Integrated Healthcare Association California Pay for Performance Program Final

Transcription

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
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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
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Commercial measure
Medicare measure
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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
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Commercial measure
Medicare measure
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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
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Commercial measure
Medicare measure
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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.
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2
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).
November 30, 2012
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.
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4
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.
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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
6
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/.
November 30, 2012
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)
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
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
8
Appropriate Resource Use
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).
May 17, 2013
June 28, 2013
June 28, 2013
June 28–July 19, 2013
July 30, 2013
August 9, 2013
Total Cost of Care
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).
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.
November 30, 2012
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
10
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).
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.
November 30, 2012
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.
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
12
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.
November 30, 2012
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
14
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.
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).
November 30, 2012
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
18
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.
November 30, 2012
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
20
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.
November 30, 2012
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
22
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.
November 30, 2012
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
24
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.
November 30, 2012
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
26
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.
November 30, 2012
…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
28
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.
November 30, 2012
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
30
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.‖
November 30, 2012
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
32
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.
November 30, 2012
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
34
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.
November 30, 2012
Clinical Domain Technical Specifications
For P4P MY 2012
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
Cardiovascular Conditions—LDL Control (<100)
Proportion of Days Covered by Medications—
Statins
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
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
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
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.
November 30, 2012
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.
_________
November 30, 2012
40
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
___________
November 30, 2012
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
___________
November 30, 2012
42
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.
___________
November 30, 2012
MY 2012 P4P Clinical Specifications: Adults’ Access to Preventive/Ambulatory Health Services
43
Adults’ Access to Preventive/Ambulatory Health Services (AAP)
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 Medicare measure set.
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 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).
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
___________
November 30, 2012
MY 2012 P4P Clinical Specifications: Annual Monitoring for Patients on Persistent Medications
45
Annual Monitoring for Patients on Persistent Medications (MPM)
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-hydrochlorothiazideolmesartan and amlodipine-telmisartan to Table MPM-A.
Deleted LOINC code 62425-4 from Table MPM-B.
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).
46
…for health
plans
Allowable gap
The measurement year in the health plan and the PO (parent level).
Anchor date
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
Note: Medications dispensed in the year prior to the measurement year must be
counted toward the 180 treatment days.
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).
November 30, 2012
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
___________
November 30, 2012
48
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
therapeutic monitoring test in the measurement year (Table MPM-B). The member
must meet one of the following criteria to be compliant.
measurement year.
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
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.
November 30, 2012
49
Table MPM-D: Drugs to Identify Members on Diuretics
Description
Antihypertensive
combinations
Loop diuretics
Potassium-sparing
diuretics
Thiazide diuretics
Numerator
Prescription
Hydrochlorothiazide-methyldopa
Hydrochlorothiazide-metoprolol
Hydrochlorothiazide-propranolol
Hydrochlorothiazide-spironolactone
Hydrochlorothiazide-timolol
Hydrochlorothiazide-triamterene
Aliskiren-hydrochlorothiazide
Aliskiren-hydrochlorothiazideamlodipine
Amiloride-hydrochlorothiazide
Amlodipine-hydrochlorothiazideolmesartan
Amlodipine-hydrochlorothiazidevalsartan
Atenolol-chlorthalidone
Bendroflumethiazide-nadolol
Bisoprolol-hydrochlorothiazide
Candesartan-hydrochlorothiazide
Chlorthalidone-clonidine
Eprosartan-hydrochlorothiazide
Bumetanide
Furosemide
Ethacrynic acid
Torsemide
Amiloride
Spironolactone
Eplerenone
Triamterene
Chlorothiazide
Indapamide
Chlorthalidone
Methyclothiazide
Hydrochlorothiazide
Metolazone
therapeutic monitoring test in the measurement year (Table MPM-B). The member
must meet one of the following criteria to be compliant.
measurement year.
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
50
MY 2012 P4P Clinical Specifications: Cholesterol Management
Cardiovascular Conditions (CMC)
LDL Screening and Control (<100)
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 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.
