HEDIS ? What is

Transcription

HEDIS ? What is

What is HEDIS®?
HEDIS® (Healthcare Effectiveness Data and Information Set) consists
of a set of performance measures utilized by more than 90 percent
of American health plans that compare how well a plan performs in
these areas:
• Quality of care
• Access to care
• Member satisfaction with the health plan and doctors
WHY HEDIS® IS IMPORTANT
HEDIS® ensures health plans are offering quality preventive care and
service to members. It also allows for a true comparison of the
performance of health plans by consumers and employers.
VALUE OF HEDIS® TO YOU, OUR PROVIDERS
HEDIS® can help save you time while also potentially reducing health
care costs. By proactively managing patients’ care, you are able to
effectively monitor their health, prevent further complications and
identify issues that may arise with their care.
HEDIS® can also help you:
• Identify noncompliant members to ensure they receive preventive
screenings
• Understand how you compare with other WellCare providers as
well as with the national average
VALUE OF HEDIS® TO YOUR PATIENTS, OUR MEMBERS
HEDIS® ensures that members will receive optimal preventive and
quality care. It gives members the ability to review and compare
plans’ scores, helping them to make informed health care choices.
WHAT YOU CAN DO
• Encourage your patients to schedule preventive exams
• Remind your patients to follow up with ordered tests
• Complete outreach calls to noncompliant members
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Source: www.ncqa.org
KY019521_PRO_FLY_ENG Internal Approved 06272012
©WellCare 2012 KY_06_12
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If you have questions about HEDIS® or need more information,
please contact your local Provider Relations representative.
HEDIS® Quick Reference Guide for Adults
The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in
®
compliance with the HEDIS 2012 Volume 2 Technical Specifications.
Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement.
Prevention and Screening
Immunizations for Adolescents:
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.
Diphtheria - 90719
Mening – 90733, 90734
CPT Codes
Td – 90714, 90718
Tdap – 90715
Tetanus – 90703
Chlamydia Screening in Women:
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.
CPT Codes
87110, 87270, 87320, 87490, 87491, 87492, 87810
Cervical Cancer Screening:
Percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer during the measurement
year or the two years prior to the measurement year.
CPT Codes
88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175
HCPCS
G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
Exclusion Criteria
Women who had a total hysterectomy with no residual cervix are excluded.
51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260,
CPT Codes
58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-58554, 58570-58573,
58951, 58953, 58954, 58956, 59135
ICD-9 CM Diagnosis
618.5, V67.01, V76.47, V88.01, V88.03
Adult BMI Assessment:
Percentage of members 18–74 years of age who had an outpatient visit and who had their body mass index (BMI) documented
during the measurement year or the year prior to the measurement year.
99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99385-99387,
CPT Codes:
99395-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
V85.21 - Body Mass Index 25.0-25.9,adult
V85.22- Body Mass Index 26.0-26.9,adult
ICD9-CM Diagnosis:
Source: HEDIS® 2012 Volume 2 Technical Specifications
NA019250_PRO_GDE_ENG Internal Approved 06202012
Updated: 10/11/2012
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HCPCS:
V85.45- Body Mass Index 70 and over, adult
G0344, G0402
Breast Cancer Screening:
Percentage of women 40–69 years of age who had a mammogram to screen for breast cancer during the measurement year or the
year prior to the measurement year.
CPT Codes:
77055, 75056, 75057
HCPCS:
G0202, G0204, G0206
Colorectal Cancer Screening:
Percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.
ICD9-CM Diagnosis:
45.24, 45.22, 45.23, 45.25, 45.42, 45.43
CPT Codes:
FOBT – 82270, 82274
Flexible Sigmoidoscopy – 45330-45335, 45337-45342, 45345
Colonoscopy – 44388-44394, 44397, 45355, 45378-45387, 45391, 45392
HCPCS:
FOBT – G0328
Flexible Sigmoidoscopy – G0104
Colonoscopy – G0105, G0121
Exclusion Criteria:
Members with a diagnosis of colorectal cancer or total colectomy are excluded.
Colorectal Cancer
ICD-9-CM Diagnosis:
153, 154.0, 154.1, 197.5, V10.05
Total colectomy
CPT Codes:
44150-44153, 44155-44158, 44210-44212
Glaucoma Screening:
Percentage of members 65 years of age or older, without a prior diagnosis of glaucoma or suspect, who received a glaucoma eye
exam by an eye care professional for early identification of glaucomatous conditions during the measurement year or the year prior
to the measurement year.
CPT Codes:
92002, 92004, 92012, 92014, 92081-92083, 92100, 92120, 92130, 92135, 92140, 99202-99205,
99213-99215, 99242-99245
HCPCS:
G0117, G0118, S0620, S0621
Care for Older Adults:
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
CPT Codes:
Medication Review – 90862, 99605, 99606
CPT II Codes:
Advanced Care Planning – 1157F, 1158F
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HCPCS:
Medication Review – 1159F, 1160F
Medication List – 1159F
Functional Status Assessment – 1170F
Pain Screening – 0521F, 1125F, 1126F
Advanced Care Planning - S0257
Utilization
Adolescent Well-Care Visits:
Percentage of members 12–21 years of age who had at least one comprehensive well care visit with a PCP or OB/GYN during the
measurement year.
ICD9-CM Diagnosis
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
CPT Codes
99383-99385, 99393-99395
Access/Availability of Care
Children & Adolescents Access to Primary Care Practitioners:
Percentage of members 12 months–19 years of age who had a visit with a PCP.
ICD9-CM Diagnosis
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395,
CPT Codes
99401-99404, 99411-99412, 99420, 99429
HCPCS
G0438, G0439
Annual Dental Visits:
Percentage of members 2–21 years of age who had at least one dental visit during the measurement year. (This measure applies
only if dental care is a covered benefit in the organization's Medicaid contract.)
Dental Visit Codes
70300, 70310, 70320, 70350, 70355
Adults’ Access to Preventive/Ambulatory Health Services:
Percentage of members 20 years of age and older who had an ambulatory or preventive care visit during the measurement year.
ICD9-CM Diagnosis:
V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Office/other outpatient services - 99201-99205, 99211-99215, 99241-99245
CPT Codes:
HCPCS:
Home services - 99341-99345, 99347-99350
Nursing facility care - 99304-99310, 99315, 99316, 99318
Domiciliary/rest home/custodial care services - 99324-99328, 99334-99337
Preventive medicine - 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429
Ophthalmology and optometry - 92002, 92004, 92012, 92014
G0344, G0402, G0438, G0439
Prenatal Care & Frequency of Ongoing Prenatal Care:
Prenatal Care - Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment.
Frequency of Ongoing Prenatal Care - The percentage of deliveries between November 6 of the year prior to the measurement year
and November 5 of the measurement year that had <21 percent, 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of
expected prenatal visits.
Updated: 10/11/2012
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ICD9-CM Diagnosis:
CPT Codes:
HCPCS:
640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3,
654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22-V23, V28
E/M – 99201-99205, 99211-99215, 99241-99245
OB Fetal Monitoring – 76801, 76805, 76811, 76813, 76815-76821, 76825-76828
OB Panel – 80055
TORCH - 86644
H1000-H1004
Postpartum Care
The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
ICD-9 CM Diagnosis
V24.1, V24.2, V25.1, V72.3, V76.2
57170, 58300, 59430, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 ,
CPT Codes
99501
HCPCS
G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
CPT II Codes
0503F
Respiratory Conditions
Use of Appropriate Medications for People with Asthma:
Percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and who
were appropriately prescribed medication during the measurement year.
