Care and Service for PCPs, Timely Care and Service for Specialist, Office Staff, Health Promotion and Overall Ratings of Care. November 30, 2012 Measurement Year 2012 P4P Manual 180 MY 2012 P4P Patient Experience Domain: Overview Specifications: Patient Population Surveyed Only adults are surveyed for multispecialty POs. There are two options for assessing pediatric performance. 1. Conduct a second group-level survey process for pediatric patients, which would be sent to the parent of the patient sample. 2. Select the doctor-level survey of pediatricians when completing the registration process. For more information on assessing pediatric performance, contact Ariel Klein by e-mail at [email protected] or by phone at 415-615-6305. Sampling A sample of 900 commercially-insured HMO and POS patients who had at least one visit between January and October of the measurement year and were enrolled in the PO as of October 31 of the measurement year are randomly selected from each PO. The sample is stratified, with 450 patients drawn from patients who had visits with their assigned PCPs and the remaining patients drawn from those who had a specialist visit. Only one eligible patient from each household is included in the patient sample. To increase the likelihood of responses, sampling is prioritized by the most recent date of visit. Patient visits are grouped into three periods during 2012: January–April, May–July and August–October. Visits are selected randomly from the enrollment files of each PO, starting with the most recent period (August–October). Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Patient Experience Domain: Overview 181 Fielding Surveys The standard survey protocol consists of two mailed surveys and includes a cover letter outlining an option to complete the survey via the survey vendor Web site, using a unique Web ID contained in the letter. The cover letter is printed with the logo of the patient’s PO and is signed by the PO’s medical director. The first mailing occurs in late January 2013; the second occurs in late February and is sent only to patients who did not respond to the first mailing. Patients who do not respond to the second mailing are contacted by phone in late March. Mail, Web and phone interviews are available in English and Spanish for all patients, and all mailed cover letters include a message in Spanish inviting patients to request a Spanish version of the survey via a toll-free number. POs are also given the option to field the survey in English and an alternative language (Chinese, Spanish or Vietnamese). Patients receiving the alternative language survey receive a cover letter in English, with a translation in the alternative language printed on the back of the letter, and a copy of the survey instrument in the alternative language. Beginning with PAS 2013, groups that register for the e-mail option and confirm that e-mail surveys are consistent with their privacy policies may include e-mail addresses in the patient file. POs that opt into e-mail surveys will have a mandatory call with the PAS Project Team before the functionality is introduced to the sample. Sampled patients will be sent an e-mail invitation at the beginning of the fielding period to complete the survey on the CSS Web site. Patients who complete the survey online within a week of the invitation will not be sent a mailed survey or called during the phone follow-up period. Response File Preparation When survey fielding is complete, the survey vendor cleans the data (e.g., removes duplicate interviews, merges response data with the original sample data, conducts consistency checks between question items). Response data files from mail, Web and telephone interview sources are cleaned for out-of-range responses for each question. All responses are kept where the patient either confirms a physician visit or—for PCP patient interviews—provides the name of another PCP in the PO and confirms a visit with the physician in the past year. The respondent’s survey is dropped from analysis if the respondent indicates a physician who cannot be matched to the PO’s provider file. Analysis of Survey Data Each PO’s results are adjusted for patient case-mix to control for differences across POs. In MY 2012, the case-mix adjustment model will control for the following. Age. Single item mental health status. Gender. Specialty type of physician that patient rated (44 categories). Education level. Race/ethnicity—primary language of respondent. Presence of chronic conditions. Survey response mode (mail, Internet, phone). Language in which survey was completed. BMI score. Single-item physical health status. November 30, 2012 Measurement Year 2012 P4P Manual 182 MY 2012 P4P Patient Experience Domain: Overview Reports POs receive the following reports of their results. P4P Results (June 2013): Each PO receives its results on the P4P set of items, along with a set of percentile cut points that demonstrate statewide performance. PO Report (July 2013): Each PO receives a report that displays its results for all question items in various formats and as compared with other POs in its region. The report also describes all survey methods and processes. Excel File (July 2013): Each PO receives an Excel file with comparative results on each question item for all POs in its region. Raw Data File (July 2013): Each PO receives a data file with the de-identified raw survey data for all patient respondents. Survey results are made publicly available for consumers in September through the PBGH California Consumer HealthScope Web site (www.healthscope.org) and the California Department of Managed Health Care’s Office of the Patient Advocate consumer Web site (www.opa.ca.gov/report_card). Note: Performance results will not be publicly reported for any question or composite that achieves a reliability score of <0.70. Key Dates for P4P PAS September 7, 2012 September 28, 2012 October 15, 2012 November 21, 2012 June 2013 POs receive invitation to participate in PAS. Deadline to register for MY 2012 PAS. Participation agreement due (via electronic consent during the registration process). File specifications to POs. PO logos/signatures confirmed and completion of online survey on coding practices and physician specialties. Data files and Attestation due to vendor. Results for P4P items to POs, plans and IHA. PO report, including all survey items, comparative results and raw data. For More Information Visit the CCHRI Web site at http://www.cchri.org/pas_registration after September 6, 2012, or contact Ariel Klein by e-mail at [email protected] or by phone at 415-615-6305. Measurement Year 2012 P4P Manual November 30, 2012 Appropriate Resource Use Domain Technical Specifications For P4P MY 2012 184 MY 2012 P4P ARU Specifications: Overview Overview In recognition of the growing issue of affordability of the HMO product in California and the consequent potential demise of the delegated model, the P4P Governance Committee (the former P4P Executive and Steering Committees) charged IHA with developing standardized, appropriate resource use (ARU) measures to be implemented as part of the Pay for Performance program. ARU measures were already being used for incentive payments by individual plans and physician groups. Incorporating them into P4P will align measurement across plans for consistent identification of unwarranted variation in care delivery, and will provide an opportunity to address these areas to ensure appropriate use of limited health care dollars in delivering quality care. Measure Development and Testing The ARU measures were selected by a multi-stakeholder group of P4P Committee and IHA board members, based on resource use measures currently in use and their potential to improve efficient delivery of appropriate, quality care. The detailed specifications on the following pages were developed by a workgroup of participating physician organizations and health plans, with technical support from Truven and NCQA. These measures are calculated by Truven from claims, encounter and eligibility data submitted by participating health plans. POs do not self-report ARU measures. Measures Inpatient Readmissions Within 30 Days. Emergency Department Visits. Inpatient Utilization—Acute Care Discharges. Generic Prescribing. Inpatient Utilization—Bed Days. Total Cost of Care. Outpatient Procedures Utilization—Percentage Done in Preferred Facility. Frequency of Selected Procedures. Calculation of Results Each measure will be calculated in two ways. 1. Results for each contracted health plan. Rates will be run on each health plan’s data for each contracted PO. Each health plan will apply its actual costs for the PO to the utilization results provided, and will share any savings generated by a PO's improvement over the previous year’s performance. 2. Results aggregated across all contracted health plans. A PO’s results for each measure will be aggregated across all contracted plans. This will allow a PO to understand how its utilization compares with other POs. Confidence intervals of 95 percent will be provided for all measures, representing the range within which the true rate would appear 95 percent of the time. Enrollment in Plan and PO For the service to be counted, members must be enrolled in the plan and the PO on the date of service, for all measures. For example, for Outpatient Procedures Utilization—Percentage Done in Preferred Facility, the procedure is attributed to the PO and plan where the member was enrolled on the date of the procedure. The service is not counted in the measure if an enrollment record does not identify a PO in which a member was enrolled on the date of service. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Overview 185 Which Services Count? Report all services the organization actually paid or expects to pay. Do not include services or days denied for any reason. In cases where a member is enrolled retroactively, count all services for which the organization has paid or expects to pay. Risk Adjustment The selected risk-adjustment methodology is indicated in each measure’s specification. Risk adjustment was determined to be unnecessary for two measures. For Outpatient Procedures Utilization, a standard list of outpatient procedures is used, which CMS has determined can be done in an ambulatory outpatient setting, independent of member risk. For Generic Prescribing, specific therapeutic areas are measured, which makes the eligible population more homogenous. Observed-to-Expected Ratio A common characteristic of the measures that includes risk adjustment is the use of an ‖observed-toexpected‖ ratio (also known as an observed/expected [O/E] ratio). In all calculations, the observed rate (per the specifications) is divided by an expected rate, which considers the risk or illness burden of the PO’s population. POs with higher-risk (i.e., sicker) members are expected to have higher utilization and, therefore, have higher expected rates. Similarly, POs with lower risk scores are expected to have lower utilization and have lower expected rates. It is important to note that the calculation of the expected rate is based on utilization and risk patterns in the P4P population, not on national or other external benchmarks. Specifically, to calculate the expected rate, a statistical model is developed that summarizes the relationship between observed rates and relative risk scores across the P4P population and provides an expected rate for a given level of risk. Because the distribution of observed rates by relative risk score varies by measure, the specific statistical model used to fit the data depends on the measure. The O/E ratio compares the PO’s observed rate to the expected rate and allows straightforward interpretation of how the PO’s performance compared with the performance of the P4P population. An O/E ratio of 1.0 means the PO’s rate was the same as expected based on the risk of its population. An O/E ratio of 1.1 means the rate was 10 percent higher than expected; an O/E ratio of 0.9 means the rate was 10 percent lower than expected. Reliability Adjustment Smaller POs will have less reliable rates than larger POs; thus, year-to-year changes of the same magnitude have less chance of being statistically significant. Reliability adjustment, often termed ―shrinkage estimation,‖ is a widely-accepted statistical method used to improve the reliability of estimates and is being used for the first time to adjust Appropriate Resource Use measure rates. Specifically, reliability-adjusted rates are calculated as a weighted average of the PO’s rate and each plan’s average PO rate across all of its contracted POs. The magnitude of the reliability adjustment depends on the precision of the PO’s own rate, which increases as the denominator increases, and on the spread of rates across POs. The size of the adjustment decreases as the spread of rates increases—this is because the larger the variation among POs, the greater the evidence that POs truly differ from one another. Therefore, as variation increases, a greater weight is put on each PO’s own rate. In general, for large POs, reliabilityadjusted rates will be similar to unadjusted rates. Note: Reliability adjustments are calculated separately for each plan, based on each plan’s distribution of PO scores. Reliability adjusted “all-plan” rate calculations are based on the distribution of PO all-plan rates. November 30, 2012 Measurement Year 2012 P4P Manual 186 MY 2012 P4P ARU Specifications: Overview A reliability-adjusted O/E ratio is calculated for Inpatient Utilization, Inpatient Utilization—Bed Days, Inpatient Readmissions Within 30 Days and Emergency Department Visits. An O/E ratio is not calculated for Outpatient Procedures Utilization—Percentage Done in Preferred Facility; therefore, reliability adjustment is applied to the observed rate. Reliability adjustment is not applied to GRX measures. The reliability-adjustment methodology assumed a gamma-Poisson model. Using this model, PO-specific rates were assumed to follow a gamma distribution and the count of numerator events was assumed to have a Poisson distribution. Bayesian methods were used to estimate the parameters of the gamma distribution (Jones and Spiegelhalter 2009). Timeline The Appropriate Resource Use measures are part of the MY 2012 P4P measure set. Calculation of improvement results is based on changes between MY2011 and MY 2012 performance. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Readmissions Within 30 Days 187 Inpatient Readmissions Within 30 Days (IRN) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. Added ―newborn care‖ to the maternity care exclusion in step C of the discharge identification methodology and coding. Added ICD-9-CM Diagnosis code V27.x to Table IRN-C. Added MS-DRG codes 765-770, 774-782 and 789-795 to Table IRN-C. Changed text in Step 7 of the inpatient readmission calculation to refer to index charges instead of admissions. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Deleted obsolete MS-DRG code 009 from tables IRN-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Non-HEDIS measure. This measure is based on the Inpatient Readmission measure submitted by UnitedHealthcare. Description The percentage of inpatient admissions that resulted in a readmission within 30 days of discharge during the measurement year. This measure is risk adjusted by CMS DRG weight. Reliability adjustment is performed using shrinkage estimation. Note: Truven will run this measure for MY 2012. Health plans and POs are not expected to report it. Definition Index Discharge Date Each date of a live discharge from an acute care hospital. Members can have multiple Index Discharge Dates. Eligible Population Product line Commercial HMO and POS. Ages All ages. Continuous enrollment Date of admission through 30 days after discharge in the health plan and in the PO (parent level). Allowable gap No gaps in enrollment. November 30, 2012 Measurement Year 2012 P4P Manual 188 MY 2012 P4P ARU Specifications: Inpatient Readmissions Within 30 Days Anchor date None. Benefit Medical. Event/ diagnosis This measure uses the same approach as Inpatient Utilization—Acute Care Discharges to identify inpatient stays. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. Discharge Identification Methodology and Coding A. Identify all acute inpatient discharges from January 1–December 1 of the measurement year. Refer to Table IRN-A. The denominator for this measure is based on discharges, not on members. Include all discharges for each member from January 1–December 1. This means that a readmission is also an index discharge for another potential readmission within 30 days. B. Skilled nursing facility. Exclude discharges to a skilled nursing facility as identified through either (1) a discharge status of ―3‖ or (2) the presence of a skilled nursing facility claim (as identified through Table IRN-B), with an admission date that is the same date as the discharge date of the acute stay, or the next day after the discharge date. C. Maternity/newborn care exclusion. Exclude maternity and newborn discharges. Refer to Table IRN-C. D. Discharged to another acute care hospital. Count transfers to another acute facility as one stay and extend the discharge date to include the transfer stay. E. Discharged deceased. Exclude discharges of members who were discharged deceased. Use UB Discharge Code 20, 40, 41 or 42. F. Mental health/chemical dependency exclusion. Exclude discharges related to mental health and chemical dependency. Refer to Table IRN-D. G. Apply an MS DRG grouper to the inpatient claims data. Table IRN-A: Codes to Identify Total Inpatient Discharges Principal ICD-9-CM Diagnosis 001-289, 317-999, V01-V29, V40-V89 OR MS—DRG 001-008,010-013, 020-042, 052-103, 113-117, 121-125, 129-139, 146-159, 163168, 175-208, 215-264, 280-316, 326-358, 368-395, 405-425, 432-446, 453-517, 533-566, 573-585, 592-607, 614-630, 637-645, 652-675, 682-700, 707-718, 722730, 734-750, 754-761, 765-770, 774-782, 789-795, 799-804, 808-816, 820-830, 834-849, 853-858, 862-872, 901-909, 913-923, 927-929, 933-935, 939-941, 947951, 955-959, 963-965, 969-970, 974-977, 981-989 WITH UB Type of Bill 11x, 12x, 41x, 84x OR Measurement Year 2012 P4P Manual POS 21 OR Revenue Code 0100-0189, 0200–0219 November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Readmissions Within 30 Days 189 Table IRN-B: Codes to Identify SNF Description SNF UB Type of Bill 21x, 22x, 28x OR POS 31, 32 OR UB Revenue 019x OR UB Discharge 3 Table IRN-C: Codes to Identify Maternity and Newborn Care Discharges Principal ICD-9-CM Diagnosis Description Maternity 630-676, 678-679, V24.0 Newborn care V27.x OR 0112, 0122, 0132, 0142, 0152, 0720-0722, 0724 MS-DRG UB Type of Bill UB Revenue OR 84x OR 765-770, 774-782 789-795 Table IRN-D: Codes to Identify Mental Health and Chemical Dependency Exclusions Principal ICD-9-CM Diagnosis 960-979 WITH Secondary ICD-9-CM Diagnosis 291-292, 303-305, 535.3, 571.1 Administrative Specification Denominator The number of qualifying index discharges for the eligible population. Numerator The discharges included in the denominator for which there was another acute care admission within 30 days. Inpatient Readmission Calculation Step 1 Use DRG weight to adjust for case mix. Run logistic regression analysis to model readmission probability (0,1) as a function of case mix of the index discharge case (case mix is be represented by CMS DRG relative weight). Logit (readmission) = а + b * relative weight from CMS DRG grouper. Step 2 Calculate readmission probability for each index case (expected readmission). Pi = e (a+bxi) / 1 + e (a+bxi). Step 3 Calculate expected readmission rate for each PO. Expected rate = (P A1 + P A2 + P A3 …. P An ) / N PO A. N PO A : The total number of discharges in the denominator for the calculation of the observed rate for PO A. Step 4 Calculate observed readmission rate for each PO. Observed rate = total number of readmissions / total numbers of index discharges. Step 5 Calculate observed/expected readmission ratio for each PO. O/E ratio = observed readmission rate / expected readmission rate. Step 6 Calculate the reliability adjusted O/E ratio for each PO. Reliability adjustment is applied to the O/E ratio. Refer to ―Reliability Adjustment‖ in the Overview section for a description of the reliability adjustment methodology. November 30, 2012 Measurement Year 2012 P4P Manual 190 MY 2012 P4P ARU Specifications: Inpatient Readmissions Within 30 Days Step 7 Calculate population rate across all members (i.e., across all plans and POs). Population rate = [sum of all readmissions] / [sum of all index discharges]. Step 8 Calculate reliability and risk adjusted readmission rate for each PO. Reliability and risk adjusted rate = [reliability adjusted O/E ratio] * population rate Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Utilization—Acute Care Discharges 191 Inpatient Utilization—Acute Care Discharges (IPU) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. Removed text from ages section of the eligible population to determine the PO’s total member years of enrollment in health plan. Added ―newborn care‖ to the maternity care exclusion in step C of the discharge identification methodology and coding. Removed note to include newborn care rendered after the baby has been discharged home and rehospitalized. Added ICD-9-CM Diagnosis code V27.x to Table IPU-D. Added MS-DRG codes 765-770, 774-782 and 789-795 to Table IPU-D. In the inpatient discharges calculation, removed intermediate calculation of total inpatient discharges PTMY and moved the step to remove outliers to after calculating the observed discharges PTMY for each PO. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Deleted obsolete MS-DRG code 009 from tables IPU-A. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Based on HEDIS Use of Services specifications. Added risk adjustment. Description This measure summarizes utilization of non-maternity-related acute inpatient services. The final reported metrics are: Reliability and risk adjusted non-maternity-related inpatient discharges PTMY (by plan). Reliability and risk adjusted non-maternity-related inpatient discharges PTMY (across all plans). Risk adjustment is performed using the concurrent DxCG Relative Risk Score (RRS), which is generated from Sightlines DxCG Risk Solutions software, Version 3.1.0, Model 18: All Medical Predicting Concurrent Total Risk. Reliability adjustment is performed using shrinkage estimation. Note Truven will run this measure for MY 2012. Health plans and POs are not expected to report the measure. Maternity discharges PTMY, both observed and risk adjusted, are provided for information purposes and are not intended as payable P4P measures. November 30, 2012 Measurement Year 2012 P4P Manual 192 MY 2012 P4P ARU Specifications: Inpatient Utilization—Acute Care Discharges Eligible Population Product lines Commercial HMO and POS. Ages All ages. Member years For each PO, calculate member years by dividing the total member days by 365. Continuous enrollment Date of admission through discharge in the health plan and in the PO (parent level). Allowable gap No gaps in enrollment. Anchor date None. Benefit Medical. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. Discharge Identification Methodology and Coding A. Identify all acute inpatient discharges from January 1–December 31 of the measurement year. Refer to Table IPU-A. B. Skilled nursing facility. Exclude discharges from a skilled nursing facility. Refer to Table IPU-B. Note: Do not exclude discharges to a skilled nursing facility. C. Mental health/chemical dependency exclusion. Exclude discharges related to mental health and chemical dependency. Refer to Table IPU-C. D. Discharged to another acute care hospital. Count transfers to another acute facility as one stay and extend the discharge date to include the transfer stay. E. Readmissions within 30 days. Exclude discharges that are qualifying readmissions within 30 days (refer to the Inpatient Readmissions numerator). F. Maternity/newborn care exclusion. Exclude maternity and newborn care discharges. Refer to Table IPU-D. G. Apply MS DRG grouper to the inpatient claims data. Table IPU-A: Codes to Identify Total Inpatient Discharges Principal ICD-9-CM Diagnosis 001-289, 317-999, V01-V29, V40-V89 MS—DRG 001-008,010-013, 020-042, 052-103, 113-117, 121-125, 129-139, 146-159, 163168, 175-208, 215-264, 280-316, 326-358, 368-395, 405-425, 432-446, 453517, 533-566, 573-585, 592-607, 614-630, 637-645, 652-675, 682-700, 707718, 722-730, 734-750, 754-761, 765-770, 774-782, 789-795, 799-804, 808816, 820-830, 834-849, 853-858, 862-872, 901-909, 913-923, 927-929, 933935, 939-941, 947-951, 955-959, 963-965, 969-970, 974-977, 981-989 OR WITH UB Type of Bill 11x, 12x, 41x, 84x OR Measurement Year 2012 P4P Manual POS 21 OR Revenue Code 0100-0189, 0200-0219 November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Utilization—Acute Care Discharges 193 Table IPU-B: Codes to Identify SNF Description UB Type of Bill SNF 21x, 22x, 28x OR POS OR 31, 32 UB Revenue 019x Table IPU-C: Codes to Identify Mental Health and Chemical Dependency Exclusions Principal ICD-9-CM Diagnosis 960-979 WITH Secondary ICD-9-CM Diagnosis 291-292, 303-305,535.3, 571.1 Table IPU-D: Codes to Identify Maternity and Newborn Care Discharges Description Principal ICD-9-CM Diagnosis Maternity 630-676, 678-679, V24.0 Newborn care V27.x OR 0112, 0122, 0132, 0142, 0152, 0720-0722, 0724 MS-DRG UB Type of Bill UB Revenue OR 84x OR 765-770, 774-782 789-795 Inpatient Discharges Calculation Step 1 Identify qualifying discharges, as defined in A, above. Step 2 Remove exclusions. Remove skilled nursing facility discharges, mental health/chemical dependency discharges, and readmissions within 30 days. Refer to B–D, above. Step 3 Remove maternity discharges. Refer to E, above. Note: The maternity discharges PTMY is calculated separately for each PO by plan and is provided to POs and plans for information purposes. Step 4 Calculate the observed discharges PTMY for each PO. Observed rate = [sum of qualifying discharges excluding maternity / total PO member years] *1000. Separate rates will be calculated for each health plan and aggregated across all contracted health plans. Step 5 Remove outliers. Remove any plan results for a PO below the outlier threshold—fewer than 15 discharges PTMY. Members from these POs will be excluded from the pool of members used in the risk adjustment calculation. In addition, expected and risk adjusted rates will not be calculated for these POs. Step 6 Calculate risk scores. Member-level relative risk scores (RRS) will be calculated by running the DxCG Relative Risk software. Appropriate RRS ―bins,‖ which define members of similar risk, are calculated by running a logistic regression model to identify bin cut points. Collect members into appropriate bins based on RRS value. Step 7 Calculate the expected inpatient discharges PTMY for each PO (expected rate). The expected rate for each member is the arithmetic mean of all rates for members attributed to each bin, based on qualifying discharges across all plans and POs (excluding outlier POs). Sum expected rates across all members in PO, within each contracted health plan and aggregated across health plans. November 30, 2012 Measurement Year 2012 P4P Manual 194 MY 2012 P4P ARU Specifications: Inpatient Utilization—Acute Care Discharges Step 8 Calculate the O/E inpatient discharges ratio for each PO. O/E ratio = Observed discharges PTMY / Expected discharges PTMY Step 9 Calculate the reliability adjusted O/E ratio for each PO. Reliability adjustment is applied to the O/E ratio. Refer to ―Reliability Adjustment‖ in the Overview section for a description of the reliability adjustment methodology Step 10 Calculate the population rate PTMY. Across all members (i.e., across all plans and POs), Population rate = [sum of discharges] / [sum of member years] * 1,000 Step 11 Calculate reliability and risk adjusted inpatient discharges PTMY for each PO. Reliability- and risk-adjusted rate = [reliability adjusted observed/expected ratio] * population rate Two sets of reliability-adjusted and risk-adjusted inpatient discharges rates are calculated per PO: 1. Plan-specific: Based on the PO’s enrollment in each health plan. A plan-specific rate is calculated by summing the observed and expected values for PO members enrolled during the measurement year. A plan-specific O/E ratio, a reliability-adjusted O/E ratio and a reliability- and risk-adjusted rate (inpatient discharges PTMY rate) are calculated for each health plan with which the PO contracts. 2. All-plan: Based on the PO’s data aggregated across all contracted health plans. The observed and expected values for all PO members are summed (across all contracted plans). An all plan O/E ratio, a reliability-adjusted O/E ratio and a reliability- and riskadjusted rate (inpatient discharges PTMY rate) are calculated for the PO. Note: All expected rates are based on the performance of the entire P4P population (i.e., across all plans and POs, excluding outlier POs). However, a PO’s expected rate will be estimated for the relative risk score specific to the PO’s members reflected in the measure. For example, a PO’s expected rate for a specific plan will use only the risk of the PO’s members enrolled in that plan to estimate the expected rate. Similarly, the all-plan rate will use the risk of the PO’s members across the plans to estimate the expected rate. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Utilization—Bed Days 195 Inpatient Utilization—Bed Days (IPBD) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Changed the truncation methodology for stays to Winsorize at a specified number of days per stay. Added measurement period to eligible population. Changed text in Step 6 of bed days calculation to refer to bed days instead of discharges. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Based on HEDIS Use of Services specifications. Added risk adjustment. Description This measure reports total bed days associated discharges, after exclusions, including maternity exclusions. The reported, payable P4P metrics for each PO are: Reliability- and risk-adjusted bed days per 1,000 member years (PTMY) (by plan). Reliability- and risk-adjusted bed days PTMY (across all plans). Risk adjustment for total bed days will be performed using the concurrent DxCG Relative Risk Score (RRS),which is generated from Sightlines DxCG Risk Solutions software, Version 3.1.0, Model 18: All Medical Predicting Concurrent Total Risk. Risk adjustment for ALOS will be performed using CMS-DRG mix. Reliability adjustment is performed using shrinkage estimation. Note Truven will run this measure for MY 2012. Health plans and POs are not expected to report the measure. Non-maternity average length of stay (ALOS), both observed and risk adjusted, are provided for information purposes and are not intended as payable P4P measures. Maternity ALOS, both observed and DRG adjusted, are provided for information purposes and are not intended as payable P4P measures. November 30, 2012 Measurement Year 2012 P4P Manual 196 MY 2012 P4P ARU Specifications: Inpatient Utilization—Bed Days Eligible Population Product lines Commercial HMO and POS. Ages All ages. Member years Determine the PO’s total member years of enrollment in a health plan as the sum of the number of days during the measurement year when each eligible member was enrolled in the health plan and PO. For each PO, calculate member years by dividing the total member days by 365. Continuous enrollment Date of admission through discharge in the health plan and in the PO (parent level). Allowable gap No gaps in enrollment. Anchor date None. Benefit Medical. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. Bed Days Calculation Step 1 Identify qualifying discharges from the IPU measure. This excludes maternity discharges, mental health/chemical dependency discharges and readmissions within 30 days. It also excludes discharges from POs that are identified as outliers. Step 2 Sum bed days. For each qualifying discharge, calculate the number of days hospitalized during the measurement year. Winsorize (e.g., truncate) each stay at a specified number of days (to be finalized by the P4P Committees). Step 3 Calculate observed bed days PTMY for each PO. Observed rate = [number of bed days / total PO member years] * 1,000 Separate rates will be calculated for each health plan and aggregated across all contracted health plans. Step 4 Calculate risk scores. Member-level RRS will be calculated by running the DxCG Relative Risk software. Appropriate RRS ―bins,‖ which define members of similar risk, are calculated by running a logistic regression model to identify bin cut points. Collect members into appropriate bins based on RRS value. Step 5 Calculate expected bed days PTMY for each PO (expected rate). The expected rate for each member is the arithmetic mean of all rates for members attributed to each bin, based on qualifying discharges across all plans and POs (excluding outlier POs). Sum expected rates across all members in PO, within each contracted health plan and aggregated across health plans. Step 6 Calculate the O/E inpatient bed days ratio for each PO. O/E ratio = O/E rate Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Inpatient Utilization—Bed Days Step 7 197 Calculate the reliability adjusted observed/expected ratio for each PO. Reliability adjustment is applied to the O/E ratio. Refer to ―Reliability Adjustment‖ in the Overview section for a description of the reliability adjustment methodology. Step 8 Calculate population rate PTMY across all members (i.e., across all plans and POs). Population rate = [sum of all bed days] / [sum of all member years] * 1,000 Step 9 Calculate reliability and risk-adjusted bed days PTMY for each PO. Reliability- and risk-adjusted rate = [reliability adjusted O/E ratio] * population rate Two sets of reliability- and risk-adjusted inpatient bed days rates are calculated per PO: 1. Plan-specific: Based on the PO’s enrollment in each health plan. A health plan-specific rate is calculated by summing the observed and expected values for PO members enrolled in the health plan during the measurement year. A plan-specific O/E ratio, a reliability adjusted O/E ratio and a reliability- and risk-adjusted rate (bed days PTMY rate) are calculated for each health plan with which the PO contracts. 2. All-plan: Based on the PO’s data aggregated across all contracted health plans. The observed and expected values for all PO members are summed (across all contracted health plans). An all-plan O/E ratio, a reliability-adjusted O/E ratio and a reliability- and risk-adjusted rate (bed days PTMY rate) are calculated for the PO. Note: All expected rates are based on the performance of the entire P4P population (i.e., across all plans and POs, excluding outlier POs). However, a PO’s expected rate will be estimated for the relative risk score specific to the PO’s members reflected in the measure. For example, a PO’s expected rate for a specific plan will use only the risk of the PO’s members enrolled in that plan to estimate the expected rate. Similarly, the all-plan rate will use the risk of the PO’s members across the plans to estimate the expected rate. Average Length of Stay Calculation Step 1 Calculate observed ALOS. For members with a qualifying discharge, the ALOS is the mean Winsorized LOS of all member level discharges. Winsorization bounds are set at three times the standard deviation for all discharges attributed to a DRG. Step 2 Calculate expected ALOS for each CMS-DRG. Collect member-level ALOS values into CMSDRG-specific ―bins.‖ The expected ALOS for each DRG is the arithmetic mean of all ALOS values attributed to that DRG-bin, based on discharges across all plans and POs (excluding outlier POs). Step 3 Calculate population-level ALOS. The population level ALOS is defined as the arithmetic mean of ALOS scores across all members, within each DRG bin. Step 4 Calculate risk-adjusted ALOS for each PO. Risk-adjusted ALOS = [O/E ALOS] * population ALOS. Two sets of risk-adjusted ALOS rates are calculated per PO: 1. Plan-specific: Based on the PO’s enrollment in each health plan. A health plan-specific rate is calculated by summing the observed and expected ALOS for PO members enrolled in the health plan during the measurement year. The resulting O/E ratio for the PO is then multiplied by the population ALOS (calculated in step 3). A plan-specific, riskadjusted ALOS rate is calculated for each health plan with which the PO contracts. November 30, 2012 Measurement Year 2012 P4P Manual 198 MY 2012 P4P ARU Specifications: Inpatient Utilization—Bed Days 2. All-plan: Based on the PO’s data aggregated across all contracted health plans. The observed and expected ALOS rates for all PO members are summed (across all contracted health plans). The resulting O/E ratio for the PO is then multiplied by the population ALOS (calculated in step 3). An all-plan risk-adjusted ALOS rate is calculated for the PO. The same process is followed for the maternity ALOS calculations, but DRGs are limited to maternity DRGs during the DRG case-mix adjustment (step 2). Note: All expected rates are based on the performance of the entire P4P population (i.e., across all plans and POs, excluding outlier POs). However, a PO’s expected rate will be estimated for the relative risk score specific to the PO’s members reflected in the measure. For example, a PO’s expected rate for a specific plan will use only the risk of the PO’s members enrolled in that plan to estimate the expected rate. Similarly, the all-plan rate will use the risk of the PO’s members across the plans to estimate the expected rate. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Outpatient Procedures Utilization in Preferred Facility 199 Outpatient Procedures Utilization— Percentage Done in Preferred Facility (OSU) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. Removed optional exclusion of members who require coordination of benefits. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Exclude outpatient procedures identified through an Emergency Department claim/encounter. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Based on a former HEDIS Use of Services measure. Description This measure summarizes utilization of preferred facilities for outpatient/ambulatory procedures. (Outpatient surgeries are included in the definition of ―procedures.‖) One metric will be reported for each PO: Reliability-adjusted percentage of outpatient procedures performed in a preferred facility (by plan). No risk adjustment will be applied. Reliability adjustment is performed using shrinkage estimation. Note: Truven will run this measure for MY 2012. Health plans and POs are not expected to report it. Eligible Population Product lines Commercial HMO and POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date None. Benefit Medical. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. November 30, 2012 Measurement Year 2012 P4P Manual 200 MY 2012 P4P ARU Specifications: Outpatient Procedures Utilization in Preferred Facility Total outpatient procedures Use Table OSU-A to identify outpatient procedures, using Option A and Option B. Report only outpatient procedures performed at a hospital outpatient facility or at a free-standing surgery center. Use only facility claims that are flagged as either preferred or not preferred by the health plan. Professional claims are not used to identify outpatient procedures. Count multiple outpatient procedures on the same date of service as one ambulatory procedure. Table OSU-A: Codes to Identify Outpatient Procedures Option A CPT Only the CPT covered surgical procedure codes included in the CMS 2012 ASC Approved HCPCS Codes and Payment Rates file * and 92953, 92970, 92971, 92975, 92980, 92982, 92986, 92990, 92992, 92993, 92995, 92996, 93501-93533, 93600-93652 AND POS 22, 24 OR UB Type of Bill 13x, 83x Option B ICD-9-CM Procedure 01-86, 88.4, 88.5, 98.5 AND UB Revenue 0320, 0321, 0323, 036x, 0480, 0481, 049x, 075x, 079x AND UB Type of Bill 13x, 83x OR POS 22, 24 * These codes can be found on the CMS Web site (http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/11_Addenda_Updates.htm). Click on October 2012 ASC Approved HCPCS codes and Payment Rates. Use only the spreadsheet titled Addendum AA–ASC Covered Surgical Procedures for October 2012. Only use 5-digit all-numeric CPT codes (Level 1 HCPCS) that are in the spreadsheet; do not include any codes with an alpha value. Exclusions (required) The measure does not include mental health or chemical dependency services. Exclude claims and encounters that contain any code in Table OSU-B. ED visits are not included in the measure. Exclude all claims and encounters that contain any code in Table OSU-C. Table OSU-B: Codes to Identify Exclusions CPT 90801-90899 OR Principal ICD-9-CM Diagnosis 290-316 OR ICD-9-CM Procedure 94.26, 94.27, 94.6 OR Principal ICD-9-CM Diagnosis 960-979 WITH Secondary ICD-9-CM Diagnosis 291-292, 303-305 Table OSU-C: Codes to Identify ED Visits CPT 99281-99285 OR UB Revenue 045x, 0981 OR CPT 10040-69979 AND POS 23 ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Outpatient Procedures Utilization in Preferred Facility 201 Outpatient Procedures Calculation Step 1 Identify the denominator. The denominator is the total outpatient procedures identified above. Step 2 Identify the numerator. The numerator is the number of denominator qualifying procedures that were conducted in preferred facilities. Health plans provide a flag on the outpatient facility claim to indicate whether the procedure was carried out in a preferred facility. Step 3 Calculate the observed rate for each PO. Observed rate = number of outpatient procedures in preferred facility / total outpatient procedures. Separate rates will be calculated for each health plan and aggregated across all contracted health plans. Step 4 Calculate the reliability adjusted observed rate for each PO. Reliability adjustment is applied to the observed rate. Refer to ―Reliability Adjustment‖ in the Overview. November 30, 2012 Measurement Year 2012 P4P Manual 202 MY 2012 P4P ARU Specifications: Emergency Department Visits Emergency Department Visits (EDV) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. Removed optional exclusion of members who require coordination of benefits. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Based on HEDIS Use of Services specifications. Added risk adjustment. Description This measure summarizes the utilization of emergency department (ED) visits. The final reported metrics for each PO are: Reliability- and risk-adjusted ED visits PTMY (by plan). Reliability- and risk-adjusted ED visits PTMY (across all plans). Risk adjustment is performed using the concurrent DxCG Relative Risk Score (RRS), which is generated from Sightlines DxCG Risk Solutions software, Version 3.1.0, Model 18: All Medical Predicting Concurrent Total Risk. Reliability adjustment is performed using shrinkage estimation. Note: Truven will run this measure for MY 2012. Health plans and POs are not expected to report it. Eligible Population Product lines Commercial HMO and POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date None. Benefit Medical. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Emergency Department Visits Member years 203 Determine the PO’s total member years of enrollment in a health plan as the sum of the number of days during the measurement year when each eligible member was enrolled in the health plan and PO. For each PO, calculate member years by dividing the total member days by 365. ED visits Use Tables EDV-A and EDV-B to identify qualifying ED visits. Each visit to an ED that does not result in an inpatient stay, regardless of the intensity or duration of the visit, counts once. Count multiple ED visits on the same date of service as one visit. Both professional and facility claims are used to identify ED visits. Table EDV-A: Codes to Identify ED Visits CPT 99281-99285 UB Revenue 045x, 0981 OR OR CPT 10040-69979 POS 23 AND Exclusions (required) This measure does not include mental health or chemical dependency services. Exclude from all categories, claims and encounters that contain any code in Table EDV-B. ED visits that result in an inpatient admission. Table EDV-B: Codes to Identify Exclusions CPT 90801-90899 OR Principal ICD-9-CM Diagnosis 290-316 OR ICD-9-CM Procedure 94.26, 94.27, 94.6 OR Principal ICD-9-CM Diagnosis 960-979 WITH Secondary ICD-9-CM Diagnosis 291-292, 303-305 ED Utilization Calculation Step 1 Identify ED Visits. Using tables EDV-A and EDV-B, count ED visits for each member. Step 2 Calculate observed ED visits PTMY for each PO. Observed rate = [sum qualifying ED visits from step 1 / total PO member years] *1,000. Separate rates will be calculated for each health plan, and aggregated across all contracted health plans. Step 3 Remove outliers. Identify POs with an ED utilization rate of <60 or >250 PTMY. Members from these POs will be excluded from the pool of members used in the risk-adjustment calculation. In addition, expected and risk-adjusted rates will not be calculated for these POs. ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 204 MY 2012 P4P ARU Specifications: Emergency Department Visits Step 4 Calculate risk scores. Member-level RRS will be calculated by running the DxCG Relative Risk software. Appropriate RRS ―bins,‖ which define members of similar risk, are calculated by running a logistic regression model to identify bin cut points. Collect members in appropriate bins by RRS value. Step 5 Calculate expected ED visits PTMY for each PO (expected rate). The expected rate for each member is the arithmetic mean of all rates for members attributed to each bin, based on qualifying discharges across all plans and POs (excluding outlier POs). Sum expected rates across all members in PO, within each contracted health plan and aggregated across health plans. Step 6 Calculate the O/E ED visits ratio for each PO. O/E ratio = O/E rate. Step 7 Calculate the reliability adjusted O/E ratio for each PO. Reliability adjustment is applied to the O/E ratio. Refer to ―Reliability Adjustment‖ in the Overview section for a description of the reliability adjustment methodology. Step 8 Calculate population ED utilization rate PTMY across all members (i.e., across all plans and POs). Population rate = [sum of all ED visits / sum of all member years] *1,000. Step 9 Calculate reliability and risk adjusted ED visits PTMY for each PO. Reliability-and risk-adjusted rate = reliability adjusted O/E ratio * population rate Two sets of reliability- and risk-adjusted ED visits PTMY rates are calculated per PO: 1. Plan-specific: Based on the PO’s enrollment in each health plan. A health plan-specific rate is calculated by summing the observed and expected values for PO members enrolled in the health plan during the measurement year. A plan-specific O/E ratio, a reliability-adjusted O/E ratio and a reliability- and risk-adjusted rate (ED visits PTMY rate) are calculated for each health plan with which the PO contracts. 2. All-plan: Based on the PO’s data aggregated across all contracted health plans. The observed and expected values for all PO members are summed (across all contracted health plans). An all-plan O/E ratio, a reliability-adjusted O/E ratio and a reliability- and risk-adjusted rate (ED visits PTMY rate) are calculated for the PO. Note: All expected rates are based on the performance of the entire P4P population (i.e., across all plans and POs, excluding outlier POs). However, a PO’s expected rate will be estimated for the relative risk score specific to the PO’s members reflected in the measure. For example, a PO’s expected rate for a specific plan will use only the risk of the PO’s members enrolled in that plan to estimate the expected rate. Similarly, the all-plan rate will use the risk of the PO’s Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Generic Prescribing 205 Generic Prescribing (GRX) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Removed Anxiety/Sedation—Sleep Aids from measures recommended for payment; the measures continue to be collected and reported internally. MEASURE UPDATES SEPTEMBER 2011 FOR P4P MY 2012 None. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Non-HEDIS measure. Description The level of generic prescribing will be measured as a simple prescription rate for seven groups of therapeutic areas (SSRIs/SNRIs; Statins; Anti-Ulcer Agents; Cardiac—Hypertension and Cardiovascular; Nasal Steroids; Diabetes—Oral; and Anxiety/Sedation—Sleep Aids) and for all prescriptions, with the exception of selfinjectable drugs. Plan-defined definitions of ―brand‖ and ―generic‖ will be used to calculate the measure, based on how a prescription was paid, and will accommodate plan-specific contracting arrangements that price brand-name drugs at generic rates. Note Truven will run this measure for MY 2012. Health plans and POs are not expected to report the measure. The generic prescribing measures for anxiety/sedation—sleep aids and for all prescriptions are provided for information purposes and are not intended as payable P4P measures. Eligible Population Product line Commercial HMO/POS. Ages All ages. Continuous enrollment None. Because the denominator of this measure is based on prescriptions, not on members, there is no continuous enrollment requirement. Benefit Members must have pharmacy benefits coverage on the fill date of the prescription. The measure is based on all pharmacy claims received by participating health plans for members enrolled in the PO at any point in the measurement year. Pharmacy claims are attributed to a PO if the member was enrolled in the PO on the fill date on the pharmacy claim. Measurement period November 30, 2012 Calendar year. The measurement period is January 1–December 31, 2012. Measurement Year 2012 P4P Manual 206 MY 2012 P4P ARU Specifications: Generic Prescribing Measure Definition 1: Therapeutic Area Generic Prescribing Efficiency Measures in seven therapeutic areas will be calculated and used for P4P reporting, and all except anxiety/ sedation—sleep aids are recommended for incentive payment purposes. Therapeutic Area Generic Prescribing Efficiency = Number of Prescriptions for Generic Rx in Therapeutic Area X _____________________________________________________ Number of Prescriptions for All Rx in Therapeutic Area X Denominator Step 1 Identify all paid pharmacy claims for members enrolled in the PO at any point during the measurement year. Step 2 Ensure that the member was enrolled in the PO on the fill date and had pharmacy benefits coverage. Step 3 Identify NDC codes of prescriptions belonging to one of the seven therapeutic areas. These are the prescriptions counted in the denominator. Step 4 Exclude prescriptions with any other NDCs. Numerator Step 1 For all prescriptions in the denominator, determine whether the prescription was filled with a generic version of the drug or with a brand drug priced as a generic for that therapeutic area. This is determined by a flag supplied by the health plan on the pharmacy claim, indicating whether the drug was a generic or a brand drug priced as a generic. Step 2 Count the prescription in the numerator if it was filled with a generic drug or a brand drug priced as a generic. Measure Definition 2: Overall Generic Prescribing Efficiency This measure is provided to physician organizations for internal use, but is not intended for P4P reporting or incentive payment purposes. Overall Generic Prescribing Efficiency (Scrips) = Number of Prescriptions for All Generic Rx _________________________________________ Number of Prescriptions for All Rx Denominator Step 1 Identify all paid pharmacy claims for members enrolled in the PO at any point during the measurement year. Step 2 Ensure that the member was enrolled in the PO on the fill date and had pharmacy benefits coverage. Step 3 Identify the NDC code for the drug filled on the prescription. Step 4 Identify and exclude claims for self-injectable drugs. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Generic Prescribing Step 5 207 All other paid pharmacy claims are included in the denominator. Note: The measures use the drug filled (as indicated on the pharmacy claim). This may be different from the drug prescribed by the physician (e.g., if a generic substitution was made at the pharmacy). Numerator Step 1 For all prescriptions in the denominator, determine whether the prescription was filled with a generic version of the drug. For this measure, the generic status of the drug is determined through the Redbook database. Step 2 Count the prescription in the numerator if it was filled with a generic drug. November 30, 2012 Measurement Year 2012 P4P Manual 208 MY 2012 P4P ARU Specifications: Total Cost of Care Total Cost of Care (TCC) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Specifications updated to reflect calculation of the measure based on member-level information supplied by plan. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 None. MODIFICATIONS FROM HEDIS Non-HEDIS measure. Description This measure is based on actual costs associated with care for members attributed to a PO, including all covered professional, pharmacy, hospital and ancillary care, as well as administrative payments and adjustments. It does not include costs associated with mental health/chemical dependency, chiropractic, acupuncture, vision or dental services. Participating health plans provide to Truven member-level total payments for each contracted PO. Payment includes both capitation payments and FFS payments, including member copayments, paid to the PO or other providers caring for members of the PO. Per member costs above $100,000 are truncated. Two metrics will be reported for each PO: Risk-adjusted total cost of care PMPY (by plan). Risk-adjusted total cost of care PMPY (across all contracted plans). Risk adjustment will be performed using concurrent DxCG Relative Risk Score, which is generated from Sightlines DxCG Risk Solutions software, Version 3.1.0, Model 19: All Medical Predicting $100K Concurrent Total Risk. Results will be reported by region to account for geographic/market-specific pricing differences. Note: Truven will run this measure for MY 2012. Health plans and POs are not expected to report it. Eligible Population Product line Commercial HMO/POS. Ages All ages. Continuous enrollment None. Include all members who are enrolled in a PO and the health plan for one day or more during the measurement year. Allowable gap NA. Anchor date None. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Total Cost of Care Benefit Medical and pharmacy. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. Member years Determine the member-level enrollment in a PO as the sum of the number of days during the measurement year for which each eligible member was enrolled in the health plan and PO. 209 For each member, calculate member years by dividing the total member days by 365. For example, a member enrolled with a PO for the entire year would have MY = 1.0. Total Cost of Care Calculation Step 1 Identify the eligible population as defined above. Step 2 Obtain member-level observed cost. This is the payment supplied by the health plan for a member’s cost while enrolled with a specific PO. The following services are excluded from the observed cost amount: Mental health. Vision. Chemical dependency. Chiropractic. Dental. Acupuncture. If any of these services are included in a PO’s capitation agreement, the plan uses its proprietary actuarial method to adjust for them. Costs above $100,000 per member are also truncated. Step 3 Calculate risk scores. For each member in the eligible population, a member-level RRS will be calculated using DxCG Relative Risk Score software (based on the claims/encounters submitted by the health plan). The RRS are then normalized for the P4P population (i.e., across all POs and plans) to a benchmark of 1.0, incorporating partial year enrollment, to generate a memberlevel RRS. Step 4 Calculate the average population cost PMPY. Average population cost PMPY = sum of member-level observed costs (across all POs and plans) / total number of member years (across all POs and plans). This average population cost PMPY will be used for both plan-specific and all-plan calculations. Step 5 Calculate member-level expected cost. Member-level expected cost PMPY = member-level RRS * average population cost PMPY. Step 6 Calculate PO-level observed/expected cost ratio. Calculate the PO-level observed costs as the sum of member-level observed costs across all members attributed to the PO. Calculate the PO-level expected costs as the sum of member-level expected costs across all members attributed to the PO. Calculate the ratio of PO-level observed costs/PO-level expected costs November 30, 2012 Measurement Year 2012 P4P Manual 210 MY 2012 P4P ARU Specifications: Total Cost of Care Step 7 Calculate the risk-adjusted total cost of care PMPY. Risk-adjusted total cost of care PMPY = [PO-level observed cost PMPY/expected cost ratio] * average population cost PMPY = PO-level observed cost PMPY/PO-level average RRS. Two sets of risk-adjusted total cost of care PMPY rates are calculated per PO: 1. Plan specific: Based on the PO’s enrollment in each health plan. A plan-specific rate is calculated by carrying out steps 3–7 based only on members enrolled in the health plan. A plan-specific, risk-adjusted total cost of care PMPY rate is calculated for each health plan with which the PO contracts. Note: Plan-specific average population costs are not calculated based on the plan’s population; rather, they are based on the entire P4P population (i.e., across all POs and plans). 2. All-plan: Based on the PO’s data aggregated across all contracted health plans. In step 4, the PO-level observed costs from all contracted health plans are summed and divided by the sum of the number of member years across all health plans. An all-plan, riskadjusted total cost of care PMPY is calculated for the PO. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Frequency of Selected Procedures 211 Frequency of Selected Procedures (FSP) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added measurement period to the eligible population. Deleted obsolete CPT codes 93501, 93510, 93511, 93514, 93524, 93526-93529, 93539-93545 from the Cardiac catheterization row in Table FSP-A. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added CPT code 22633 to Table FSP-A. Added text stating that measure is for internal reporting only. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 P4P Appropriate Resource Use measure set. MODIFICATIONS FROM HEDIS P4P does not collect tonsillectomy, hysterectomy, cholecystectomy, prostatectomy, mastectomy, lumpectomy. P4P collects carotid endarterectomy, total hip replacement and total knee replacement for the commercial HMO/POS. Description This measure summarizes the utilization of frequently performed procedures that often show wide regional variation and have generated concern regarding potentially inappropriate utilization. This measure is for internal reporting only. Methodologies for adjusting for age/sex differences will be developed and tested. Adjusted rates of procedures will be reported per 1,000 member years. Note: Truven will run this measure. Health plans and POs are not expected to report it. Calculations Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment None. Include all members who are enrolled in a PO and in the health plan for one day or more during the measurement year. Allowable gap NA. Anchor date None. Benefit Medical. Measurement period Calendar year. The measurement period is January 1–December 31, 2012. _____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved November 30, 2012 Measurement Year 2012 P4P Manual 212 MY 2012 P4P ARU Specifications: Frequency of Selected Procedures Member years Determine the PO’s total member years of enrollment in a health plan as the sum of the number of days during the measurement year when each eligible member was enrolled in the plan and the PO. For each PO, calculate member years by dividing the total member days by 365. Procedures Use Table FSP-A to identify procedures for reporting. Report counts for procedures as specified, regardless of the site of care (e.g., inpatient or ambulatory setting). Report the number of procedures rather than the number of members who had the procedures. Do not double-count the same procedure. The two examples below illustrate scenarios counted as one procedure. Count as one procedure if… The date of service for two procedures is the same and both codes indicate CABG. The date of service for a procedure falls between the admission and discharge dates for an inpatient stay where the procedure was performed. – For example, if a CABG was billed by a surgeon on March 4 of the measurement year and the facility bill shows a CABG for an admission that started on March 2 and lasted until March 7 of the measurement year, combine these to count one CABG. Musculoskeletal procedures Back surgery Report all spinal fusion and disc surgery, including codes relating to laminectomy with and without disc removal. Total hip replacement Report the number of total hip replacements. Total knee replacement Report the number of total knee replacements. Cardiovascular procedures Bariatric weight loss surgery PCI Cardiac catheterization Report the number of bariatric weight loss surgeries. Percutaneous coronary intervention. Report all PCIs performed separately. Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI rate or the cardiac catheterization rate; report only the CABG. Report all cardiac catheterizations performed separately. Do not report a cardiac catheterization performed in conjunction with (i.e., on the same date of service as) an PCI in the cardiac catheterization rate; report only the PCI. Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI or the cardiac catheterization rate; report only the CABG. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P ARU Specifications: Frequency of Selected Procedures CABG 213 Coronary artery bypass graft. Report each CABG only once for each date of service per patient, regardless of the number of arteries involved or the number or types of grafts involved. Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI or the cardiac catheterization rate; report only the CABG. Carotid endarterectomy Report the number of carotid endarterectomies. Table FSP-A: Codes to Identify Selected Procedures Description Back surgery Total hip replacement Total knee replacement Bariatric weight loss surgery PCI Cardiac catheterization CABG Carotid endarterectomy CPT 22220, 22222, 22224, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22830, 22856, 22857, 22861, 22862, 22864, 22865, 63001, 63003, 63005, 63011, 63012, 6301563017, 63020, 63030, 63040, 63042, 6304563047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102 27130, 27132, 27134 27446, 27447, 27486, 27487 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888 92980, 92982, 92995 93451-93453, 93456-93461 33510-33514, 33516-33519, 33521-33523, 3353333536 34001, 35001, 35301, 35501, 35601 HCPCS S2348, S2350 ICD-9-CM Procedure 03.02, 03.09, 80.5, 81.0, 81.3, 81.6, 84.6, 84.8 00.70, 81.51, 81.53 00.80, 81.54, 81.55 44.68, 44.93, 44.94, 44.95, 44.96, 44.97, 44.98 G0290 S2205-S2209 00.66, 36.06, 36.07 37.21-37.23, 88.55-88.57 36.1, 36.2 38.12 _____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved November 30, 2012 Measurement Year 2012 P4P Manual 214 MY 2012 P4P ARU Specifications: All-Cause Readmissions All-Cause Readmissions (PCR) The All-Cause Readmission (PCR) measure specifications are located in the Clinical Domain section. In MY 2012, PCR is a mandatory testing measure for the commercial product line, and part of the measure set for the Medicare product line. Although this is an Appropriate Resource Use measure, data for this measure will be collected with the clinical measures. Refer to page 131 for the complete measure specifications. Measurement Year 2012 P4P Manual November 30, 2012 Relative Improvement For P4P MY 2012 216 MY 2012 P4P Relative Improvement: Overview Overview Relative improvement calculations measure the percentage of the distance the PO has moved from the previous year’s rate toward a goal of 100 percent (except for the case of HbA1c Poor Control, where the relative improvement goal is 0 percent). Relative improvement scores are calculated for each measure that had no major specification change for each PO that had a reportable result for both the current and the previous measurement year. The method of calculating relative improvement was selected by the former P4P Technical Quality and Steering Committees, based on a Journal of the American Medical Association article authored by Jencks et al in 2003: MY 2012 Performance – MY 2011 Performance _________________________________________ 100 – MY 2011 Performance For example, if a PO’s rate for Breast Cancer Screening improved to 70 percent in the current measurement year, compared with 60 percent in the previous measurement year, the relative improvement score would be 25 percent because the improvement of 10 percentage points from last year to this year is 25 percent of the 40 percentage point distance from the previous measurement year (60 percent) to the ideal goal (100 percent). For HbA1c Poor Control, the ideal goal is 0 and improvement is calculated relative to 0 rather than to 100. In the Health Plan Payout Report, a relative improvement score for the PO is provided only if the PO had rates for both years and the measure rate improved from the previous year to the current measurement year. For measures where the PO could not report for both years, the relative improvement score is listed as ―NA.