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).
November 30, 2012
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 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 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.
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
__________
November 30, 2012
52
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
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
__________
November 30, 2012
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
__________
November 30, 2012
54
MY 2012 P4P Clinical Specifications: Proportion of Days Covered by Medications
Proportion of Days Covered by Medications (PDC)
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 to the MY 2012 P4P quality and Medicare measure sets.
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.
November 30, 2012
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 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
None.
…for health
plans
None.
November 30, 2012
56
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.
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
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-valsartanhydrochlorothiazide
Azilsartan-chlorthalidone
Candesartanhydrochlorothiazide
Enalapril-felodipine
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.
November 30, 2012
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
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
Step 2
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
November 30, 2012
58
Calculate
performance rate
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
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
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)
November 30, 2012
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
Step 2
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
Calculate
performance
rate
Exclusions (optional)
None.
November 30, 2012
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),
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.
Added ICD-9 CM Diagnosis code 294.1 to Table CDC-G.
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 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.
__________
November 30, 2012
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.
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.
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.
__________
November 30, 2012
62
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).
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
Commercial
HMO/POS









Medicare





November 30, 2012
Ages
63
Continuous
enrollment
…for health
plans
Allowable gap
The measurement year in the health plan and the PO (parent level).
Anchor date
…for health
plans
Enrolled in the health plan and the PO (parent level, or, for eligible POs, subgroup level)
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
64
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
Denominator
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
__________
November 30, 2012
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%.
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
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%.
__________
November 30, 2012
66
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.
November 30, 2012
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
68
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
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.
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.
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November 30, 2012
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).
__________
November 30, 2012
70
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.
__________
November 30, 2012
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-hydrochlorothiazide-valsartan
Amlodipine-hydrochlorothiazide-olmesartan
Amlodipine-telmisartan
Prescription
Lisinopril
Perindopril
Moexipril
Quinapril
Losartan
Telmisartan
Olmesartan
Valsartan
Candesartan-hydrochlorothiazide
Eprosartan-hydrochlorothiazide
Ramipril
Trandolapril
Trandolapril-verapamil
__________
November 30, 2012
72
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
November 30, 2012
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.
___________
November 30, 2012
74
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).
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).
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
___________
November 30, 2012
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
76
MY 2012 P4P Clinical Specifications: Use of Imaging Studies for Low Back Pain
Use of Imaging Studies for Low Back Pain (LBP)
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.
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
___________
November 30, 2012
77
Continuous
enrollment
…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 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.
____________
November 30, 2012
78
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.
Denominator
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
____________
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)
None.
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.
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
Continuous
enrollment
…for health
plans
Allowable gap
Anchor date
…for health
plans
November 30, 2012
80
Benefit
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
Denominator
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.
____________
November 30, 2012
81
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
82
MY 2012 P4P Clinical Specifications: Osteoporosis Management
Osteoporosis Management in Women Who Had a Fracture (OMW)
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 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.
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.
November 30, 2012
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
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 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
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
84
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.
____________
November 30, 2012
85
Denominator
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.
____________
November 30, 2012
86
MY 2012 P4P Clinical Specifications: Childhood Immunization Status
Childhood Immunization Status (CIS)
24-Month Continuous Enrollment
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).
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.
____________
November 30, 2012
87
Eligible Population
Product line
Commercial HMO/POS.
Age
Children who turn 2 years of age during the measurement year.
Continuous
enrollment
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
enrollment.
Anchor date
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.
Denominator
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
88
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.
____________
November 30, 2012
89
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
90
MY 2012 P4P Clinical Specifications: Immunizations for Adolescents
Immunizations for Adolescents (IMA)
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.
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 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
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.
November 30, 2012
MY 2012 P4P Clinical Specifications: Immunizations for Adolescents
Benefit
Medical.
Event/diagnosis
None.
91
Denominator
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
Adolescents who had a contraindication for a specific vaccine may be excluded from the denominator for all
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
Description
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.