ICD-9 CM Diagnosis
493.0, 493.1, 493.8, 493.9
FDA-Approved Asthma Medications
Antibody inhibitor
Inhaled steroid
combinations
Inhaled corticosteroids
Leukotriene modifiers
Mast cell stabilizers
Methylxanthines
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Omalizumab
Budesonide-formoterol
Fluticasone-salmeterol
Mometasone-formoterol
Beclomethasone
Budesonide
Flunisolide
Fluticasone CFC free
Mometasone
Montelukast
Zafirlukast
Cromolyn
Aminophylline
Theophylline
Medication Management for People with Asthma:
Percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were
dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
1. Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
2. Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
ICD9-CM Diagnosis
493.0, 493.1, 493.8, 493.9
Antibody inhibitor
Inhaled steroid
combinations
•
•
•
Omalizumab
Updated: 10/11/2012
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Methylxanthines
•
•
•
•
•
•
•
•
•
•
•
Beclomethasone
Budesonide
Flunisolide
Mometasone
Montelukast
Zafirlukast
Cromolyn
Aminophylline
Theophylline
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis:
Percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.
ICD9-CM Diagnosis:
466.0
Use of Spirometry testing in COPD:
Percentage of adults 40 and older newly diagnosed or newly active chronic obstructive pulmonary disease (COPD) who received
appropriate spirometry testing to confirm the diagnosis.
CPT Codes:
94010, 94014-94016, 94060, 94070, 94375, 94620
Pharmacotherapy Management of COPD Exacerbation:
Percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter on
or between January 1– November 30 of the measurement year and who were dispensed appropriate medications. Two rates are
reported:
1. Dispensed a systemic corticosteroid within 14 days of the event
2. Dispensed a bronchodilator within 30 days of the event
ICD9-CM Diagnosis:
491, 492, 496
CPT Codes:
99281-99285
Bronchodilators
• Albuterol-ipratropium
Anticholinergic agents
• Ipratropium
• Albuterol
• Budesonide-formoterol
• Fluticasone-salmeterol
Beta 2-agonists
• Formoterol
• Mometasone-formoterol
• Salmeterol
• Aminophylline
Methylxanthines
• Theophylline
Systemic Corticosteroids
• Betamethasone
• Dexamethasone
• Hydrocortisone
• Methylprednisolone
• Prednisolone
• Prednisone
• Triamcinolone
Updated: 10/11/2012
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Behavioral Health
Follow-Up After Hospitalization for Mental Illness:
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health
disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner.
ICD9-CM Diagnosis
295-299, 300.3, 300.4, 301, 308, 309, 311-314
Antidepressant Medication Management:
Percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and treated with
antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported:
1. Effective Acute Phase Treatment - Percentage of newly diagnosed and treated members who remained on an antidepressant
medication for at least 84 days (12 weeks)
2. Effective Continuation Phase Treatment - Percentage of newly diagnosed and treated members who remained on an
antidepressant medication for at least 180 days (6 months)
ICD9-CM Diagnosis:
296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311
Antidepressant Medications
• Phenelzine
Monoamine oxidase
• Selegiline
inhibitors
• Tranylcypromine
Phenylpiperazine
• Nefazodone
antidepressants
• Trazodone
Psychotherapeutic
• Amitriptyline-chlordiazepoxide
antidepressants
• Amitriptyline-perphenazine
SSNRI antidepressants
• Venlafaxine
• Citalopram
• Fluoxetine
SSRI antidepressants
• Paroxetine
• Sertraline
Tetracyclic
• Maprotiline
antidepressants
• Mirtazapine
Tricyclic
• Amitriptyline
antidepressants
• Amoxapine
• Clomipramine
• Desipramine
• Doxepin
• Imipramine
• Notriptyline
• Protriptyline
Miscellaneious
• Bupropion
antidepressants
Cardiovascular Conditions
Controlling High Blood Pressure:
Percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) on or before June 30 of the measurement
year and whose BP was adequately controlled (<140/90) during the measurement year.
CPT Codes:
99201-99205, 99211-99215, 99241-99245, 99384-99387, 99394-99397
Updated: 10/11/2012
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ICD9-CM Diagnosis:
CPT II Codes:
401
Systolic – 3074F (<130 mm Hg), 3075F (130-139 mm Hg), 3077F (≥140 mm Hg)
Diastolic – 3078F (<80 mm Hg), 3079F (80-89 mm Hg), 3080F (≥910 mm Hg)
Cholesterol Management for Patients with Cardiovascular Conditions:
Percentage of members 18–75 years of age who were discharged alive for 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 and the year prior to the measurement year, who had
each of the following during the measurement year.

LDL-C screening

LDL-C control (<100 mg/dl)
CPT Codes:
80061, 83700, 83701, 83704, 83721
CPT II Codes:
3048F, 3049F, 3050F
Persistence of Beta-Blocker Treatment After a Heart Attack:
Percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from
July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received
persistent beta-blocker treatment for six months after discharge.
ICD-CM Diagnosis:
410.x1
Beta Blockers
• Atenolol
Cardioselective beta• Betaxolol
blockers
• Bisoprolol
• Metoprolol
• Carteolol
• Carvedilol
• Labetalol
Noncardioselective beta• Nadolol
blockers
• Pindolol
• Propranolol
• Timolol
• Sotalol
• Atenolol-chlorthalidone
Antihypertensive
• Bisoprolol-hydrochlorothiazide
combinations
• Hydrochlorothiazide-propranolol
Updated: 10/11/2012
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Diabetes
Comprehensive Diabetes Care (CDC):
The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had each of the following:
• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• HbA1c control (<7.0%)
• Eye exam (retinal) performed by an eye care provider
• LDL-C screening
• LDL-C control (<100 mg/dL)
• Medical attention for nephropathy
• BP control (<140/80 mm Hg)
• BP control (<140/90 mm Hg)
*Additional exclusion criteria are required for this indicator. This indicator is reported only for the commercial and Medicaid product
lines. The exclusion criteria are: CABG or PCI, IVD, CHF, Prior MI, CRF, Dementia, Blindness, Amputation of lower extremity.
CPT Codes – 83036, 83037
HbA1C Testing
CPT II Codes – 3044F (<7.0%), 3045F (7.0 – 9.0%), 3046F (>9%)
LDL-C Screening
CPT Codes – 80061, 83700, 83701, 83704, 83721
CPT II Codes – 3048F (<100 mg/dl), 3049F (100-129 mg/dl), 3050F (≥130 mg/dl)
Nephropathy Screening
CPT Codes – 82042, 82043, 82044, 84156
CPT II Codes – 3060F, 3061F
Urine Macroalbumin
CPT Codes – 81000-81003, 81005
CPT II Codes – 3062F
Evidence of Treatment
for Nephropathy
ICD9-CM Diagnosis - 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0,
V45.1
CPT Codes - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320,
50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966,
90969, 90970, 90989, 90993, 90997, 90999, 99512
ACE/ARB Therapy
CPT II Codes:
Angiotensin converting
enzyme inhibitors
Angiotensin II inhibitors
Antihypertensive
combinations
4009F
• Benazepril
• Captopril
• Enalapril
• Lisinopril
• Losartan
• Benazepril-hydrochlorothiazide
• Captopril-hydrochlorothiazide
• Enalapril-hydrochlorothiazide
• Hydrochlorothiazide-lisinopril
• Hydrochlorothiazide-losartan
Updated: 10/11/2012
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G:\2012 HEDIS Toolkits\KY\NA019250_PRO_GDE_ENG_KY_06_12.docx
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HEDIS Quick Reference Guide for Adults
compliance with the HEDIS® 2012 Volume 2 Technical Specifications
Musculoskeletal Conditions
Use of Imaging Studies for Low Back Pain:
Percentage of members 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study within 28 days
of the 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,
ICD9-CM Diagnosis:
739.4, 846, 847.2
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.