‖ For measures where the PO did not make an improvement, the relative improvement score is listed as ―NI‖ (No Improvement). Note: The relative improvement score does not measure absolute improvement. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 Testing Measures For P4P MY 2012 Health Plans and Self-Reporting POs 218 MY 2012 P4P Testing Specifications: Overview Overview There will be opportunity for Public Comment before testing measures are finalized by the P4P Technical Measurement and Governance Committees in November 2012. Selected measures will be tested in 2013 and are expected to be added to the MY 2013 P4P measure set (barring problems identified during testing). The P4P Committees will confirm adoption of these measures in November 2013, with input from Public Comment and recommendations from the P4P Technical Measurement Committee. All health plans and self-reporting POs are strongly encouraged to participate in testing. The MY 2012 testing measures are listed below. Clinical Childhood Imminuzation Status: Hepatitis A Human Papillomavirus Vaccine for Male Adolescents (HPV) Unexpected Complications in Full-Term Newborns (UNC) <1500gm Delivered at a Level III Center (LBW) Episiotomy Rate (EPS) Meaningful Use of Health IT None Patient Experience None Appropriate Resource Use Cesarean Section Rate for Low Risk Births(NTSV) (CSX) VBAC Rate (VBC) All-Cause Readmissions (PCR)* Medicare Care for Older Adults (COA) will be a second-year testing measure in MY 2012. *In MY 2012 PCR is a mandatory testing measure for the commercial product line; it is part of the measure set for the Medicare product line. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Childhood Immunization Status 219 Childhood Immunization Status (CIS) 24-Month Continuous Enrollment MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added Hepatitis A as a testing measure to the MY 2012 P4P quality measure set. MODIFICATIONS FROM HEDIS Continuous enrollment for P4P is 24 months (instead of 12 months for HEDIS). Continuous enrollment is calculated at the PO level. One gap is allowed in each year of continuous enrollment. Description The percentage of enrolled children two years of age who were identified as having completed the following antigen series by their second birthday. The measure calculates a rate for each vaccine. One hepatitis A (Hep A) Eligible Population Product line Commercial HMO/POS. Age Children who turn 2 years of age during the measurement year. Continuous enrollment …for selfreporting POs From birth to the child’s second birthday in the PO (parent level). …for health From birth to the child’s second birthday in the health plan and in the PO (parent level). plans Allowable gap No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. Anchor date …for selfreporting POs Enrolled in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan on the child’s second birthday. …for health Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup plans level) on the child’s second birthday. Benefit Medical. Event/diagnosis None. November 30, 2012 Measurement Year 2012 P4P Manual 220 MY 2012 P4P Clinical Specifications: Childhood Immunization Status Administrative Specification Denominator The eligible population. Numerators For hepatitis A count any of the following. Evidence of the antigen or combination vaccine, or Documented history of the illness, or A seropositive test result for each antigen. Hepatitis A At least one hepatitis A vaccination, with a date of service falling on or before the child’s second birthday. Table CIS-A: Codes to Identify Childhood Immunizations Immunization Hepatitis A CPT HCPCS 90633 ICD-9-CM Diagnosis* 070.0, 070.1 ICD-9-CM Procedure * ICD-9-CM Diagnosis codes indicate evidence of disease. ** The two-dose hepatitis B antigen Recombivax is recommended for children between 11 and 14 years of age only and is not included in this table. Exclusions (optional) Children who had a contraindication for a specific vaccine should be excluded from the denominator for all antigen rates and the combination rate. The denominator for all rates must be the same. Contraindicated children may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered in its entirety. The exclusion must have occurred by the second birthday. Look for contraindications as far back as possible in the member’s history and use the contraindications and codes in Table CIS-B to identify allowable exclusions. Table CIS-B: Codes to Identify Exclusions Immunization Any particular vaccine Description Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis 999.42* *Use ICD-9-CM Diagnosis code 999.4 (without the fifth digit) to identify anaphylactic reaction prior to October 1, 2011; the date of service must be before October 1, 2011. ____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Clinical Specifications: Human Papillomavirus Vaccine for Male Adolescents 221 Human Papillomavirus Vaccine for Male Adolescents (HPV) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 None. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added as a testing measure to the MY 2012 P4P quality measure set. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure adapted for males from the HEDIS measure Human Papillomavirus Vaccine for Female Adolescents (HPV). The only change in the specification is that ―female‖ is replaced with ―male.‖ Description The percentage of male adolescents 13 years of age who had three doses of human Papillomavirus (HPV) vaccine by their 13th birthday. Eligible Population Product lines Commercial HMO/POS. Age Male adolescents who turn 13 years of age during the measurement year. Continuous enrollment …for selfreporting POs …for health plans Allowable gap 12 months prior to the member’s 13th birthday in the PO (parent level). 12 months prior to the member’s 13th birthday in the health plan and in the PO (parent level). No more than one gap in enrollment of up to 45 days during the 12 months prior to the 13th birthday. Anchor date …for selfreporting POs Enrolled in the PO (parent level; or for eligible POs, the subgroup level) and in a P4P plan on the member’s 13th birthday. …for health plans Enrolled in the health plan and the PO (parent level; or for eligible POs, the subgroup level) on the member’s 13th birthday. Benefit Medical. Event/diagnosis None. November 30, 2012 Measurement Year 2012 P4P Manual 222 MY 2012 P4P Testing Specifications: Human Papillomavirus Vaccine for Male Adolescents Administrative Specification Denominator The eligible population. Numerators At least three HPV vaccinations with different dates of service, on or between the member’s 9th and 13th birthdays. HPV vaccines administered prior to the 9th birthday cannot be counted. Table HPV-A: Codes to Identify Adolescent Immunizations Immunization HPV CPT 90649, 90650 Exclusion (optional) Adolescents who had a contraindication for the HPV vaccine may be excluded from the denominator. The exclusion must have occurred by the member’s 13th birthday. Look for exclusions as far back as possible in the member’s history and use the codes in Table HPV-B to identify exclusions. Table HPV-B: Codes to Identify Exclusions Immunization Any particular vaccine Description Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis 999.42* * Use ICD-9-CM Diagnosis code 999.4 (without fifth digit) to identify anaphylactic reaction prior to October 1, 2011; the date of service must be before October 1, 2011. Note NCQA follows the Centers for Disease Control and Prevention (CDC) and Advisory Council on Immunization Practices (ACIP) guidelines for immunizations. HEDIS implements the guidelines after three years to account for the measure’s look-back period and to allow the industry time to adapt to the new guidelines. ___________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Unexpected Complications in Full Term Newborns 223 Unexpected Complications in Full-Term Newborns (UNC) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added to the manual as a MY 2012 testing measure. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure developed by the California Maternal Quality Care Collaborative (CMQCC). Description The rate of unexpected newborn morbidity in full-term newborns. Truven and CMQCC will run this measure using data submitted by health plans, linked with California birth certificate data. Health plans and POs are not expected to report this measure. Eligible Population Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date Date of delivery. Benefit Medical. Event/diagnosis All singleton, full-term live births without conditions likely present prior to labor. Identify full-term infants according to gestational age and birthweight (Table UNC-B). If gestational age is missing, birthweight must be 3,000– 8,165 grams. Table UNC-A: Codes to Identify Singleton, Inborn Live Birth Description Singleton, inborn live births ICD-9 CM Diagnosis V3000, V3001, V301 Table UNC-B: Codes to Identify Full Term Infants Description Vital Statistics Vital Statistics AND Full-term infant Gestational age ≥37 and ≤47 weeks* Birthweight ≥2,500 grams and ≤8,165 grams *Infants missing gestational age are required to have birth weight of at least 3,000 grams and no more than 8,165 grams. Exclusions Exclude stillbirths in the data matching process with Vital Statistics Birth Certificate Data, which include records for live births only. Fetal conditions likely to be present before labor. November 30, 2012 Measurement Year 2012 P4P Manual 224 MY 2012 P4P Testing Specifications: Unexpected Complications in Full-Term Newborns Table UNC-B: Codes to Identify Fetal Conditions Present Before Labor Description Congenital malformations Noncongenital malformations Influence of maternal drug use ICD-9 CM Diagnosis 740.0, 740.1, 740.2, 741.0, 741.9, 742.0, 742.1, 742.2, 742.3, 742.4, 742.5, 742.8, 742.9, 743.0, 743.1, 743.2, 743.3, 743.4, 743.5, 743.6, 743.8, 743.9, 745.0, 745.1, 745.2, 745.3, 745.4, 745.5, 745.6, 745.7, 745.8, 745.9, 746.0, 746.1, 746.2, 746.3, 746.4, 746.5, 746.6, 746.7, 746.8, 746.9, 747.0, 747.1, 747.2, 747.3, 747.4, 748.0, 748.1, 748.2, 748.3, 748.4, 748.5, 748.6, 748.8, 748.9, 749.0, 749.1, 749.2, 750.3, 750.4, 750.5, 750.6, 750.7, 750.8, 750.9, 751.0, 751.1, 751.2, 751.3, 751.4, 751.5, 751.6, 751.7, 751.8, 751.9, 753.0, 753.1, 753.2, 753.3, 753.5, 753.6, 753.8, 753.9, 754.0, 754.1, 754.2, 754.3, 754.4, 754.5, 754.6, 754.7, 754.8, 757.1, 758.0, 758.1, 758.2, 758.3, 758.5, 758.6, 758.8, 758.9, 759.5, 759.6, 759.7, 759.81, 759.82, 759.83, 759.89, 255.2 762.0, 762.1, 762.6, 764.0, 764.1, 764.9, 773.0, 773.2, 773.3, 779.5 778.0, 760.70, 760.71, 760.72, 760.73, 760.74, 760.75, 760.76, 760.77, 760.78, 760.79 Administrative Specification Denominator The eligible population. Numerator Number of newborns with morbidity that occurred during delivery and nursery care. Include discharges to acute care, discharge deceased, and the morbidities identified in Table UNC-C. Do not include newborn morbidities identified through a hospital readmission subsequent to the newborn’s initial discharge home following delivery. Table UNC-C: Codes to Identify Morbidity Occurring During Delivery and Nursery Care Description Discharge neonatal death and transfers to acute care Apgar at 5 minutes Birth trauma injuries Disposition Codes 2,5,11 Vital Statistics ICD-9 CM Procedure ≤3 Hypoxia/asphyxia Shock/resuscitation and complications Respiratory complications Infection Neurologic complications Measurement Year 2012 P4P Manual ICD-9 CM Diagnosis 38.91, 38.92, 99.15, 43.1, 96.35, 99.6 96.70, 96.71, 96.72, 0.12, 34.04 87.03, 87.04, 88.91, 89.14, 767.2, 767.8, 767, 767.11, 767.3, 767.4, 767.5, 767.6, 767.7 768.5, 768.6 768.7 768.9 343.0 343.1 343.2 343.3 343.4 343.8 343.9 776.2, 777.5,785.5, 584.5 747.83, 769, 770.12, 770.2, 770.3 770, 771.83, 995.92 772.10, 772.11, 772.12, 772.13, 772.14, 772.2, 779.0, 345.3, 779.1, 779.2, 779.7, 779.85, 427.5, 348.3, 348.5 November 30, 2012 MY 2012 P4P Testing Specifications: Unexpected Complications in Full Term Newborns 225 Table UNC-C: Codes to Identify Morbidity Occurring During Delivery and Nursery Care (continued) Description Birth trauma injuries Respiratory complications Length of Stay None >4 days for Cesarean births >2 days for vaginal births None >4 days for Cesarean births >2 days for vaginal births Infection >4 days for Cesarean births >2 days for vaginal births Description Long length of stay without social or jaundice reasons Length of Stay >5 days for all births November 30, 2012 ICD-9 CM Procedure 93.9 93.91,93.93,93.94,93.95, 93.96, 93.98,93.99 WITHOUT ICD-9 CM Procedure 99.83 ICD-9 CM Diagnosis 767.2, 767.8 763.0, 763.1, 763.2, 763.3, 763.4, 763.5 770.6 770.4,770.5,770.14,770.81, 770.82, 770.83, 770.84, 770.86, 770.87, 770.88, 770.89 771.81 ICD-9 CM Diagnosis 773.1, V053, 774.6, V60.0, V60.1, V60.2, V60.3, V60.4, V60.6, V60.8,V60.9, V61.05, V61.06 Measurement Year 2012 P4P Manual 226 MY 2012 P4P Testing Specifications: Infants Under 1,500g at Appropriate Level of Care Infants Under 1,500g Delivered at Appropriate Level of Care (LBW) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added to the manual as a MY 2012 testing measure. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure based on the measure developed by the California Maternal Quality Care Collaborative (CMQCC). Description The rate of live births of infants weighing <1500 grams delivered at hospitals with NICU Level III status. Truven and CMQCC will run this measure using data submitted by health plans, linked with California birth certificate data. Health plans and POs are not expected to report this measure. Eligible Population Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment 90 days prior to the date of delivery. Allowable gap None. Anchor date Date of delivery. Benefit Medical. Event/diagnosis All live births delivered with a gestational age of at least 24 weeks and weighing less than 1,500 grams. Table LBW-A: Codes to Identify Deliveries Description Complications mainly related to pregnancy (Joint Commission Table 11.01) Normal delivery and other indications for care (Joint Commission Table 11.02) ICD-9 CM Diagnosis 640.81, 640.91, 641.01, 641.11, 641.21, 641.31, 641.81, 641.91, 642.01, 642.02, 642.11, 642.12, 642.21, 642.22, 642.31, 642.32, 642.41, 642.42, 642.51, 642.52, 642.61, 642.62, 642.71, 642.72, 642.91, 642.92, 643.01, 643.11, 643.21, 643.81, 643.91, 644.21, 645.11, 645.21, 646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62, 646.71, 646.81, 646.82, 646.91, 647.01, 647.02, 647.11, 647.12, 647.21, 647.22, 647.31, 647.32, 647.41, 647.42, 647.51, 647.52, 647.61, 647.62, 647.81, 647.82, 647.91, 647.92, 648.01, 648.02, 648.11, 648.12, 648.21, 648.22, 648.31, 648.32, 648.41, 648.42, 648.51, 648.52, 648.61, 648.62, 648.71, 648.72, 648.81, 648.82, 648.91, 648.92, 649.01, 649.02, 649.11, 649.12, 649.21, 649.22, 649.31, 649.32, 649.41, 649.42, 649.51, 649.61, 649.62, 649.81, 649.82 650, 651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91, 652.01, 652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91, 653.01, 653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91, 654.01, 654.02, 654.11, 654.12, 654.21, 654.31, 654.32, 654.41, 654.42, 654.51, 654.52, 654.61, 654.62, 654.71, 654.72, 654.81, 654.82, 654.91, 654.92, 655.01, 655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91, 656.01, 656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.01, 658.11, 658.21, 658.31, 658.41, 658.81, 658.91, 659.01, 659.11, 659.21, 659.31, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91 Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Infants Under 1,500g at Appropriate Level of Care 227 Table LBW-A: Codes to Identify Deliveries (continued) Description Complication mainly in the course of delivery (Joint Commission Table 11.03) Complication of the puerperium (Joint Commission Table 11.04) ICD-9 CM Diagnosis 660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91, 661.01, 661.11, 661.21, 661.31, 661.41, 661.91, 662.01, 662.11, 662.21, 662.31, 663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91, 664.01, 664.11, 664.21, 664.31, 664.41, 664.51, 664.81, 664.91, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.02, 666.12, 666.22, 666.32, 667.02, 667.12, 668.01, 668.02, 668.11, 668.12, 668.21, 668.22, 668.81, 668.82, 668.91, 668.92, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92 670.02, 670.12, 670.22, 670.32, 670.82, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.01, 673.02, 673.11, 673.12, 673.21, 673.22, 673.31, 673.32, 673.81, 673.82, 674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92, 675.01, 675.02, 675.11, 675.12, 675.21, 675.22, 675.81, 675.82, 675.91, 675.92, 676.01, 676.02, 676.11, 676.12, 676.21, 676.22, 676.31, 676.32, 676.41, 676.42, 676.51, 676.52, 676.61, 676.62, 676.81, 676.82, 676.91, 676.92 Exclusions Exclude stillbirths in the data matching process with Vital Statistics Birth Certificate Data, which includes records for live births only. Deliveries with an estimated gestational age less than 24 weeks. Deliveries with newborns weighing 1,500 grams or more. Table LBW-B: Codes to Identify 24 or More Weeks Gestation Description Gestation ≥24 weeks Vital Statistics Data Field “Best Obstetric Estimate of Gestational Age” OR LMP-based gestational age Table LBW-C: Codes to Identify Birthweight Description Not very low birthweight Vital Statistics Data Field “Birthweight” ≥1,500 grams Administrative Specification Denominator The eligible population. Numerator Number born at a hospital with NICU Level III status. November 30, 2012 Measurement Year 2012 P4P Manual 228 MY 2012 P4P Testing Specifications: Incidence of Episiotomy Incidence of Episiotomy (EPS) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added to the manual as a MY 2012 testing measure. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure based on an NQF-endorsed measure developed by the National Perinatal Information Center. Description The percentage of vaginal deliveries during the measurement year with evidence of an episiotomy. Truven and CMQCC will run this measure using data submitted by health plans, linked with California birth certificate data. Health plans and POs are not expected to report this measure. Eligible Population Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date Date of delivery. Benefit Medical. Event/diagnosis All live birth vaginal deliveries without shoulder dystocia during the measurement year. Table EPS-A: Codes to Identify Deliveries Description Complications mainly related to pregnancy (Joint Commission Table 11.01) Normal delivery and other indications for care (Joint Commission Table 11.02) ICD-9 CM Diagnosis 640.81, 640.91, 641.01, 641.11, 641.21, 641.31, 641.81, 641.91, 642.01, 642.02, 642.11, 642.12, 642.21, 642.22, 642.31, 642.32, 642.41, 642.42, 642.51, 642.52, 642.61, 642.62, 642.71, 642.72, 642.91, 642.92, 643.01, 643.11, 643.21, 643.81, 643.91, 644.21, 645.11, 645.21, 646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62, 646.71, 646.81, 646.82, 646.91, 647.01, 647.02, 647.11, 647.12, 647.21, 647.22, 647.31, 647.32, 647.41, 647.42, 647.51, 647.52, 647.61, 647.62, 647.81, 647.82, 647.91, 647.92, 648.01, 648.02, 648.11, 648.12, 648.21, 648.22, 648.31, 648.32, 648.41, 648.42, 648.51, 648.52, 648.61, 648.62, 648.71, 648.72, 648.81, 648.82, 648.91, 648.92, 649.01, 649.02, 649.11, 649.12, 649.21, 649.22, 649.31, 649.32, 649.41, 649.42, 649.51, 649.61, 649.62, 649.81, 649.82 650, 651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91, 652.01, 652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91, 653.01, 653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91, 654.01, 654.02, 654.11, 654.12, 654.21, 654.31, 654.32, 654.41, 654.42, 654.51, 654.52, 654.61, 654.62, 654.71, 654.72, 654.81, 654.82, 654.91, 654.92, 655.01, 655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91, 656.01, 656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.01, 658.11, 658.21, 658.31, 658.41, 658.81, 658.91, 659.01, 659.11, 659.21, 659.31, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91 Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Incidence of Episiotomy 229 Table EPS-A: Codes to Identify Deliveries (continued) Description Complication mainly in the course of delivery (Joint Commission Table 11.03) Complication of the puerperium (Joint Commission Table 11.04) ICD-9 CM Diagnosis 660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91, 661.01, 661.11, 661.21, 661.31, 661.41, 661.91, 662.01, 662.11, 662.21, 662.31, 663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91, 664.01, 664.11, 664.21, 664.31, 664.41, 664.51, 664.81, 664.91, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.02, 666.12, 666.22, 666.32, 667.02, 667.12, 668.01, 668.02, 668.11, 668.12, 668.21, 668.22, 668.81, 668.82, 668.91, 668.92, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92 670.02, 670.12, 670.22, 670.32, 670.82, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.01, 673.02, 673.11, 673.12, 673.21, 673.22, 673.31, 673.32, 673.81, 673.82, 674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92, 675.01, 675.02, 675.11, 675.12, 675.21, 675.22, 675.81, 675.82, 675.91, 675.92, 676.01, 676.02, 676.11, 676.12, 676.21, 676.22, 676.31, 676.32, 676.41, 676.42, 676.51, 676.52, 676.61, 676.62, 676.81, 676.82, 676.91, 676.92 Exclusions Exclude stillbirths in the data matching process with Vital Statistics Birth Certificate Data, which include records for live births only. Cesarean deliveries. Vaginal deliveries with shoulder dystocia. Table EPS-B: Codes to Identify Cesarean Deliveries Description Cesarean deliveries ICD-9 CM Procedure 74.0, 74.1, 74.2, 74.4, 74.99 Table EPS-C: Codes to Identify Shoulder Dystocia Description Shoulder dystocia ICD-9 Diagnosis 660.41, 660.42 Administrative Specification Denominator The eligible population. Numerator Number with episiotomy performed. Table EPI-D: Codes to Identify Episiotomy Description Episiotomy November 30, 2012 ICD-9 Procedure 72.1, 72.21, 72.31, 72.71, 73.6 Measurement Year 2012 P4P Manual 230 MY 2012 P4P Testing Specifications: Cesarean Section Rate for Low-Risk Births Cesarean Section Rate for Low-Risk Births (CSX) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added to the manual as a MY 2012 testing measure. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure based on the measure developed by the Joint Commission and adapted by the California Maternal Quality Care Collaborative (CMQCC) to use birth certificate data. Description The percentage of deliveries to nulliparous women with a term, singleton baby in a vertex position (NTSV) that are delivered by cesarean section. Truven and CMQCC will run this measure using data submitted by health plans, linked with California birth certificate data. Health plans and POs are not expected to report this measure. Eligible Population Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date Date of delivery. Benefit Medical. Event/diagnosis All nulliparous single live births with gestational age of 37 weeks or more. Table CSX-A: Codes to Identify Deliveries Description Complications mainly related to pregnancy (Joint Commission Table 11.01) Normal delivery and other indications for care (Joint Commission Table 11.02) ICD-9 CM Diagnosis 640.81, 640.91, 641.01, 641.11, 641.21, 641.31, 641.81, 641.91, 642.01, 642.02, 642.11, 642.12, 642.21, 642.22, 642.31, 642.32, 642.41, 642.42, 642.51, 642.52, 642.61, 642.62, 642.71, 642.72, 642.91, 642.92, 643.01, 643.11, 643.21, 643.81, 643.91, 644.21, 645.11, 645.21, 646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62, 646.71, 646.81, 646.82, 646.91, 647.01, 647.02, 647.11, 647.12, 647.21, 647.22, 647.31, 647.32, 647.41, 647.42, 647.51, 647.52, 647.61, 647.62, 647.81, 647.82, 647.91, 647.92, 648.01, 648.02, 648.11, 648.12, 648.21, 648.22, 648.31, 648.32, 648.41, 648.42, 648.51, 648.52, 648.61, 648.62, 648.71, 648.72, 648.81, 648.82, 648.91, 648.92, 649.01, 649.02, 649.11, 649.12, 649.21, 649.22, 649.31, 649.32, 649.41, 649.42, 649.51, 649.61, 649.62, 649.81, 649.82 650, 651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91, 652.01, 652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91, 653.01, 653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91, 654.01, 654.02, 654.11, 654.12, 654.21, 654.31, 654.32, 654.41, 654.42, 654.51, 654.52, 654.61, 654.62, 654.71, 654.72, 654.81, 654.82, 654.91, 654.92, 655.01, 655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91, 656.01, 656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.01, 658.11, 658.21, 658.31, 658.41, 658.81, 658.91, 659.01, 659.11, 659.21, 659.31, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91 Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Cesarean Section Rate for Low-Risk Births 231 Table CSX-A: Codes to Identify Deliveries (continued) Description Complication mainly in the course of delivery (Joint Commission Table 11.03) Complication of the puerperium (Joint Commission Table 11.04) ICD-9 CM Diagnosis 660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91, 661.01, 661.11, 661.21, 661.31, 661.41, 661.91, 662.01, 662.11, 662.21, 662.31, 663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91, 664.01, 664.11, 664.21, 664.31, 664.41, 664.51, 664.81, 664.91, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.02, 666.12, 666.22, 666.32, 667.02, 667.12, 668.01, 668.02, 668.11, 668.12, 668.21, 668.22, 668.81, 668.82, 668.91, 668.92, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92 670.02, 670.12, 670.22, 670.32, 670.82, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.01, 673.02, 673.11, 673.12, 673.21, 673.22, 673.31, 673.32, 673.81, 673.82, 674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92, 675.01, 675.02, 675.11, 675.12, 675.21, 675.22, 675.81, 675.82, 675.91, 675.92, 676.01, 676.02, 676.11, 676.12, 676.21, 676.22, 676.31, 676.32, 676.41, 676.42, 676.51, 676.52, 676.61, 676.62, 676.81, 676.82, 676.91, 676.92 Exclusions Exclude stillbirths in the data matching process with Vital Statistics Birth Certificate Data, which include records for live births only. Women with contraindication to vaginal delivery due to malpresentation. Women with multiple gestations. Women with previous births. Deliveries with an estimated gestational age less than 37 weeks. Table CSX-B Codes to Identify Contraindications to Vaginal Delivery Description Contraindications to vaginal delivery ICD-9 CM Diagnosis 644.21, 651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91, 652.21, 652.31, 652.41, 652.61, 652.81, 654.21, 656.41, 660.51, 662.31, 669.61, 761.5, V27.1-V27.7 Table CSX-C: Codes to Identify Multiple Gestations Description Multiple gestations Vital Statistics “Plurality” >1 Table CSX-D: Codes to Identify Previous Births Description Parity >0 Vital Statistics Sum of “Total Number of prior children still living” and “Total number of prior children no longer living” >0. Table CSX-E: Codes to Identify Live Births 37 Or More Weeks Gestation Description Live birth ≥37 weeks gestation November 30, 2012 Vital Statistics Data Field “Best Obstetric Estimate of Gestational Age” OR LMP-based gestational age ≥37 weeks Measurement Year 2012 P4P Manual 232 MY 2012 P4P Testing Specifications: Cesarean Section Rate for Low-Risk Births Administrative Specification Denominator The eligible population. Numerator The number of Cesarean section deliveries. Table CSX-F: Codes to Identify Cesarean Section Description Cesarean section ICD-9 CM Procedure 74.0, 74.1, 74.2, 74.4, 74.99 Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Vaginal Birth After Cesarean Delivery Rate 233 Vaginal Birth After Cesarean Delivery Rate (VBC) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added to the manual as a MY 2012 testing measure. MODIFICATIONS FROM HEDIS This is a non-HEDIS measure developed by the California Maternal Quality Care Collaborative (CMQCC). Description The rate of vaginal deliveries during the measurement year to women with evidence of a prior Cesarean section. Truven and CMQCC will run this measure using data submitted by health plans, linked with California birth certificate data. Health plans and POs are not expected to report this measure. Eligible Population Product lines Commercial HMO/POS. Ages All ages. Continuous enrollment None. Allowable gap NA because there is no continuous enrollment requirement. Anchor date Date of delivery. Benefit Medical. Event/diagnosis All live birth deliveries with a previous Cesarean delivery diagnosis. Identify prior Cesarean deliveries (Table VBAC-B). Table VBC-A: Codes to Identify Deliveries Description Complications mainly related to pregnancy (Joint Commission Table 11.01) Normal delivery and other indications for care (Joint Commission Table 11.02) November 30, 2012 ICD-9 CM Diagnosis 640.81, 640.91, 641.01, 641.11, 641.21, 641.31, 641.81, 641.91, 642.01, 642.02, 642.11, 642.12, 642.21, 642.22, 642.31, 642.32, 642.41, 642.42, 642.51, 642.52, 642.61, 642.62, 642.71, 642.72, 642.91, 642.92, 643.01, 643.11, 643.21, 643.81, 643.91, 644.21, 645.11, 645.21, 646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62, 646.71, 646.81, 646.82, 646.91, 647.01, 647.02, 647.11, 647.12, 647.21, 647.22, 647.31, 647.32, 647.41, 647.42, 647.51, 647.52, 647.61, 647.62, 647.81, 647.82, 647.91, 647.92, 648.01, 648.02, 648.11, 648.12, 648.21, 648.22, 648.31, 648.32, 648.41, 648.42, 648.51, 648.52, 648.61, 648.62, 648.71, 648.72, 648.81, 648.82, 648.91, 648.92, 649.01, 649.02, 649.11, 649.12, 649.21, 649.22, 649.31, 649.32, 649.41, 649.42, 649.51, 649.61, 649.62, 649.81, 649.82 650, 651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91, 652.01, 652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91, 653.01, 653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91, 654.01, 654.02, 654.11, 654.12, 654.21, 654.31, 654.32, 654.41, 654.42, 654.51, 654.52, 654.61, 654.62, 654.71, 654.72, 654.81, 654.82, 654.91, 654.92, 655.01, 655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91, 656.01, 656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.01, 658.11, 658.21, 658.31, 658.41, 658.81, 658.91, 659.01, 659.11, 659.21, 659.31, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91 Measurement Year 2012 P4P Manual 234 MY 2012 P4P Testing Specifications: Vaginal Birth After Cesarean Delivery Rate Table VBC-A: Codes to Identify Deliveries (continued) Description Complication mainly in the course of delivery (Joint Commission Table 11.03) Complication of the puerperium (Joint Commission Table 11.04) ICD-9 CM Diagnosis 660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91, 661.01, 661.11, 661.21, 661.31, 661.41, 661.91, 662.01, 662.11, 662.21, 662.31, 663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91, 664.01, 664.11, 664.21, 664.31, 664.41, 664.51, 664.81, 664.91, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.02, 666.12, 666.22, 666.32, 667.02, 667.12, 668.01, 668.02, 668.11, 668.12, 668.21, 668.22, 668.81, 668.82, 668.91, 668.92, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92 670.02, 670.12, 670.22, 670.32, 