___________
November 30, 2012
92
MY 2012 P4P Clinical Specifications: HPV for Female Adolescents
Human Papillomavirus Vaccine for Female Adolescents (HPV)
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.
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 health
plans
Allowable gap
(parent level).
the 13th birthday.
Anchor date
…for health
plans
Benefit
Event/diagnosis
Medical.
None.
November 30, 2012
MY 2012 P4P Clinical Specifications: HPV for Female Adolescents
93
Denominator
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
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
Description
ICD-9-CM Diagnosis
999.42*
Note
guidelines.
___________
November 30, 2012
94
MY 2012 P4P Clinical Specifications: Chlamydia Screening in Women
Chlamydia Screening in Women (CHL)
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.
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 health
plans
Allowable gap
The measurement year in the health plan and in the PO (parent level).
November 30, 2012
95
Anchor date
…for health
plans
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
November 30, 2012
96
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
_____________
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97
Denominator
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
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.
____________
November 30, 2012
98
MY 2012 P4P Clinical Specifications: Evidence-Based Cervical Cancer Screening
Evidence-Based Cervical Cancer Screening of Average-Risk,
Asymptomatic Women (ECS)
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.
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.
Stated that for Immunodeficiency, including genetic (congenital) immunodeficiency syndromes, look as far
back as possible in the member’s history for possible exclusions.
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.
November 30, 2012
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
enrollment.
Anchor date
….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.
as of December 31 of the measurement year.
Benefits
Medical.
Event/
diagnosis
None.
November 30, 2012
100
Report each of the three rates separately.
Rate 1: Appropriately Screened
Denominator
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.
__________
November 30, 2012
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
Numerator
The number of women who did not receive a Pap test according to evidence based
guidelines.
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
Step 3
This is the numerator for Rate 2: Not Screened.
Rate 3: Screened Too Frequently
Denominator
Numerator
The number of women who received more Pap tests than necessary according to
evidence-based guidelines.
__________
November 30, 2012
102
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
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
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)
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 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.
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
__________
November 30, 2012
104
Continuous
enrollment
…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).
enrollment.
Anchor date
…for health
plans
Benefit
Medical.
Event/diagnosis
None.
Denominator
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
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).
__________
November 30, 2012
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.
__________
November 30, 2012
106
MY 2012 P4P Clinical Specifications: Colorectal Cancer Screening
Colorectal Cancer Screening (COL)
None.
None.
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
Continuous
enrollment
…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
enrollment.
Anchor date
…for health
plans
Benefit
Medical.
Event/diagnosis
None.
November 30, 2012
MY 2012 P4P Clinical Specifications: Colorectal Cancer Screening
107
Denominator
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
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
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
__________
November 30, 2012
108
MY 2012 P4P Clinical Specifications: Adult BMI Assessment
Adult BMI Assessment (ABA)
None.
Deleted obsolete HCPCS code G0344 from Table ABA-A.
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
Continuous
enrollment
…for health
plans
Allowable gap
November 30, 2012
MY 2012 P4P Clinical Specifications: Adult BMI Assessment
109
Anchor date
…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
Denominator
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
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
_____________
November 30, 2012
110
MY 2012 P4P Clinical Specifications: Glaucoma Screening in Older Adults
Glaucoma Screening in Older Adults (GSO)
None.
Deleted obsolete CPT code 92135 from Table GSO-A.
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
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
enrollment.
Anchor date
…for health
plans
___________
November 30, 2012
MY 2012 P4P Clinical Specifications: Glaucoma Screening in Older Adults
Benefit
Medical.
Event/
diagnosis
None.
111
Denominator
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
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
___________
November 30, 2012
112
MY 2012 P4P Clinical Specifications: Asthma Medication Ratio
Asthma Medication Ratio (AMR)
Added two overall age bands for reporting, 5-50 years and 5-64 years.
Added indacaterol to Table AMR-C.
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 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.
None.