CPT Codes:
76977, 77078-77083, 78350, 78351
HCPCS
G0130
FDA-Approved Osteoporosis Therapies
Description
Biphosphonates
•
Alendronate
•
Conjugated estrogens
•
Conjugated estrogens synthetic
Estrogens
•
Esterified estrogens
•
Estradiol
•
Estropipate
•
Conjugated estrogens-medroxy-progesterone
Sex Hormones
Combinations
•
Ethinyl estradiol-norethindrone
•
Calcitonin
Other agents
•
Raloxifene
•
Teriparatide
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis:
Percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one
ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).
ICD9-CM Diagnosis:
714.0, 714.1, 714.2, 714.81
DMARDs
5-Aminosalicylates
•
Sulfasalazine
Alkylating agents
•
Cyclophosphamide
Aminoquinolines
•
Hydroxychloroquine
Anti-rheumatics
•
Auranofin
•
Leflunomide
•
Methotrexate
Immunomodulators
•
Adalimumab
•
Golimumab
Immunosuppressive
•
Azathioprine
agents
• Cyclosporine
•
Mycophenolate
Tetracyclines
•
Minocycline
Updated: 10/11/2012
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Medication Management
Medication Reconciliation Post-Discharge:
Percentage of discharges from January 1 to December 1 of the measurement year for members 66 years of age and older for whom
medications were reconciled on or within 30 days of discharge.
CPT II Codes:
1111F
Annual Monitoring for Patients on Persistent Medications:
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.
CPT Codes:
Physiologic Monitoring Tests – 80047, 80048, 80050, 80051, 80053, 80069, 82565, 82575, 84132, 84520,
84525
Drug Serum Concentration Monitoring Tests – 80156, 80157, 80164, 80184, 80185, 80186
Diuretics
Inotropic agents
•
Digoxin
Antihypertensive
•
Amiloride-hydrochlorothiazide
combinations
•
Atenolol-chlorthalidone
•
Benazepril-hydrochlorothiazide
•
Bisoprolol-hydrochlorothiazide
•
Captopril-hydrochlorothiazide
•
Enalapril-hydrochlorothiazide
•
Hydrochlorothiazide-lisinopril
•
Hydrochlorothiazide-losartan
•
Hydrochlorothiazide-methyldopa
•
Hydrochlorothiazide-propranolol
•
Hydrochlorothiazide-spironolactone
•
Hydrochlorothiazide-triamterene
Loop diuretics
•
Bumetanide
•
Furosemide
Potassium-sparing
•
Spironolactone
diuretics
Thiazide Diuretics
•
Chlorothiazide
•
Chlorthalidone
•
Hydrochlorothiazide
•
Indapamide
•
Metolazone
Anticonvulsants
Barbiturates
•
Phenobarbital
Dibenzazepine
•
Carbamazepine
Hydantoin
•
Phenytoin
Miscellaneous
•
Divalproex sodium
•
Valproic acid
Updated: 10/11/2012
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Potentially Harmful Drug-Disease Interactions in the Elderly:
Percentage of members 65 years of age and older who have evidence of an underlying disease, condition of health concern and who
were dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis.
Falls - E880, E884, E885.9, E887, E888
ICD9-CM Diagnosis:
Psychosis - 290.11, 290.12, 290.20, 290.3, 290.41, 290.42, 290.8, 290.9, 293, 294.11, 295, 296.x4, 297, 298
Dementia - 290, 291.2, 292.82, 294.0, 294.1, 294.8, 331.0, 331.1, 331.82
Hip Fractures - 27230, 27232, 27235, 27236, 27238, 27240, 27244-27246, 27248, 27254, 27267-27269,
27767-27769
CPT Codes:
Chronic Renal Failure - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300,
50320, 50340, 50360, 50365, 50370, 50380, 90921, 90925, 90935, 90937, 90940, 90945, 90947, 9096090962, 90966, 90970, 90989, 90993, 90997, 90999, 99512
Tricyclic Antidepressants
Psychotherapeutic
•
Amitriptyline-chlordiazepoxide
combinations
•
Amitriptyline-perphenazine
Tricyclic
•
Amitriptyline
antidepressants
•
Amoxapine
•
Clomipramine
•
Doxepin
•
Imipramine
Antipsychotics and Sleep Agents
Miscellaneous
•
Clozapine
antipsychotic agents
•
Haloperidol
•
Loxapine
• Pimozide
• Quetiapine
•
Risperidone
Miscellaneous
•
Zolpidem
anxiolytics, sedatives
and hypnotics
Phenothiazine
•
Prochlorperazine
antipsychotics
• Chlorpromazine
• Fluphenazine
• Perphenazine
• Thioridazine
•
Trifluoperazine
Thioxanthenes
•
Thiothixene
Medications for Dementia
Cholinesterase
•
Donepezil
inhibitors
•
Rivastigmine
Miscellaneous central
•
Memantine
nervous system agents
Anticholinergic Agents
Anticholinergic agents
•
Meclizine
Anticholinergic anti•
Benztropine
Parkinson agents
•
Trihexyphenidyl
Anticholinergics/
•
Dicyclomine
Updated: 10/11/2012
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antispasmodics
Antihistamines
Skeletal muscle
relaxants
Upper respiratory
combinations
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hyoscyamine
Propantheline
Chlorpheniramine
Cyproheptadine
Diphenhydramine
Hydroxyzine hydrochloride
Hydroxyzine pamoate
Carisoprodol
Chlorzoxazone
Cyclobenzaprine
Methocarbamol
Brompheniramine/dextromethorphan
Chlorpheniramine/codeine/pseudoephedrine
Chlorpheniramine/dextromethorp/phenylephrine
Chlorpheniramine/dextromethorphan/PSE
Chlorpheniramine/hydrocodone/PSE
Codeine/phenylephrine/promethazine
Codeine-promethazine
Phenylephrine-promethazine
Urinary
•
Oxybutynin
antispasmodics
NSAIDs and Cox-2 Selective NSAIDs
Cox-2 inhibitors
•
Celecoxib
Nonsteroidal anti•
Diclofenac potassium
inflammatory agents
•
Diclofenac sodium
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Etodolac
Fenoprofen
Flurbiprofen
Ibuprofen
Indomethacin
Ketoprofen
Ketorolac
Meloxicam
Nabumetone
Naproxen
Naproxen sodium
Oxaprozin
Piroxicam
Sulindac
Tolmetin
Use of High Risk Medications in the Elderly:
Updated: 10/11/2012
46077
®
Percentage of members 65 years of age and older who received at least one high-risk medication.
Percentage of members 65 years of age and older who received at least two different high-risk medications.