670.82, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.01, 673.02, 673.11, 673.12, 673.21, 673.22, 673.31, 673.32, 673.81, 673.82, 674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92, 675.01, 675.02, 675.11, 675.12, 675.21, 675.22, 675.81, 675.82, 675.91, 675.92, 676.01, 676.02, 676.11, 676.12, 676.21, 676.22, 676.31, 676.32, 676.41, 676.42, 676.51, 676.52, 676.61, 676.62, 676.81, 676.82, 676.91, 676.92 Exclusions Exclude stillbirths in the data matching process with Vital Statistics Birth Certificate Data, which include records for live births only. Exclude Cesarean deliveries from the eligible population to calculate the number of vaginal deliveries. Table VBC-B: Codes to Identify Prior Cesarean Deliveries Description Previous C-section, nos-unspec Previous C-section, nos-deliver Previous C-section, nos-antepart ICD-9 CM Diagnosis 65420 65421 65423 Administrative Specification Denominator The eligible population. Numerator Number of vaginal deliveries. Table VBC-C: Codes to Identify Cesarean Deliveries Description Cesarean delivery Measurement Year 2012 P4P Manual ICD-9 CM Procedure 74.0, 74.1, 74.2, 74.4, 74.99 November 30, 2012 MY 2012 P4P Testing Specifications: All-Cause Readmissions 235 All-Cause Readmissions (PCR) The All-Cause Readmission (PCR) measure specifications are located in the Clinical Domain section. In MY 2012, PCR is a mandatory testing measure for the commercial product line, and part of the measure set for the Medicare product line. Although this is an Appropriate Resource Use measure, data for this measure will be collected with the clinical measures. Refer to page 131 for the complete measure specifications. November 30, 2012 Measurement Year 2012 P4P Manual 236 MY 2012 P4P Testing Specifications: Care for Older Adults Care for Older Adults (COA) MEASURE UPDATES NOVEMBER 2012 FOR P4P MY 2012 Added advance care planning to the measure. MEASURE UPDATES SEPTEMBER 2012 FOR P4P MY 2012 Added text stating how the measure is labeled by CMS. COA is a second-year testing measure in MY 2012. MEASURE UPDATES DECEMBER 2011 FOR P4P MY 2012 Added to the MY 2012 P4P Medicare measure set. MODIFICATIONS FROM HEDIS Advance care planning not collected. Description Care for Older Adults—Medication Review is the same measure as the CMS Stars Measure Care for Older Adults—Medication Review. Care for Older Adults—Functional status assessment is the same measure as the CMS Stars Measure Care for Older Adults—Functional Status Assessment. Care for Older Adults: Pain screening is the same measure as the CMS Stars Measure Care for Older Adults—Pain Screening. The percentage of adults 66 years and older who had each of the following during the measurement year. Advance care planning. Medication review. Functional status assessment. Pain screening. Definitions Medication list A list of the member’s medications in the medical record, which may include prescriptions, over-the-counter (OTC) medications and herbal or supplemental therapies. Medication review A review of all a member’s medications, including prescription medications, OTC medications and herbal or supplemental therapies. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Testing Specifications: Care for Older Adults 237 Eligible Population Product line Medicare Special Needs Plan (SNP). Ages 66 years and older as of December 31 of the measurement year. Continuous enrollment ...for selfreporting POs The measurement year in the PO (parent level). …for health plans The measurement year in the health plan and PO (parent level). Allowable gap No more than one gap in enrollment of up to 45 days during the measurement year. Anchor date ...for selfreporting POs December 31 of the measurement year in the PO (parent level, or, for eligible POs, subgroup level) and in a P4P plan. …for health plans December 31 of the measurement year in the health plan and the PO (parent level, or, for eligible POs, subgroup level). Benefit Medical. Event/diagnosis None. Administrative Specification Denominator The eligible population. Numerators Advance Care Planning Evidence of advance care planning during the measurement year (Table COA-A). Table COA-A: Codes to Identify Advance Care Planning Description Advance care planning Medication review CPT Category II 1157F, 1158F HCPCS S0257 At least one medication review (Table COA-B) conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record (Table COA-C), as documented through administrative data. The claim/encounter for a member’s medication review and medication list must be on the same date of service. Table COA-B: Codes to Identify Medication Review Description Medication review CPT 90862, 99605, 99606 CPT Category II 1160F _____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 238 MY 2012 P4P Testing Specifications: Care for Older Adults Table COA-C: Codes to Identify Medication List Description Medication list Functional Status Assessment CPT Category II 1159F At least one functional status assessment during the measurement year (Table COA-D). Table COA-D: Codes to Identify Functional Status Assessment Description Functional status assessment Pain Screening CPT Category II 1170F At least one pain screening or pain management plan during the measurement year. A member had a pain screening if a submitted claim/encounter contains any code in Table COA-E. Table COA-E: Codes to Identify Pain Screening Description Pain screening CPT Category II 0521F, 1125F, 1126F _____________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Specifications: Summary of Changes 239 Summary Table of Quality Measures and Changes MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Encounter Rate by Service Type September 2012 December 2011 Modifications From HEDIS November 2012 Adults’ Access to Preventive/Ambulatory Health Services September 2012 December 2011 Modifications From HEDIS November 2012 Annual Monitoring for Patients on Persistent Medications September 2012 December 2011 Modifications From HEDIS November 30, 2012 Measure Update Removed reference to physician organizations in Calculation section. Deleted obsolete HCPCS code G0344 from Table ENR-B. Removed obsolete HCPCS code G0394 from table ENR-D. Added new HCPCS code G0450 to table ENR-D. Removed UB Revenue codes 036x, 049x, 075x and 079x from table ENR-F (Option B). Added UB Revenue codes 0360, 0361, 0362, 0367, 0369, 0490, 0499, 0750 and 0790 to table ENR-F (Option B). Removed Encounter Rate by Service Type 1-6: Overall Rate threshold requirement. Non-HEDIS measure. Deleted obsolete HCPCS code G0344 from Table AAP-A. Added text stating how the measure is labeled by CMS. Added HCPCS codes S0620, S0621 to Table AAP-A Added to the MY 2012 P4P quality measure set. None. Changed language in allowable gap section to refer to measurement year instead of each year of continuous enrollment. Added LOINC code 62425-4 to Table MPM-B. Clarified that organizations sum the days supply for all medications to determine treatment days in the Event/diagnosis criteria. Deleted Aliskiren-hydrochlorothiazide-amlodipine from the ―Antihypertensive combinations‖ description in Table MPM-A. Added aliskiren-valsartan, amlodipine-hydrochlorothiazide-valsartan, amlodipine-hydrochlorothiazide-olmesartan and mlodipine-telmisartan to Table MPM-A. Deleted LOINC code 62425-4 from Table MPM-B. Excluded annual monitoring for the ―members on anticonvulsants‖ rate. Measurement Year 2012 P4P Manual 240 MY 2012 P4P Specifications: Summary of Changes Summary Table of Quality Measures and Changes (continued) MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Cholesterol Management for Patients With Cardiovascular Conditions: LDL Screening LDL Control (<100) September 2012 December 2011 Modifications From HEDIS November 2012 Proportion of Days Covered by Medications: Renin Angiotensin System (RAS) Antagonists Statins Oral Diabetes Medications September 2012 December 2011 Modifications From HEDIS Measurement Year 2012 P4P Manual Measure Update Added instructions to use both facility and professional claims to identify AMI and CABG for the event/ diagnosis. Added LOINC code 69419-0 to Table CMC-D. Added text stating how the measure is labeled by CMS. Added instructions to use only facility claims (not professional claims) to identify AMI and CABG for the event/diagnosis. Clarified that codes from Table CMC-D should be used to identify the most recent LDL-C test for the LDL-C control indicator. None. None. Measure description changed to emphasize that members must have filled at least two prescriptions in a given medication category to be included in the measure. Clarified that if the pharmacy benefit ends, the measurement period ends. Added language to the additional eligible population criteria and the numerator calculation to clarify that only paid, nonreversed claims should be used in the calculation of the measure. PDC: ACEI/ARB Medications renamed PDC: Renin Angiotensin System (RAS) Antagonists Continuous enrollment section changed to refer to measure period for both self-reporting POs and health plans. Allowable gap section clarified to reflect that members with two distinct measurement periods are excluded due to a gap in enrollment. Added Direct Renin Inhibitor, Direct Renin Inhibitor Combinations and azilsartan-chlorthalidone to Table PDC-A. Removed lisinopril-nutritional supplement from Table PDC-A. Added sitagliptin-simvastatin to Table PDC-B Deleted all duplicate categories in Table PDC-C. Added sitagliptin-simvastatin and lingaliptin-metformin to Table PDC-C. Added text stating how the measure is labeled by CMS. Added to the MY 2012 P4P quality measure set. Non-HEDIS measure. November 30, 2012 MY 2012 P4P Specifications: Summary of Changes 241 Summary Table of Quality Measures and Changes (continued) MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Diabetes Care: HbA1c Testing HbA1c Poor Control (>9.0%) HbA1c Control (<8.0%) HbA1c Control (<7.0%) Eye Exam LDL Screening and Control (<100) Nephropathy Monitoring Blood Pressure Control (<140/90) Optimal Diabetes Care September 2012 Measure Update Blood Pressure Control (<140/90): Added option for POs and plans to identify appropriate setting for BP reading by using the requirement that the blood pressure reading must be during an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. POs and plans may use either this method or the exclusion criteria for Blood Pressure Control (<140/90) to identify BPs taken in an appropriate setting; POs and plans must use one of these methods. Changed language in allowable gap section to refer to measurement year instead of each year of continuous enrollment. Added instructions to use both facility and professional claims to identify CABG for the required exclusion for the HbA1c control (<7.0%) for a selected population. Added LOINC code 71875-9 to Table CDC-D. Added LOINC code 69419-0 to Table CDC-K. Blood Pressure Control (<140/90): Removed the requirement that the blood pressure reading must be in conjunction with an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. Blood Pressure Control (<140/90): Added exclusion criteria. Added saxagliptin, sitagliptin-simvastatin, liraglutide and metformin-repaglinide to Table CDC-A. Added text stating how the measure is labeled by CMS. Added sitagliptin-simvastatin to the description of ―Antidiabeteic combinations‖ in Table CDC-A. Removed insulin regular beef-pork, insulin regular pork, insulin zinc beef-pork, insulin zinc extended human and Insulin zinc pork from Table CDC-A. Deleted CPT codes 92002, 92004, 92012, 92014 from Table CDC-C. Added ICD-9-CM Diagnosis codes 425 and 294.2 to Table CDC-G. Deleted ICD-9-CM Diagnosis code 294.8 from Table CDC-G. Added thoracic aortic aneurysm to the required exclusions for HbA1c control (<7.0%) for a selected population and added corresponding codes to Table CDC-G. Added instructions to use only facility claims to identify CABG for the required exclusion for the HbA1c control (<7.0%) for a selected population (do not use professional claims). Clarified that a negative dilated eye exam in the year prior to the measurement year meets criteria for the Eye Exam indicator. Deleted ICD-9-CM Procedure codes (which identify procedures that occur in an inpatient setting) from Table CDCJ: Codes to Identify Eye Exams. The intent of the measure is to identify eye visits performed in an outpatient setting, which are identified by CPT and HCPCS. Deleted obsolete CPT code 36145 from Table CDC-N. Deleted obsolete HCPCS codes G0392, G0393 from Table CDC-N. Deleted Aliskiren-hydrochlorothiazide-amlodipine from the ―Antihypertensive combinations‖ description in Table CDC-O. Clarified that an incomplete reading is not compliant for the BP control indicator. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 242 MY 2012 P4P Specifications: Summary of Changes Summary Table of Quality Measures and Changes (continued) Date of Update/ MY 2012 Measures Modification From HEDIS December 2011 Diabetes Care (continued) Modifications From HEDIS Use of Imaging Studies for Low Back Pain November 2012 September 2012 December 2011 Modifications From HEDIS November 2012 Disease-Modifying AntiRheumatic Drug Therapy for Rheumatoid Arthritis September 2012 December 2011 Modifications From HEDIS November 2012 Osteoporosis Management in Women Who Had a Fracture September 2012 December 2011 Modifications From HEDIS Measure Update Added Eye Exam to the MY 2012 P4P quality measure set. Removed CPT code 36801-36809, 36811-36814 and 36816-36817 from Table CDC-G. Renamed Tables CDC-J – CDC-P. Optimal Diabetes Care is an ―all or none‖ combination rate of three HEDIS measures. Blood Pressure Control (<140/90): No requirement that the blood pressure reading must be in conjunction with an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. None. Removed invalid CPT code 72011 from table LBP-D; replaced it with CPT code 72010. Replaced codes 724.70, 724.71, 724.79 with code 724.7 in Table LBP-A. Replaced codes 846.0, 846.1, 846.2, 846.3, 846.8, 846.9 with code 846 in Table LBP-A. None. None. Added text stating how the measure is labeled by CMS. Replaced ―nonacute inpatient encounters‖ with ―nonacute inpatient discharges‖ to identify the event/ diagnosis and deleted codes that identify nonacute inpatient encounters. The organization should use its own methodology to identify nonacute inpatient discharges. Added to the MY 2012 P4P quality measure set. None. Added note that physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. Added text stating how the measure is labeled by CMS. Added J code J0897 to description of ―Other agents‖ in Table OMW-C. Added Table OMW-D: Codes to Identify Visit Type. In step 1 of Event/diagnosis criteria, a fracture code must be in conjunction with a visit code from Table OMW-D. Added outpatient, ED, nonacute inpatient or acute inpatient encounter (Table OMW-D) for a fracture to the exclusion in Step 2. Added to the MY 2012 P4P quality measure set. None. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Specifications: Summary of Changes 243 Summary Table of Quality Measures and Changes (continued) MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 September 2012 Childhood Immunization Status December 2011 Modifications From HEDIS November 2012 Immunizations for Adolescents September 2012 December 2011 Modifications From HEDIS November 2012 Human Papillomavirus Vaccine for Female Adolescents September 2012 December 2011 Modifications From HEDIS November 2012 Chlamydia Screening in Women September 2012 December 2011 Modifications From HEDIS Measure Update Renamed Combination—All Antigen to Combination 3. Added specifications for rotavirus; added CPT codes 90681 and 90680 to Table CIS-A. Clarified the Exclusion text to state that contraindicated children may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered in its entirety. Added ICD-9-CM Diagnosis code 999.42 to Table CIS-B. Added a footnote to Table CIS-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. Added rotavirus for internal reporting only. None. Continuous enrollment for P4P is 24 months instead of 12 months for HEDIS. Continuous enrollment is calculated at the PO level. One gap is allowed in each year of continuous enrollment. Two antigens in the HEDIS measure are not included in the P4P measure: hepatitis A (HepA) and influenza (flu). None. Added ICD-9-CM Diagnosis code 999.42 to Table IMA-B. Added a footnote to Table IMA-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. None. None. None. Added ICD-9-CM Diagnosis code 999.42 to Table HPV-B. Added a footnote to Table HPV-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011. Added to the MY 2012 P4P quality measure set. None. Added LOINC codes 71793-4, 71431-1 to Table CHL-B. Added HCPCS code G0450 to Table CHL-B. Added ICD-9-CM Diagnosis codes 302.76, 625.0 to Table CHL-B. Added LOINC codes 63464-2, 64088-8, 64094-6 and 69002-4 to Table CHL-B. None. None. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 244 MY 2012 P4P Specifications: Summary of Changes Summary Table of Quality Measures and Changes (continued) Date of Update/ MY 2012 Measures Modification From HEDIS November 2012 Evidence-Based Cervical Cancer Screening of AverageRisk, Asymptomatic Women September 2012 December 2011 Modifications From HEDIS November 2012 Breast Cancer Screening Colorectal Cancer Screening Adult BMI Assessment September 2012 December 2011 Modifications From HEDIS November 2012 September 2012 December 2011 Modifications From HEDIS November 2012 September 2012 December 2011 Modifications From HEDIS Measure Update Added LOINC codes 21440-3, 30167-1, 38372-9, 49896-4 and 59420-0 to Table ECS-C. Deleted Table ECS-D: Categoreis by Age and Number of Pap Tests. Clarified that step 3 of the Appropriately Screened rate should not double-count women already identified in step 2. Added a step to the Not Screened rate, to exclude women who had a Pap test and HPV test in the measurement year or 4 years prior to the measurement year. Added ICD-9-CM Diagnosis code 752.43 to Table ECS-A. Removed code V76.47 from Table ECS-A. Added a new category to Appropriately Screened: Aged 30-65 with Pap test and HPV test in the measurement year or 4 years prior to the measurement year. Added text stating that for immunodeficiency, including genetic (congenital) immunodeficiency syndromes, look as far back as possible in the member’s history for possible exclusions. Non-HEDIS measure. Modified age stratifications for for reporting. Report ages 42 to 69 for the Medicare product line; report ages 52 to 69 and 70 to 74 separately for the commercial product line. Added text stating how the measure is labeled by CMS. Added CPT modifier codes RT and LT to Table BCS-B and revised the optional exclusion for bilateral mastectomy to include instances where a mastectomy is performed on the right side and the left side of the body on the same date of service. Added two new age bands (40-49 years and 70-74 years) for internal reporting, and the requirement to report three age stratifications and an overall rate. None. None. None. Added text stating how the measure is labeled by CMS. None. None. None. Added text stating how the measure is labeled by CMS. Deleted obsolete HCPCS code G0344 from Table ABA-A. Added to the MY 2012 P4P quality measure set. Adapted for Medicare Advantage product lines only. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. Measurement Year 2012 P4P Manual November 30, 2012 MY 2012 P4P Specifications: Summary of Changes Summary Table of Quality Measures and Changes (continued) Date of Update/ MY 2012 Measures Modification From HEDIS November 2012 Glaucoma Screening in Older Adults September 2012 December 2011 Modifications From HEDIS November 2012 September 2012 Asthma Medication Ratio December 2011 Modifications From HEDIS November 2012 Appropriate Testing for Children With Pharyngitis September 2012 December 2011 Modifications From HEDIS 245 Measure Update None. Added text stating how the measure is labeled by CMS. Deleted obsolete CPT code 92135 from Table GSO-A. Added to the MY 2012 P4P quality measure set. None. Added two overall age bands for reporting, 5-50 years and 5-64 years. Clarified medication dispensing events for multiple prescriptions. Created separate definitions for ―inhaler‖ and ―injection.‖ Clarified that members must have a ratio of 0.50 or greater during the measurement year. Added that four outpatient visit types listed in bullet three under step one, must be on different dates of service. In Step 3 under required exclusion changed table reference ARM-D to AMR-E in second bullet. Changed upper age limit band from 50 to 64, modified age bands as a result, adding 19-50 and 51-64, report four age stratifications and a total rate. Modified the dispensing event criteria for inhalers so that each individual inhaler canister counts as one dispensing event. Instead of a 90-days supply counting as one dispensing event it now counts as three dispensing events. Modified multiple prescriptions dispensed on the same day criteria so that multiple prescriptions for the same medication dispensed on the same day, should be counted individually. Added Table AMR-C to indentify Asthma Medication. Removed note after Step 2 to exclude members from the eligible population who had no reliever and no controller medications. Changed exclusions from optional to a required and added it as a 3rd step under the Eligible Population section. Under Ratio Calculation for Persistent Asthmatics, restated the measure denominator and numerator. Under Ratio Calculation for Persistent Asthmatics, clarified required steps 3-5. Renamed former Table AMR-C, Asthma Medications to Table AMR-E, Asthma Controller and Reliever Medications. None. Removed gatifloxacin, lomefloxacin and sparfloxacin from Table CWP-C. Removed cephradine and erythromycin estolate from Table CWP-C. Added cefditoren to Table CWP-C. Added LOINC code 68954-7 to Table CWP-D. . None. None. __________ Current Procedural Terminology © 2012 American Medical Association. All rights reserved. November 30, 2012 Measurement Year 2012 P4P Manual 246 MY 2012 P4P Specifications: Summary of Changes Summary Table of Quality Measures and Changes (continued) Date of Update/ MY 2012 Measures Modification From HEDIS November 2012 Appropriate Treatment for Children With Upper Respiratory Infection September 2012 December 2011 Modifications From HEDIS November 2012 Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis September 2012 December 2011 Modifications From HEDIS November 2012 All-Cause Readmissions September 2012 December 2011 Modifications From HEDIS Measurement Year 2012 P4P Manual Measure Update Removed gatifloxacin, lomefloxacin and sparfloxacin from Table URI-D. Removed cephradine and erythromycin estolate from Table URI-D. Added cefditoren to Table URI-D. Clarified that claims/encounters with only a diagnosis for URI should be identified in step 2 of the Event/diagnosis criteria. None. None. Removed gatifloxacin, lomefloxacin and sparfloxacin from Table AAB-E. Removed rows ―5-aminosalicylates,‖ ―Amebicides‖ and ―Sulfamethoxazole-trimethoprim DS‖ from Table AAB-E. Removed neomycin, cephradine and cefoperazone from Table AAB-E. Added vancomycin, penicillin G benzathine, cefditoren and cefpodoxime to Table AAB-E. None. None. Added text stating that PCR is a mandatory testing measure for the commercial product line for MY 2012 and part of the measure set for the Medicare product line for MY 2012. Added modification from HEDIS; age 18-64 age band not reported for Medicare. Removed Medicare age band 18-64. Added text stating how the measure is labeled by CMS. Added the commercial product line to the measure. Added PCR-Comm-DischCC-Weight, PCR-Comm-ComorbHCC-Weight and PCR-Comm-OtherWeights to the Risk Adjustment Tables. Clarified the variance calculation in step 8 of the Risk Adjustment Weighting section. Added the variance calculation to Sample Table: PCR—Risk Adjustment Weighting. Clarified how to calculate the average adjusted probability in step 1 in the Reporting: Risk Adjustment section. Revised the rounding requirements in steps 2 and 4 in the Reporting: Risk Adjustment section. Added a Note section and a note that Risk Assessment Protocols may not be used. Added the observed-to-expected ratio and lower and upper confidence interval calculations to the reporting tables. Changed Table PCR-A-2/3 to PCR-A-2. Clarified that Table PCR-A-2 is for the commercial product line. Clarified that Table PCR-B-3 is for the Medicare product line. Added to the MY 2012 P4P quality measure set. NCQA refers to this measure as Plan All-Cause Readmissions. November 30, 2012 MY 2012 P4P Specifications: Summary of Changes 247 Summary Table of Meaningful Use of Health IT Changes MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Meaningful Use of Health IT September 2012 December 2011 November 30, 2012 Measure Update PO Reporting Structure, including whether the PO reports based on PCPs or EPs and the total number of PCPs or EPs in each PO, moved to the beginning of the MUHIT survey, rather than in the required submission of every measure. Added number of PCPs or EPs excluded from the measure to the required submission for all applicable measures. Removed ―assign points‖ from the required submission for Measures 1—20. Added submission requirements and examples for each of the three conditions in Measure 21. Clarified that a PO must be able to track the care management activities performed by a vendor for Measure 21. Removed reference to CMS requirements for the time frame in which PCPs or EPs must have functional EHRs in place. Attestation of Accuracy moved to the end of the MUHIT survey, rather than in every question. Requirement to attach documentation to support submitted numbers, including measure threshold if applicable, added to required submissions in the MUHIT survey. A PO must report either by PCP or EP, not a combination of the two. Added language clarifying the Meaningful Use of Health IT audit process. Health plans do not submit for the Meaningful Use of Health IT domain; POs voluntarily self-report this domain. Added information on the survey tool and submission requirements for POs. POs report performance based on the percentage of Primary Care Practitioners (PCPs) who meet the intent of the measure or POs may report performance based on the percentage of EPs. Defined Primary Care Practitioners (PCPs). Removed option to report based on the number of patients assigned to PCPs who meet the intent of the measure. Removed option to report based on EHRs that are not ONC-ATCB certified software. Removed Measure 16 (generate patient lists by specific conditions). Removed Measure 17 (send patient reminders per patient preference for preventive/follow-up care). Added Measures 16-20 (report any five CMS/ONC menu set measures). Renumbered Measure 18 to Measure 21. Measurement Year 2012 P4P Manual 248 MY 2012 P4P Specifications: Summary of Changes Summary Table of Patient Experience Changes MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Patient Experience September 2012 December 2011 Measure Update Clarified that the Overall Rating of Care composite is made of the Rating of PCP and Rating of All Healthcare indicators. Clarified that health plans do not submit for the Patient Experience domain; POs voluntarily self-report this domain. Starting in MY 2012, the survey used to collect data for the Patient Experience Domain, will be the national standard CAHPS®2 Clinician & Group (CG-CAHPS) Patient Experience Survey endorsed by the National Quality Forum (NQF). Added information about an email version of the survey. None. Summary Table of Appropriate Resource Use Measures and Changes MY 2012 Measures Date of Update/ Modification From HEDIS November 2012 Inpatient Readmission Within 30 Days September 2012 December 2011 Modifications From HEDIS Inpatient Utilization—Acute Care Discharges November 2012 September 2012 Measurement Year 2012 P4P Manual Measure Update Added measurement period to the eligible population. Added ―newborn care‖ to the maternity care exclusion in step C of the discharge identification methodology and coding. Added ICD-9-CM Diagnosis code V27.x to Table IRN-C. Added MS-DRG codes 765-770, 774-782 and 789-795 to Table IRN-C. Changed text in Step 7 of the inpatient readmission calculation to refer to index charges instead of admissions. Deleted obsolete MS-DRG code 009 from tables IRN-A. None. Non-HEDIS measure. This measure is based on the NQF-endorsed Inpatient Readmission measure submitted by UnitedHealthcare. Added measurement period to the eligible population. Removed text from ages section of the eligible population to determine the PO’s total member years of enrollment in health plan. . Added ―newborn care‖ to the maternity care exclusion in step C of the discharge identification methodology and coding. Removed note to include newborn care rendered after the baby has been discharged home and rehospitalized. Added ICD-9-CM Diagnosis code V27.x to Table IPU-D. Added MS-DRG codes 765-770, 774-782 and 789-795 to Table IPU-D. In the inpatient discharges calculation, removed intermediate calculation of total inpatient discharges PTMY and moved the step to remove outliers to after calculating the observed discharges PTMY for each PO. Deleted obsolete MS-DRG code 009 from tables IPU-A. November 30, 2012 MY 2012 P4P Specifications: Summary of Changes 249 Summary Table of Appropriate Resource Use Measures and Changes (continued) MY 2012 Measures Date of Update/ Modification From HEDIS December 2011 Modifications From HEDIS November 2012 Inpatient Utilization—Bed Days September 2012 December 2011 Modifications From HEDIS November 2012 Outpatient Procedures Utilization—Percentage Done in Preferred Facility September 2012 December 2011 Modifications From HEDIS November 2012 Emergency Department Visit September 2012 December 2011 Modifications From HEDIS November 2012 Generic Prescribing November 30, 2012 September 2012 December 2011 Modifications From HEDIS Measure Update None. Based on HEDIS Use of Services specifications. Added risk adjustment. Changed the truncation methodology for stays to Winsorize at a specified number of days per stay. Added measurement period to the eligible population. Changed text in Step 6 of bed days calculation to refer to bed days instead of discharges. None None. Based on HEDIS Use of Services specifications. Added risk adjustment. Added measurement period to the eligible population. Removed optional exclusion of members who require coordination of benefits. Exclude outpatient procedures identified through an Emergency Department claim/encounter. None. Based on HEDIS Use of Services specifications. Table OSU-A Options A and B both allow POS or UB Type of Bill codes. Added measurement period to the eligible population. Removed optional exclusion of members who require coordination of benefits. None. None. Based on HEDIS Use of Services specifications. Added risk adjustment. Removed Anxiety/Sedation—Sleep Aids from measures recommended for payment; the measures continue to be collected and reported internally. None. None. Non-HEDIS measure. Measurement Year 2012 P4P Manual 250 MY 2012 P4P Specifications: Summary of Changes Summary Table of Appropriate Resource Use Measures and Changes (continued) MY 2012 Measures Total Cost of Care Date of Update/ Modification From HEDIS November 2012 September 2012 December 2011 Modifications From HEDIS November 2012 Frequency of Selected Procedures September 2012 December 2011 Modifications From HEDIS Measurement Year 2012 P4P Manual Measure Update Added measurement period to the eligible population. Specifications updated to reflect calculation of the measure based on member-level information supplied by plan. None. Non-HEDIS measure. Added measurement period to the eligible population. Deleted obsolete CPT codes 93501, 93510, 93511, 93514, 93524, 93526-93529, 93539-93545 from the Cardiac catheterization row in Table FSP-A. Added CPT code 22633 to Table FSP-A. Added to the MY 2012 P4P Appropriate Resource Use measure set.. P4P does not collect tonsillectomy, hysterectomy, cholecystectomy, prostatectomy, mastectomy, lumpectomy. P4P collects carotid endarterectomy, total hip replacement, and total knee replacement for the commercial HMO/POS. November 30, 2012
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