November 30, 2012
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
114
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
level)
…for health
plans
The measurement year and the year prior to the measurement year in the health plan
Allowable gap
enrollment.
Anchor date
…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
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).
November 30, 2012
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
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).
______________
November 30, 2012
116
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
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
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.
November 30, 2012
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
November 30, 2012
118
MY 2012 P4P Clinical Specifications: Appropriate Testing for Children With Pharyngitis
Appropriate Testing for Children With Pharyngitis (CWP)
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.
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.
November 30, 2012
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 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
Anchor date:
Episode Date.
….for health
plans
Episode Date.
Benefits
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.
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
120
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
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
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.
__________
November 30, 2012
121
Denominator
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
__________
November 30, 2012
122
MY 2012 P4P Clinical Specifications: Appropriate Treatment for Children With URI
Appropriate Treatment for Children With
Upper Respiratory Infection (URI)
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.
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.
November 30, 2012
Negative
Medication
History
123
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 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
Anchor date
…for health
plans
on the Episode Date.
on the Episode Date.
Benefits
Event/
diagnosis
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
124
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
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
November 30, 2012
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
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.
Denominator
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
First generation cephalosporins
Folate antagonist
Macrolides
Natural penicillins
Penicillinase resistant penicillins
Quinolones
Second generation cephalosporins
Sulfonamides
Tetracyclines
Third generation cephalosporins
Prescriptions
Ampicillin
Amoxicillin
Cefadroxil
Cefazolin
Trimethoprim
Clindamycin
Azithromycin
Clarithromycin
Erythromycin
Penicillin G potassium
Penicillin G sodium
Dicloxacillin
Ciprofloxacin
Levofloxacin
Cefaclor
Cefprozil
Sulfamethoxazoletrimethoprim
Doxycycline
Minocycline
Cefdinir
Cefixime
Cefditoren
Cephalexin
Penicillin V potassium
Moxifloxacin
Ofloxacin
Cefuroxime
Loracarbef
Sulfisoxazole
Tetracycline
Cefpodoxime
Ceftibuten
Ceftriaxone
November 30, 2012
126
MY 2012 P4P Clinical Specifications: Avoidance of Antibiotic Treatment
Avoidance of Antibiotic Treatment for
Adults With Acute Bronchitis (AAB)
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.
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.
November 30, 2012
Negative
Medication History
127
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
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).
128
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
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
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).
__________
November 30, 2012
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.
Denominator
Numerator
Dispensed prescription for antibiotic medication (Table AAB-E) on or within three days
after the IESD.
November 30, 2012
130
Table AAB-E: Antibiotic Medications
Description
Aminoglycosides
Aminopenicillins
Antipseudomonal penicillins
First generation cephalosporins
Fourth generation cephalosporins
Ketolides
Macrolides
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
Ticarcillin-clavulanate
Ampicillin-sulbactam
Cefadroxil
Cephalexin
Cefazolin
Cefepime
Telithromycin
Clindamycin
Lincomycin
Azithromycin
Erythromycin
Clarithromycin
Aztreonam
Daptomycin
Metronidazole
Chloramphenicol
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).
November 30, 2012
MY 2012 P4P Clinical Specifications: All-Cause Readmissions
131
All-Cause Readmissions (PCR)
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 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 and Medicare measure sets.
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
132
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.
November 30, 2012
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.
Denominator
Step 1
Identify all acute inpatient stays with a discharge date on or between January 1 and
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
134
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.
____________
November 30, 2012
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
136
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
1
HCC-16
2
HCC-17
3
HCC-18
CC-19
Manifestation
Diabetes Without Complication
4
HCC-19
CC-17
1
HCC-17
CC-18
Manifestation
2
HCC-18
3
HCC-19
Manifestation
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.
November 30, 2012
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 commercial product lines: Use Table PCR-Comm-OtherWeights.
Step 5
Identify the base risk weight.
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
138
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.
November 30, 2012
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
140
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.