High-Risk Medications
Antianxiety
•
Meprobamate
Analgesics
•
Ketorolac
Antihistamines
•
Cyproheptadine
•
Diphenhydramine
•
Hydroxyzine hydrochloride
• Hydroxyzine pamoate
• Phenylephrine-promethazine
•
Promethazine
Antipsychotic, typical
•
Thioridazine
Amphetamines
•
Amphetamine-dextroamphetamine
• Dexmethylphenidate
• Dextroamphetamine
•
Methylphenidate
Barbiturates
•
Phenobarbital
Long-acting
•
Amitriptyline-chlordiazepoxide
benzodiazepines
•
Chlordiazepoxide
•
Diazepam
Calcium channel
•
Nifedipine—short-acting only
blockers
Gastrointestinal anti•
Dicyclomine
spasmodics
•
Propantheline
Belladonna alkaloids
•
Atropine
•
Atropine-diphenoxylate
•
Hyoscyamine
•
Hyoscyamine/methenam/m-blue/phenyl salicyl
Skeletal muscle
•
Carisoprodol
relaxants
•
Chlorzoxazone
•
Cyclobenzaprine
•
Methocarbamol
Oral estrogens
•
Conjugated estrogen
•
Conjugated estrogen-medroxyprogesterone
•
Esterified estrogen
•
Estropipate
Oral hypoglycemic
•
Chlorpropamide
Narcotics
•
Naloxone-pentazocine
Vasodilators
•
Dipyridamole—short-acting only
•
Ergot mesyloid
Others (including
•
Methyltestosterone
androgens and
•
Nitrofurantoin macrocrystals
anabolic steroids,
•
Nitrofurantoin macrocrystals-monohydrate
thyroid drugs, urinary
•
Thyroid desiccated
anti-infectives)
Updated: 10/11/2012
46077
HEDIS® Quick Reference Guide for Pediatrics
®
Prevention and Screening
Lead Screening in Children:
Percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second
birthday.
CPT Codes
83655
nd
Childhood Immunizations by their 2 Birthday:
Percentage of children two years of age who had four DTaP, three IPV, one MMR, two H influenza type B, three hepatitis B, one
chickenpox vaccine (VZV), four pneumococcal conjugate, two hepatitis A, two or three rotavirus, and two influenza vaccines on or
before their second birthday.
DTap – 90698, 90700 90721, 90723
HepA - 90633
HepB – 90723, 90740, 90744, 90747, 90748
HIB – 90645, 90646, 90647, 90648, 90698, 90721, 90748
Influenza – 90655, 90657, 90661, 90662
IPV – 90698, 90713, 90723
MMR – 90707, 90710
CPT Codes
MR – 90708
Measles – 90705
Mumps – 90704
Rubella – 90706
Pneumo – 90669, 90670
Rotavirus (2 dose) – 90681 / (3 dose) - 90680
VZV – 90710, 90716
Immunizations for Adolescents:
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.
Diphtheria - 90719
Mening – 90733, 90734
CPT Codes
Td – 90714, 90718
Tdap – 90715
Tetanus – 90703
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents:
Percentage of members 3 –17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI
percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
*Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than
an absolute BMI value.
th
V85.51 - Body Mass Index, pediatric, less than 5 percentile for age
th
th
V85.52- Body Mass Index, pediatric, 5 percentile to less than 85 percentile for age
ICD9-CM
th
th
Diagnosis
V85.53- Body Mass Index, pediatric, 85 percentile to less than 95 percentile for age
th
V85.54- Body Mass Index, pediatric, greater than or equal to 95 percentile for age
Outpatient Visits – 99201-99205, 99211-99215, 99217-99220, 99411, 99412, 99241-99245, 99341-99345,
99347-99350
CPT Codes
Evaluations – 99420, 99455, 99456
Counseling – 99381-99387, 99391-99397, 99401-99404, 99429, 97802-97804
HCPCS
Nutritional Counseling - G0270, G0271, S9449, S9452, S9470
NA019251_PRO_GDE_ENG Internal Approval 06202012
Updated: 10/11/2012
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Physical Activity Counseling – S9451
Chlamydia Screening in Women:
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.
CPT Codes
87110, 87270, 87320, 87490, 87491, 87492, 87810
Cervical Cancer Screening:
Percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer during the
measurement year or the two years prior to the measurement year.
CPT Codes
88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175
HCPCS
G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
Exclusion Criteria
Women who had a total hysterectomy with no residual cervix are excluded.
51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260,
CPT Codes
58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-58554, 58570-58573,
58951, 58953, 58954, 58956, 59135
ICD-9 CM Diagnosis
618.5, V67.01, V76.47, V88.01, V88.03
Utilization
Well-Child Visits in the First 15 months of Life:
Percentage of members who turned 15 months old during the measurement year and who had 6 or more well-child visits with a
primary care provider during their first 15 months of life.
ICD9-CM Diagnosis
V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
CPT Codes
99381, 99382, 99391, 99392, 99432, 99461
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life:
Percentage of members who were three, four, five, or six years of age who received one or more well-child visits with a primary care
provider during the measurement year.
ICD9-CM Diagnosis
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
CPT Codes
99382, 99383, 99392, 99393
Adolescent Well-Care Visits:
Percentage of members 12 –21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN during the
measurement year.
ICD9-CM
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Diagnosis
CPT Codes
99383-99385, 99393-99395
Access/Availability of Care
Children & Adolescents Access to Primary Care Practitioners:
Percentage of members 12 months – 19 years of age who had a visit with a PCP.
ICD9-CM
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Diagnosis
99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401CPT Codes
99404, 99411-99412, 99420, 99429
Updated: 10/11/2012
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HCPCS
G0438, G0439
Annual Dental Visits:
Percentage of members 2–21 years of age who had at least one dental visit during the measurement year. (This measure applies
only if dental care is a covered benefit in the organization's Medicaid contract.)
Dental Visit Codes
70300, 70310, 70320, 70350, 70355
Prenatal Care & Frequency of Ongoing Prenatal Care:
Prenatal Care - Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment.
Frequency of Ongoing Prenatal Care - The percentage of deliveries between November 6 of the year prior to the measurement year
and November 5 of the measurement year that had <21 percent, 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of
expected prenatal visits.
ICD9-CM Diagnosis:
640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3,
654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22-V23, V28
E/M – 99201-99205, 99211-99215, 99241-99245
OB Fetal Monitoring – 76801, 76805, 76811, 76813, 76815-76821, 76825-76828
CPT Codes:
OB Panel – 80055
TORCH - 86644
HCPCS:
H1000-H1004
Postpartum Care
The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
ICD-9 CM Diagnosis
V24.1, V24.2, V25.1, V72.3, V76.2
57170, 58300, 59430, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175,
CPT Codes
99501
HCPCS
G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
CPT II Codes
0503F
Respiratory Conditions
Appropriate Testing for Children With Pharyngitis:
Percentage of children 2 –18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A
streptococcus (strep) test; 3 days before diagnosis, the day of diagnosis, or 3 days after diagnosis.
Strep Test Codes
87070, 87071, 87081, 87430, 87650-87652, 87880
Appropriate Treatment for Children with Upper Respiratory Infection:
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.
ICD9-CM Diagnosis
460, 465
Use of Appropriate Medications for People with Asthma:
Percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and who
were appropriately prescribed medication during the measurement year.
ICD9-CM Diagnosis
493.0, 493.1, 493.8, 493.9
Antibody inhibitor
Inhaled steroid
•
•
Omalizumab
Updated: 10/11/2012
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®
combinations
Methylxanthines
•
•
•
•
•
•
•
•
•
•
•
•
Beclomethasone
Budesonide
Flunisolide
Mometasone
Montelukast
Zafirlukast
Cromolyn
Aminophylline
Theophylline
Medication Management for People with Asthma:
Percentage of members 5– 64 years of age during the measurement year who were identified as having persistent asthma and
were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
1.
Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
2.
Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
ICD9-CM Diagnosis
493.0, 493.1, 493.8, 493.9
Antibody inhibitor
Inhaled steroid
combinations
Inhaled
corticosteroids
Methylxanthines
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Omalizumab
Beclomethasone
Budesonide
Flunisolide
Mometasone
Montelukast
Zafirlukast
Cromolyn
Aminophylline
Theophylline
Updated: 10/11/2012
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®
Diabetes
Comprehensive Diabetes Care (CDC):
The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had each of the following:
•
Hemoglobin A1c (HbA1c) testing
•
HbA1c poor control (>9.0%)
•
HbA1c control (<8.0%)
•
HbA1c control (<7.0%)
•
Eye exam (retinal) performed by an eye care provider
•
LDL-C screening
•
LDL-C control (<100 mg/dL)
•
Medical attention for nephropathy
•
BP control (<140/80 mm Hg)
•
BP control (<140/90 mm Hg)
*Additional exclusion criteria are required for this indicator. This indicator is reported only for the commercial and Medicaid product
lines. The exclusion criteria are: CABG or PCI, IVD, CHF, Prior MI, CRF, Dementia, Blindness, Amputation of lower extremity.
CPT Codes – 83036, 83037
HbA1C Testing
CPT II Codes – 3044F (<7.0%), 3045F (7.0 – 9.0%), 3046F (>9%)
LDL-C Screening
CPT Codes – 80061, 83700, 83701, 83704, 83721
CPT II Codes – 3048F (<100 mg/dl), 3049F (100-129 mg/dl), 3050F (≥130 mg/dl)
Nephropathy
Screening
CPT Codes – 82042, 82043, 82044, 84156
CPT II Codes – 3060F, 3061F
Urine
Macroalbumin
CPT Codes – 81000-81003, 81005
CPT II Codes – 3062F
Evidence of
Treatment for
Nephropathy
ICD9-CM Diagnosis - 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0, V45.1
CPT Codes - 36145, 36147, 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320,
50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966,
90969, 90970, 90989, 90993, 90997, 90999, 99512
ACE/ARB Therapy
CPT II Codes:
Angiotensin converting enzyme
inhibitors
Angiotensin II inhibitors
Antihypertensive combinations
4009F
•
•
•
•
•
•
•
•
•
•
Benazepril
Captopril
Enalapril
Lisinopril
Losartan
Benazepril-hydrochlorothiazide
Captopril-hydrochlorothiazide
Enalapril-hydrochlorothiazide
Hydrochlorothiazide-lisinopril
Hydrochlorothiazide-losartan
Updated: 10/11/2012
46079
HEDIS® Quick Reference Billing Guide
The following diagnosis and/or procedure codes are in compliance with
the HEDIS® 2012 Volume 2 Technical Specifications
Reimbursements of these codes may be different based on your contractual fee schedule.
Behavioral Health
Follow-Up After Hospitalization for Mental Illness:
Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health
disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner.
ICD9-CM
295-299, 300.3, 300.4, 301, 308, 309, 311-314
Diagnosis
Follow-Up Care for Children Prescribed ADHD Medications:
Percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up
care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed.
Two rates are reported.
Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD
medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.
Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory
prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in
the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
90804-90815, 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245,
CPT Codes
99341-99345, 99347-99350, 99383, 99384, 99393, 99394, 99401-99404, 99411, 99412, 99510
G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000,
HCPCS
H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485
ADHD Medications
CNS Stimulants
•
•
•
•
Amphetamine- dextroamphetamin
Dexmethylphenidate
Dextroamphetamine
Methylphenidate
Updated: 10/11/2012
46079
CLINICAL PRACTICE GUIDELINE FOR PROVIDERS:
ADULT PREVENTIVE HEALTH
HS-1018
Clinical Practice Guideline for Providers: Adult Preventive Health
The best practice recommendations detailed below represent services that are considered medically necessary by
WellCare for the prevention of certain diseases and medical conditions in adults. WellCare strongly recommends that all
members receive the necessary preventive services, leading to improved healthcare quality and outcomes.
Frequency of Physical Examination
All members should visit their physician on a regular basis. A baseline physical exam visit should occur for all new nonpregnant adult members regardless of age, within the first 90 days of enrollment. Pregnant members should be seen
within the first 14 days of enrollment. Recommendations for periodic health exam visits for asymptomatic adults are as
follows:
•
•
•
Ages: 18 to 39 years: Exam frequency: every 1 to 3 years (annual Pap smears are indicated for females
unless 3 consecutive normal smears, allowing pap smears every 3 years)
Ages 40 to 64 years: Exam Frequency: every 1 to 2 years based on risk factors
Ages 65 and Over: Exam frequency: every year
Screening
Frequency
•
18 and older
Age
Blood Pressure, Height, Body
Mass Index (BMI), Alcohol
Use
Annually, 18-21 years. After 21, every 1-2
years or per PCP recommendations
•
Male > 35 years or female > 45 years of
age or any adults age 20 or older at high
risk
Cholesterol
Every 5 years
(More frequent if elevated)
•
Male 35 – 65 years
Cholesterol
•
Female 45 - 65 years
Every 5 years
(More frequent if elevated)
•
Female 18 years of age and older who are
sexually active or pregnant (consider at age
12 if sexually active)
Female 40 years and older
50 years and older
50 years and older
Female > 65 years old, or > 60 years at
risk
Pap Smear and Chlamydia
Every 1-3 Years or per PCP’s
recommendations
Mammography
Colorectal
Hearing Screening
Osteoporosis (Bone Mass
Measurement)
Every 1-2 years
Periodically depending upon test
Periodically
Every two years or per PCP’s
recommendations
65 years and older, or younger for those
that have diabetes or other risk factors
Vision including a
Glaucoma or Diabetic Retinal
exam as needed
Every two years for routine exams or
Annual if Diabetic or other risk factors
•
•
•
•
•
Clinical Practice Guideline
page 1
Original Effective Date: 2/2008 Revised: 2/2010, 5/19/2011
47664
HS-1018
Immunization* (see attached schedule)
18 years and older, Tdap: Substitute 1-time dose of Tdap for Td then boost with Td
•
Tetanus-Diphtheria and acellular
every 10 years
pertussis (Td/Tdap)
All adults without evidence of immunity to varicella should receive 2 doses of single•
Varicella (VZV)
antigen varicella vaccine if not previously vaccinated or the second dose if they have
received only 1 dose,.
Adults born during or after 1957 should receive 1-2 doses
•
Measles, Mumps, Rubella
(MMR)
•
Pneumococcal polysaccharide
65 years of age and older, all adults who smoke or have certain chronic medical
nd
conditions – 1 dose may, need a 2 dose if identified at risk.
(PPSV)
All adults annually
•
Seasonal Influenza
All unvaccinated individual who anticipate close contact with an international adoptee
•
Hepatitis A Vaccine (HepA)
or those with certain high-risk behaviors.
Adults at risk, 18 years of age and older – 3 doses
•
Hepatitis B vaccine (HepB)
College freshmen living in dormitories not previously vaccinated with MCV and
•
Meningococcal conjugate
others at risk, 18 years of age and older – 1 dose. Meningococcal polysaccharide
vaccine (MCV)
vaccine) is preferred for adults aged > 56 years.
Human Papillomavirus (HPV)**
Zoster
Haemophilus Influenza type b
(Hib)
•
•
•
* For eligible members through 26 years of age (three dose series)
Age 60 and older 1 dose
For eligible members who are at high-risk and who have not previously received Hib
vaccine (1 dose)
Prevention
•
•
•
Discuss aspirin to prevent cardiovascular events.
 Men – 40 years and older periodically
 Women – 50 years and older periodically
Discuss the importance of preventive exams (Mammograms and Breast self-examination for women at high risk
and who have family history.)
Discuss prostate-specific antigen (PSA) test and rectal exam for men after 40 years old per PCP discretion.
Counseling
•
•
•
•
•
•
Calcium intake: 1,000mg/day (women age 18-50 years old), 1200-1500 mg/day (women >50 years).
Folic Acid: 0.4 mg/day (women of childbearing age) ; women who have had children with Neural Tube Defects
(NTD) should take 4 mg/day.
Breastfeeding: Women after childbirth.
Tobacco cessation, drug and alcohol use, STD’s and HIV, nutrition, physical activity, sun exposure, oral health,
and injury prevention.
Medication list.
Advance directives.
* Unless there is a medical reason not to get a specific vaccine
**Subject to individual state coverage.
page 2
47664
HS-1018
Recommended adult immunization schedule,
by vaccine and age group United States 2011
Vaccines that might be indicated for adults, based on medical
and other indications - United States, 2011
page 3
47664
HS-1018
References
Centers for Disease Control and Prevention. Recommended adult immunization schedule---United States, 2011. MMWR
2011;60(4). The recommended adult immunization schedule has been approved by the Advisory Committee on
Immunization Practices, the American Academy of Family Physicians, the American College of Obstetricians and
Gynecologists, and the American College of Physicians.
Guide to Clinical Preventive Services, 2007: Recommendations of the U.S. Preventive Services Task Force, 2007.
Press Release CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination June 29, 2006
Recommended Adult Immunization Schedule – United States, 2010
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) May 2001
Bone Health and Osteoporosis: A Report of the Surgeon General (2004)
Cleveland Clinic www.cchs.net/health/health-info Periodic Health Exams and Cancer Screening
ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice, April
2008.
page 4
47664
HS-1018
Legal Disclaimer: Clinical practice guidelines made available by WellCare are informational in nature and are not a substitute for the professional
medical judgment of treating physicians or other health care practitioners. These guidelines are based on information available at the time and may not
be updated with the most current information available at subsequent times.
Individuals should consult with their physician(s) regarding the
appropriateness of care or treatment options to meet their specific needs or medical condition. Disclosure of clinical practice guidelines is not a
guarantee of coverage. Members of WellCare health plans should consult their individual coverage documents for information regarding covered
benefits. WellCare does not offer medical advice or provide medical care, and therefore cannot guarantee any results or outcomes. WellCare does not
warrant or guarantee, and shall not be liable for any deficiencies in the information contained herein or for any inaccuracies or recommendations made
by independent third parties from whom any of the information contained herein was obtained.
The WellCare Group of Companies
Harmony Behavioral Health, Inc. ~ Harmony Behavioral Health of Florida, Inc. ~ Harmony Health Plan of Illinois, Inc.
HealthEase of Florida, Inc. ~ ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
WellCare Health Insurance of Illinois, Inc. ~ WellCare Health Insurance of New York, Inc. WellCare
Health Plans of New Jersey, Inc. ~ WellCare of Florida, Inc. ~ WellCare of Connecticut, Inc.
WellCare of Georgia, Inc. ~ WellCare of Kentucky, Inc. ~ WellCare of Louisiana, Inc. ~ WellCare of New York, Inc.
WellCare of Ohio, Inc. ~ WellCare of Texas, Inc. ~ WellCare Prescription Insurance, Inc.
Date
12/1/2011
5/19/2011
History and Revisions
• New template design approved by MPC.
• Approved by MPC.
page 5
47664
PEDIATRIC PREVENTIVE HEALTH CARE GUIDELINES FOR PROVIDERS
HS-1019
2011 Pediatric Preventive Health Care Guidelines for Providers
Copyright © 2008 by the American Academy of Pediatrics. Please see the following link for additional information concerning the AAP recommendations. http://brightfutures.aap.org/
Reference: American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008.
page 1
Original Effective Date: 2/2010 Revised: 10/2010, 5/2011
47668
HS-1019
Recommended immunization schedule for persons aged 0 through 6 years --- United States, 2011
(for those who fall behind or start late, see the catch-up schedule)
Reference: The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the Advisory Committee on
Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
Recommended immunization schedule for persons aged 7 through 18 years --- United States, 2011
(for those who fall behind or start late, see the schedule below and the catch-up schedule)
Reference: The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the Advisory Committee on
Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
page 2
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HS-1019
Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are
more than 1 month behind --- United States, 2011
PERSONS AGED 4 MONTHS THROUGH 6 YEARS
Vaccine
Hepatitis B
1
Minimum
Age for
Dose 1
Minimum Interval Between Doses
Dose 1 to Dose 2
Dose 2 to Dose 3
Birth
4 weeks
8 weeks
Dose 3 to Dose 4
Dose 4 to
Dose 5
6 months
6 months3
(and at least 16 weeks after first
dose)
Rotavirus
2
Diphtheria, Tetanus, Pertussis
3
Haemophilus influenzae type b
4
6 wks
4 weeks
4 weeks
6 wks
4 weeks
4 weeks
6 wks
4 weeks
4 weeks
2
4
8 weeks (as final dose)
if first dose administered at younger if current age is younger than 12
than age 12 months
months
4
This dose only necessary for
children aged 12 months
through 59 months who
received 3 doses before age
12 months
if first dose administered at age 12-- if current age is 12 months or older
14 months
and first dose administered at
younger than age 12 months and
second dose administered at younger
No further doses needed
than 15 months
if first dose administered at age 15
months or older
if previous dose administered at age
15 months or older
page 3
47668
HS-1019
Pneumococcal
5
6 wks
4 weeks
4 weeks
if first dose administered at younger if current age is younger than 12
than age 12 months
months
8 weeks (as final dose for healthy 8 weeks
children)
(as final dose for healthy children)
if first dose administered at age 12
months or older or current age 24
through 59 months
for healthy children if first dose
administered at age 24 months or
older
Inactivated Poliovirus
6
Measles,Mumps, Rubella
Varicella
7
8
Hepatitis A
9
6 wks
4 weeks
12 mos
4 weeks
12 mos
3 months
12 mos
6 months
This dose only necessary for
children aged 12 months
through 59 months who
received 3 doses before age
12 months or for high-risk
children who received 3 doses
at any age
if current age is 12 months or older
for healthy children if previous dose
administered at age 24 months or
older
4 weeks
6 months
4 weeks
6 months
if first dose administered at younger
than age 12 months
if first dose administered at
younger than age 12 months
PERSONS AGED 7 THROUGH 18 YEARS
Tetanus,Diphtheria/
10
Tetanus,Diphtheria,Pertussis
7 yrs
10
4 weeks
6 months
if first dose administered at 12
months or older
page 4
47668
HS-1019
Human Papillomavirus
11
11
9 yrs
Routine dosing intervals are recommended
Hepatitis A
9
12 mos
6 months
Hepatitis B
1
Birth
4 weeks
8 weeks
(and at least 16 weeks after first
dose)
Inactivated Poliovirus
6
Measles,Mumps, Rubella
Varicella
7
8
6 wks
4 weeks
12 mos
4 weeks
12 mos
3 months
4 weeks
6 months
if person is younger than age 13
years
4 weeks
if person is aged 13 years or older
For more information on Pediatric Immunization schedules, please click here: http://www.cdc.gov/vaccines/recs/schedules/default.htm
References
Centers for Disease Control and Prevention. Recommended childhood immunization schedule---United States, 2011. MMWR 2011;60(4).