November 30, 2012
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)
For P4P MY 2012
Self-Reporting POs
MY 2012 P4P Meaningful Use of Health IT: Overview
143
Overview
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.
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.
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
144
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.
November 30, 2012
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
146
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.
November 30, 2012
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
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
148
MY 2012 P4P Meaningful Use of Health IT: PO Reporting Structure
PO Reporting Structure
PO Denominator
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.).
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
150
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
152
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
2. Number of PCPs or EPs who qualify for the exclusion criteria.
applicable.
November 30, 2012
153
Measure 5: Maintain active medication list
Intent
Objective
The organization’s PCPs or EPs maintain active medication list.
Measure
at least one entry (or an indication that the patient is not currently prescribed any
medication) recorded as structured data.
Exclusions
No exclusion.
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
154
Measure 6: Maintain active medication allergy list
Intent
Objective
The organization’s PCPs or EPs maintain active medication allergy list.
Measure
at least one entry (or an indication that the patient has no known medication allergies)
recorded as structured data.
Exclusions
No exclusion.
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
156
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
Record the following information.
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
158
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
160
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
162
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
November 30, 2012
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.
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.
166
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
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
2. Number of PCPs or EPs who qualify for the exclusion criteria, if applicable.
applicable.
November 30, 2012
167
Intent
Objective
Select one menu set item from Table MUHIT-A. Organizations must meet the objective,
measure and exclusion requirements.
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
Record the following information.
applicable.
November 30, 2012
168
Intent
Objective
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
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Intent
Objective
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
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170
Intent
Objective
Scoring
1–24
25–49
50–74
75+
Required
submission
Certified Software
1
3
4
5
applicable.
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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).
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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).
November 30, 2012
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:
__________
__________
(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).
__________
audit.
One other
clinically
important
condition
Record the following information for the condition:
Number of patients with condition:
__________
__________
(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).
__________
audit.
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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?
November 30, 2012
For P4P MY 2012
Self-Reporting POs
176
MY 2012 P4P Patient Experience Domain: Overview
Overview
Clarified that the Overall Rating of Care composite is made of the Rating of PCP and Rating of All
Healthcare measures.
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.
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.
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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.
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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)
doctor explain things in a way that was easy
to understand? (Q16)
doctor spend enough time with you? (Q22)
doctor show respect for what you had to say?
(Q21)
doctor give you easy to understand
information about taking care of these health
problems or concerns? (Q19)
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)
doctor seem informed and up-to-date about
the care you got from specialists? Q27)
Specialist Version
doctor listen carefully to you? (Q15)
doctor explain things in a way that was easy
to understand? (Q14)
doctor spend enough time with you? (Q20)
doctor show respect for what you had to
say? (Q19)
doctor give you easy to understand
information about taking care of these
health problems or concerns? (Q17)
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)
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
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)
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)
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
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)
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
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.
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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).
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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.
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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.
November 30, 2012
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.
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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.
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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.
November 30, 2012
MY 2012 P4P ARU Specifications: Inpatient Readmissions Within 30 Days
187
Inpatient Readmissions Within 30 Days (IRN)
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 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
188
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
POS
21
OR
Revenue Code
0100-0189, 0200–0219
November 30, 2012
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
960-979
WITH
Secondary ICD-9-CM Diagnosis
291-292, 303-305, 535.3, 571.1
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
190
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
November 30, 2012
MY 2012 P4P ARU Specifications: Inpatient Utilization—Acute Care Discharges
191
Inpatient Utilization—Acute Care Discharges (IPU)
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.
None.
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.
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
192
Eligible Population
Product lines
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
Anchor date
None.
Benefit
Medical.
Measurement
period
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
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
POS
21
OR
Revenue Code
0100-0189, 0200-0219
November 30, 2012
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
960-979
WITH
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
194
Step 8
Calculate the O/E inpatient discharges ratio for each PO.
O/E ratio = Observed discharges PTMY / Expected discharges PTMY
Step 9
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.
November 30, 2012
MY 2012 P4P ARU Specifications: Inpatient Utilization—Bed Days
195
Inpatient Utilization—Bed Days (IPBD)
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.
None.
None.
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.
Note
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
196
Eligible Population
Product lines
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.
Continuous
enrollment
Date of admission through discharge in the health plan and in the PO (parent level).
Allowable gap
Anchor date
None.
Benefit
Medical.
Measurement
period
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
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
November 30, 2012
Step 7
197
Calculate the reliability adjusted observed/expected ratio for each PO.
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.
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.
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:
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
198
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).
November 30, 2012
MY 2012 P4P ARU Specifications: Outpatient Procedures Utilization in Preferred Facility
199
Outpatient Procedures Utilization—
Percentage Done in Preferred Facility (OSU)
Removed optional exclusion of members who require coordination of benefits.
Exclude outpatient procedures identified through an Emergency Department claim/encounter.
None.
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.
Eligible Population
Product lines
Ages
All ages.
Continuous
enrollment
None.
Allowable gap
NA because there is no continuous enrollment requirement.
Anchor date
None.
Benefit
Medical.
Measurement
period
November 30, 2012
200
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.
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
960-979
WITH
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
___________
November 30, 2012
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.
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
202
MY 2012 P4P ARU Specifications: Emergency Department Visits
Emergency Department Visits (EDV)
None.
None.
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.
Eligible Population
Product lines
Ages
All ages.
Continuous
enrollment
None.
Allowable gap
Anchor date
None.
Benefit
Medical.
Measurement
period
November 30, 2012
Member years
203
enrolled in the health plan and PO.
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
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
960-979
WITH
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.
___________
November 30, 2012
204
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
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:
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.
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.
November 30, 2012
MY 2012 P4P ARU Specifications: Generic Prescribing
205
Generic Prescribing (GRX)
Removed Anxiety/Sedation—Sleep Aids from measures recommended for payment; the measures
continue to be collected and reported internally.
None.
None.
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
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
206
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.
November 30, 2012
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
208
MY 2012 P4P ARU Specifications: Total Cost of Care
Total Cost of Care (TCC)
Specifications updated to reflect calculation of the measure based on member-level information supplied by
plan.
None.
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.
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.
November 30, 2012
Benefit
Measurement
period
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
210
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.
November 30, 2012
MY 2012 P4P ARU Specifications: Frequency of Selected Procedures
211
Frequency of Selected Procedures (FSP)
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 text stating that measure is for internal reporting only.
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.
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
_____________
November 30, 2012
212
Member years
enrolled in the plan and the PO.
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.
November 30, 2012
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
_____________
November 30, 2012
214
MY 2012 P4P ARU Specifications: All-Cause Readmissions
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
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.
November 30, 2012
MY 2012 Testing Measures
For P4P MY 2012
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.
November 30, 2012
219
Childhood Immunization Status (CIS)
24-Month Continuous Enrollment
Added Hepatitis A as a testing measure to the MY 2012 P4P quality measure set.
Continuous enrollment for P4P is 24 months (instead of 12 months for HEDIS).
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
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
enrollment.
Anchor date
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
220
Denominator
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.
Children who had a contraindication for a specific vaccine should be excluded from the denominator for all
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
Table CIS-B: Codes to Identify Exclusions
Immunization
Description
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.
____________
November 30, 2012
MY 2012 P4P Clinical Specifications: Human Papillomavirus Vaccine for Male Adolescents
221
Human Papillomavirus Vaccine for Male Adolescents (HPV)
None.
Added as a testing measure to the MY 2012 P4P quality measure set.
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 health
plans
Allowable gap
(parent level).
the 13th birthday.
Anchor date
…for health
plans
Benefit
Medical.
Event/diagnosis
None.
November 30, 2012
222
MY 2012 P4P Testing Specifications: Human Papillomavirus Vaccine for Male Adolescents
Denominator
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
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
Description
ICD-9-CM Diagnosis
999.42*
Note
guidelines.