The recommended immunization schedules for persons aged 0 through 18 years and the catch-up immunization schedule for 2009 have been approved by the
Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
page 5
47668
HS-1019
Legal Disclaimer: Clinical practice guidelines made available by WellCare are informational in nature and are not a substitute for the professional medical judgment of treating physicians or other health
care practitioners. These guidelines are based on information available at the time and may not be updated with the most current information available at subsequent times. Individuals should consult
with their physician(s) regarding the appropriateness of care or treatment options to meet their specific needs or medical condition. Disclosure of clinical practice guidelines is not a guarantee of coverage.
Members of WellCare health plans should consult their individual coverage documents for information regarding covered benefits. WellCare does not offer medical advice or provide medical care, and
therefore cannot guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for any deficiencies in the information contained herein or for any inaccuracies or
recommendations made by independent third parties from whom any of the information contained herein was obtained.
The WellCare Group of Companies
Harmony Behavioral Health, Inc. ~ Harmony Behavioral Health of Florida, Inc. ~ Harmony Health Plan of Illinois, Inc.
HealthEase of Florida, Inc. ~ ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
WellCare Health Insurance of Illinois, Inc. ~ WellCare Health Insurance of New York, Inc. WellCare
Health Plans of New Jersey, Inc. ~ WellCare of Florida, Inc. ~ WellCare of Connecticut, Inc.
WellCare of Georgia, Inc. ~ WellCare of Kentucky, Inc. ~ WellCare of Louisiana, Inc. ~ WellCare of New York, Inc.
WellCare of Ohio, Inc. ~ WellCare of Texas, Inc. ~ WellCare Prescription Insurance, Inc.
Date
12/1/2011
5/2011
History and Revisions
•New template design approved by MPC.
•Approved by MPC.
page 6
47668
HEDIS Guide
ADULT QUICK TIPS
Submit consistent, detailed claims to help reduce medical record
review in your offices. Include all existing conditions on the claim
at the time of each visit.
Schedule regular checkups and/or blood work for members who
are on long term medications.
Assess member compliance/adherence to long-term medication
therapy.
Document in your medical record all the procedures done by
other physicians, including the date performed and the result of
the test. Include physician’s name and specialty type (i.e. GYN).
Men and Women’s Preventive Health Visit: One annual
preventive health visit.
CPT Codes: Ages 18–39: 99385, Ages 40–64: 99386,
Ages 65+: 99387
• Cervical Cancer Screening: Women ages 21–64 years
should have an exam every 1-3 years (annual Pap
smears are indicated for females unless 3 consecutive
normal Pap smears, then may decrease to every 3
years). Sample must be sent to lab vendor for analysis.
Exam can be done by PCP.
• Chlamydia Screening: Sexually active women ages
16–24 years should be tested with either a urine analysis
or Pap smear. Sample must be sent to lab vendor for
analysis.
• Breast Cancer Screening: Women ages 40–69 years
should be referred for a Screening Mammogram at least
every 2 years.
• Osteoporosis Management: Women ages 67+ years,
who have had a fracture need a Bone Mineral Density
Test or a prescription for appropriate osteoporosis
treatment within 6 months of the fracture.
Referrals for Adult Men and Women:
Colorectal Cancer Screening: Ages 50–75 years should
have an annual FOBT. Samples sent to lab vendor for
analysis, or refer for a Sigmoidoscopy or Colonoscopy.
Glaucoma Screening: Ages 65+ years, or younger for
those that have diabetes, or other risk factors by an
optometrist or ophthalmologist, at least every other year.
Body Mass Index (BMI): To be calculated and
documented at every visit.
Please add the following Dx codes to your claim:
Adult BMI values:
o Less than 19: V85.0
o 19 to 24: V85.1
o 25.0 to 29.9: V85.21 - V85.25
o 30.0 to 39.9: V85.30 – V85.39
o 40.0 to 49.9: V85.41 – V85.42
o 50.0 to 59.9: V85.43
o 60.0 to 69.9: V85.44
o 70+: V85.45
If dispensing an antibiotic please submit an appropriate diagnosis
to substantiate reason for prescription (i.e. Secondary infection
such as sinusitis or otitis media).
Tobacco Cessation: For active tobacco users, counsel
regarding Tobacco Cessation Strategies and Medications.
CPT Codes: 99406, 99407
Source: HEDIS® 2012 Volume 2 Technical Specifications.
The guidelines above are HEDIS measures and should not take the
place of clinical practice guidelines.
GA019209_PRO_GDE_ENG State Approved MMDDYYYY
ADULT QUICK TIPS
Care of Older Adults: Ages 66+ years, an annual
assessment of the following:
• Advance Care Planning: Advanced directives, living
wills. CPT II Code: 1157F
• Medication Review and List of Medications: Must
review medications and have a list of medications in the
medical record with the same date of service as the
review of the medications.
o Med. Review CPT Code: 90862 AND
o Medication List CPT II Code: 1159F
• Functional Status Assessment: Documentation of
IADLs, cognitive status, ambulation status, sensory
ability. CPT II Code: 1170F
• Pain Screening: Notation of a comprehensive pain
assessment and treatment plan or notation of no pain and
documentation of any interventions to alleviate the pain.
CPT II Code: 0521F
Medication Reconciliation Post-Discharge: Ages 66+
years, who have had an inpatient admission should be seen
within 30 days of discharge and their medications should be
reviewed, including a list of the current medications.
CPT II Code: 1111F
High Risk Medication Management: Please review
members’ medication list for “high risk” medications
according to CMS requirements and adjust accordingly.
Appropriate Testing for Persistent Medications:
Members on ACE/ARBs, digoxin or diuretics should have a
serum K+ AND a serum creatinine or a BUN annually.
Members on anticonvulsant therapy should have a serum
drug level annually.
Comprehensive Diabetes Care: Annual screenings for
diabetic members. Samples should be sent to lab vendor
for analysis. If labs done in the office, please use the
following codes on claims for results:
• HbA1c Results: HbA1c is <7%: 3044F; HbA1c is 7%9%: 3045F; HbA1c is >9%: 3046F
• LDL-C Results: LDL-C <100: 3048F; LDL-C 100–129:
3049F; LDL-C >130: 3050F
• Nephropathy Screening: CPT II Codes: 3060F, 3061F
• Annual Dilated Retinal Eye Exam: By optometrist or
ophthalmologist
• Blood Pressure:
o Systolic BP <130: 3074F; Systolic BP 130–139: 3075F;
Systolic BP >140: 3077F
o Diastolic BP <80: 3078F; Diastolic BP 80–89: 3079F;
Diastolic BP >90: 3080F
Use of Appropriate Medications for People with
Asthma:
Ages 5–64 years diagnosed with persistent asthma should
be on appropriate medications for control. Ensure members
are filling prescriptions regularly.
• Appropriate Medications: Anti-asthmatic combinations,
antibody inhibitors, inhaled steroid combinations, inhaled
corticosteroids, leukotriene modifiers, mast cell
stabilizers, methylxanthines.
• Continued medication use: Please ensure members
refill medications for long-term control of asthma.
HEDIS® is a registered trademark of the National Committee for Quality
Assurance (NCQA). Reimbursement for these services will be in
accordance with the terms and conditions of your agreement.