___________
November 30, 2012
MY 2012 P4P Testing Specifications: Unexpected Complications in Full Term Newborns
223
Unexpected Complications in Full-Term Newborns (UNC)
Added to the manual as a MY 2012 testing measure.
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
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
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
Denominator
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
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
Infection
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
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)
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.
Eligible Population
Product lines
Commercial HMO/POS.
Ages
All ages.
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
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
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
11.03)
Complication of the
puerperium
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
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
Field “Birthweight” ≥1,500 grams
Denominator
Numerator
Number born at a hospital with NICU Level III status.
November 30, 2012
228
MY 2012 P4P Testing Specifications: Incidence of Episiotomy
Incidence of Episiotomy (EPS)
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.
Eligible Population
Product lines
Commercial HMO/POS.
Ages
All ages.
None.
Allowable gap
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
11.01)
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
November 30, 2012
MY 2012 P4P Testing Specifications: Incidence of Episiotomy
229
Table EPS-A: Codes to Identify Deliveries (continued)
Description
course of delivery
11.03)
Complication of the
puerperium
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
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
Denominator
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
230
MY 2012 P4P Testing Specifications: Cesarean Section Rate for Low-Risk Births
Cesarean Section Rate for Low-Risk Births (CSX)
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.
Eligible Population
Product lines
Commercial HMO/POS.
Ages
All ages.
None.
Allowable gap
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
to pregnancy
11.01)
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
November 30, 2012
231
Table CSX-A: Codes to Identify Deliveries (continued)
Description
course of delivery
11.03)
Complication of the
puerperium
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
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
Field “Best Obstetric Estimate of Gestational Age”
OR
LMP-based gestational age ≥37 weeks
232
Denominator
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
November 30, 2012
MY 2012 P4P Testing Specifications: Vaginal Birth After Cesarean Delivery Rate
233
Vaginal Birth After Cesarean Delivery Rate (VBC)
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.
Eligible Population
Product lines
Commercial HMO/POS.
Ages
All ages.
None.
Allowable gap
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
to pregnancy
11.01)
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
234
MY 2012 P4P Testing Specifications: Vaginal Birth After Cesarean Delivery Rate
Table VBC-A: Codes to Identify Deliveries (continued)
Description
course of delivery
11.03)
Complication of the
puerperium
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 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
Denominator
Numerator
Number of vaginal deliveries.
Table VBC-C: Codes to Identify Cesarean Deliveries
Description
Cesarean delivery
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
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
236
MY 2012 P4P Testing Specifications: Care for Older Adults
Care for Older Adults (COA)
Added advance care planning to the measure.
COA is a second-year testing measure in MY 2012.
Added to the MY 2012 P4P Medicare measure set.
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.
November 30, 2012
237
Eligible Population
Product line
Medicare Special Needs Plan (SNP).
Ages
Continuous
enrollment
…for health plans
Allowable gap
Anchor date
…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.
Denominator
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
_____________
November 30, 2012
238
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
_____________
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
November 2012
Annual Monitoring for Patients
on Persistent Medications
September 2012
December 2011
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 HCPCS codes S0620, S0621 to Table AAP-A
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.
240
Summary Table of Quality Measures and Changes (continued)
MY 2012 Measures
Date of Update/
November 2012
Cholesterol Management for
Patients With Cardiovascular
Conditions:
LDL Screening
LDL Control (<100)
September 2012
December 2011
November 2012
Proportion of Days Covered by
Medications:
Renin Angiotensin System
(RAS) Antagonists
Statins
September 2012
December 2011
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 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.
Non-HEDIS measure.
November 30, 2012
241
MY 2012 Measures
Date of Update/
November 2012
Diabetes Care:
HbA1c Testing
HbA1c Poor Control (>9.0%)
Eye Exam
LDL Screening and Control
(<100)
Nephropathy Monitoring
Blood Pressure Control
(<140/90)
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 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.