© WellCare 2012 GA_05_12
45930
HEDIS Guide
PEDIATRIC QUICK TIPS
Submit consistent, detailed claims to help to reduce medical
record review in your offices. Include all existing conditions on the
claim, at the time of each visit. Every time you see a member is an
opportunity for preventive care as well as sick care.
Schedule regular check-ups and/or blood work for members who
are on long term medications.
Assess member compliance/adherence to long term medication
therapy (i.e. Asthma medications.)
Document all procedures done by other physicians with a date
and result.
All Well-Child / Well Care Visits must include:
• A comprehensive health and developmental history:
physical health, mental health (including social, emotional
and behavioral issues), development and nutrition.
• A comprehensive unclothed physical exam:
measurements, height/weight, head circumference,
general appearance, head/neck/eyes/ears,
cardiovascular, respiratory, gastrointestinal, neurological
evaluation, reproductive systems and breast,
musculoskeletal, lymphatic system, integument, speech
patterns, orientation and mental alertness, parent and
child interaction/behavior.
• Health education/anticipatory guidance, oral health, infant
care, parent interaction, injury/illness prevention and
community resources.
Well-Child Visits (0–15 months): Children should be seen
6+ times on or before their 15 month birthday.
CPT Codes: Ages 0–12 months: 99391, Ages 1–4: 99392
Childhood Immunizations: Should be given to members
according to AAP guidelines and completed by the 2nd
birthday. Combination vaccine CPT codes should be used
when applicable.
o DTP: 90700
o IPV: 90713
o HIB: 90645
o HEP B: 90744
o VZV: 90716
o MMR: 90707
o HEP A: 90633
o Pneumococcal conjugate: 90669 (7 valent), 90607
(13 valent)
o Influenza: 90655
o Rotovirus: Two doses: 90681; Three doses: 90680
Lead Screening: One completed by 2nd birthday. Sample
sent to lab vendor for analysis. CPT: 83655
Well-Child Visits (3–6 years): Annual visit for children.
CPT Codes: Ages 1–4: 99392, Ages 5–11: 99393
Adolescent Well-Care Visits (12–21 years): Annual visit
for members. Remember to notate discussions around
tobacco use, drugs and alcohol, sexual activity, physical
activity, tobacco cessation and depression in the medical
record. Consider Pelvic exam, Pap Smear and Chlamydia
testing at age 12 years, if sexually active
CPT Codes: Ages 12–17: 99394, Ages 18–39: 99395
Source: HEDIS® 2012 Volume 2 Technical Specifications.
The guidelines above are HEDIS measures and should not take the place
of clinical practice guidelines.
GA019209_PRO_GDE_ENG State Approved MMDDYYYY
PEDIATRIC QUICK TIPS
Immunizations for Adolescents: Members 13 years of
age
o One dose of Meningococcal vaccine:
CPT Code: 90733
o One Tdap, or Td: CPT Code: 90715
o Females only: Three doses of HPV by 13 th birthday:
CPT Code: 90649
Weight Assessment & Counseling for Nutrition and
Physical Activity for Children/Adolescents (for all
children 3–21 years):
• Measure BMI Percentile or Value depending on age:
Adult BMI Value (Ages 20+ years):
o Less than 19: V85.0
o 19 to 24: V85.1
o 25.0 to 29.9: V85.21 - V85.25
o 30.0 to 39.9: V85.30 – V85.39
o 40.0 to 49.9: V85.41 – V85.42
o 50.0 to 59.9: V85.43
o 60.0 to 69.9: V85.44
o 70+: V85.45
Pediatric BMI (Ages 2–20 years):
o Less than 5th percentile for age: V85.51
o 5th percentile to less than 85th percentile for age:
V85.52
o 85th percentile to less than 95th percentile for age:
V85.53
o greater than or equal to 95th percentile for age:
V85.54
• Nutritional Counseling: Dx Code: V65.3
• Physical Activity: Dx Code: V65.41
Chlamydia Screening: Sexually active females aged 16–
24 years should be tested with either a urine analysis or
Pap. Samples sent to lab vendor for analysis.
Strep Test: Rapid Strep Test-throat culture samples sent to
lab vendor for analysis.
• If dispensing an antibiotic please submit a diagnosis to
substantiate reason for prescription. CPT Code: 87880
Use of Appropriate Medications for People with
Asthma:
Ages 5–64 years diagnosed with asthma should be on
appropriate medications for control. Ensure members are
filling prescriptions regularly.
• Appropriate Medications: Anti-asthmatic combinations,
antibody inhibitors, inhaled steroid combinations, inhaled
corticosteroids, leukotriene modifiers, mast cell
stabilizers, methylxanthines.
• Continued medication use: Please ensure members
refill medications for long-term control of asthma.
Dental Visit: Ages 2–21 years, Annual dental visit.
HEDIS® is a registered trademark of the National Committee for Quality
Assurance (NCQA). Reimbursement for these services will be in
accordance with the terms and conditions of your agreement.
© WellCare 2012 GA_05_12
45930
Documentation Standards for Medical Record Requirements
This document outlines the required medical record documentation needed to demonstrate compliance
with State required medical record documentation standards.
Kentucky Medical Record Requirements
The medical record organization and documentation shall, at a minimum, require the following:
• Member identification information on each page;
• Personal/biographical data, including:
o Date of birth
o Age
o Gender
o Marital status for adults
o Race or ethnicity
o Mailing address
o Home and work addresses as applicable
o Home and work telephone numbers as applicable
o Employer, if applicable
o School name for children
o Name and telephone information for emergency contact(s)
o Consent forms
o Language spoken
o Guardianship/parent information for children
• Date of data entry and date of encounter;
• Provider identification by name;
• Allergies, adverse reactions and any known allergies are noted in a prominent location in the
record;
• Past medical history, including serious accidents, operations, illnesses. For children, past medical
history includes prenatal care and birth information, operations, and childhood illnesses (i.e.
documentation of chickenpox);
• Identification of current problems;
• The consultation, laboratory, and radiology reports filed in the medical record shall contain the
ordering provider’s initials or other documentation indicating review;
• Behavioral health summary reports as applicable, initial evaluation and routine follow up
consultations;
• Documentation of immunizations pursuant to 902 KAR 2:060;
• Identification and history of nicotine, alcohol use or substance abuse;
• Documentation of reportable diseases and conditions to the local health department serving the
jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR
2:020 as applicable;
• Follow-up visits provided secondary to reports of emergency room care as applicable;
• Hospital discharge summaries as applicable;
• Advanced medical directives for adults. PCPs have the responsibility to discuss advance medical
directives with adult members at the first medical appointment and chart that discussion in the
medical record of the member;
• All written denials of service and the reason for the denial as applicable;
• Signature of the provider conducting the encounter; and
• Record legibility to at least a peer of the writer. Records judged illegible by one reviewer are
evaluated by another reviewer.
© WellCare 2012 KY_07_12
47807
In addition, a member’s medical record shall include the following minimal detail for individual clinical
encounters:
• History and physical examination for presenting complaints containing relevant psychological and
social conditions affecting the member’s medical/behavioral health, including mental health, and
substance abuse status;
• Unresolved problems, referrals and results from diagnostic tests including results and/or status of
preventive screening services (i.e. EPSDT) are addressed from previous visits; and
• Plan of treatment that includes:
o Medication history, medications prescribed, including the strength, amount, directions for
use and refills;
o Therapies and other prescribed regimen; and
o Follow-up plans including consultation and referrals and directions, including time to
return.
© WellCare 2012 KY_07_12
47807

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