__________
November 30, 2012
242
Date of Update/
MY 2012 Measures
December 2011
Diabetes Care (continued)
Use of Imaging Studies for Low
Back Pain
November 2012
September 2012
December 2011
November 2012
Disease-Modifying AntiRheumatic Drug Therapy for
Rheumatoid Arthritis
September 2012
December 2011
November 2012
Osteoporosis Management in
Women Who Had a Fracture
September 2012
December 2011
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.
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.
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 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.
None.
__________
November 30, 2012
243
MY 2012 Measures
Date of Update/
November 2012
September 2012
Childhood Immunization Status
December 2011
November 2012
Immunizations for Adolescents
September 2012
December 2011
November 2012
Human Papillomavirus Vaccine
for Female Adolescents
September 2012
December 2011
November 2012
Chlamydia Screening in
Women
September 2012
December 2011
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.
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.
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.
__________
November 30, 2012
244
Date of Update/
MY 2012 Measures
November 2012
Evidence-Based Cervical
Cancer Screening of AverageRisk, Asymptomatic Women
September 2012
December 2011
November 2012
Adult BMI Assessment
September 2012
December 2011
November 2012
September 2012
December 2011
November 2012
September 2012
December 2011
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 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.
None.
None.
None.
Deleted obsolete HCPCS code G0344 from Table ABA-A.
__________
November 30, 2012
Date of Update/
MY 2012 Measures
November 2012
Glaucoma Screening in Older
Adults
September 2012
December 2011
November 2012
September 2012
Asthma Medication Ratio
December 2011
November 2012
Appropriate Testing for
Children With Pharyngitis
September 2012
December 2011
245
Measure Update
None.
Deleted obsolete CPT code 92135 from Table GSO-A.
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.
__________
November 30, 2012
246
Date of Update/
MY 2012 Measures
November 2012
Appropriate Treatment for
Children With Upper
Respiratory Infection
September 2012
December 2011
November 2012
Avoidance of Antibiotic
Treatment for Adults With
Acute Bronchitis
September 2012
December 2011
November 2012
All-Cause Readmissions
September 2012
December 2011
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 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.
NCQA refers to this measure as Plan All-Cause Readmissions.
November 30, 2012
247
Summary Table of Meaningful Use of Health IT Changes
MY 2012 Measures
Date of Update/
November 2012
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.
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.
248
Summary Table of Patient Experience Changes
MY 2012 Measures
Date of Update/
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/
November 2012
Inpatient Readmission Within
30 Days
September 2012
December 2011
Inpatient Utilization—Acute
Care Discharges
November 2012
September 2012
Measure Update
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.
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
249
Summary Table of Appropriate Resource Use Measures and Changes (continued)
MY 2012 Measures
Date of Update/
December 2011
November 2012
Inpatient Utilization—Bed Days
September 2012
December 2011
November 2012
Outpatient Procedures
Utilization—Percentage Done
in Preferred Facility
September 2012
December 2011
November 2012
Emergency Department Visit
September 2012
December 2011
November 2012
Generic Prescribing
November 30, 2012
September 2012
December 2011
Measure Update
None.
Changed the truncation methodology for stays to Winsorize at a specified number of days per stay.
Changed text in Step 6 of bed days calculation to refer to bed days instead of discharges.
None
None.
Exclude outpatient procedures identified through an Emergency Department claim/encounter.
None.
Table OSU-A Options A and B both allow POS or UB Type of Bill codes.
None.
None.
Removed Anxiety/Sedation—Sleep Aids from measures recommended for payment; the measures continue to be
collected and reported internally.
None.
None.
Non-HEDIS measure.
250
Summary Table of Appropriate Resource Use Measures and Changes (continued)
MY 2012 Measures
Total Cost of Care
Date of Update/
November 2012
September 2012
December 2011
November 2012
Frequency of Selected
Procedures
September 2012
December 2011
Measure Update
Specifications updated to reflect calculation of the measure based on member-level information supplied by plan.
None.
Non-HEDIS measure.
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

Integrated Healthcare Association California Pay for Performance Program Final

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