QUICK REFERENCE GUIDE FOR HEDIS/QARR CHILDREN AND ADULT MEASURES
*Listed are commonly used codes that are acceptable for HEDIS/QARR reporting but not limited to:
MEASURES COMPREHENSIVE DIABETES REQUIRED SERVICE Hemoglobin A1c testing annually (Goal < 7.0 %) LDL-C Screening annually (Goal <100 mg/dL) Retinal or Dilated eye exam annually Nephropathy Screening Test annually (microalbumin, macroalbuminuria, 24hr urine) Blood Pressure Control (Goal <130/80 mm Hg) CHOLESTEROL MANAGEMENT LDL-C (Goal < 100 mg/dl) Screening for members 18-75 yrs old cardiovascular condition (AMI, CABG, PTCA, IVD) Ages 21-64 years PAP should be done at least once every 3 years Ages 16-25 who are sexually active, use contraceptives, or had a sonogram Prenatal care should be done during the first trimester or within 42 days of enrollment Frequency of prenatal care. Visits every 4 weeks for the first 28 weeks of pregnancy, every 2-3 weeks until 36 weeks of gestation and weekly thereafter. ACOG recommends 14 visits for 40 weeks gestation. ACCEPTABLE CPT CODES 83036, 83037 80061, 83700, 83701, 83704, 83716, 83721 Primarily medical record review 82042, 82043, 82044, 84156
Primarily medical record review 80061, 83700, 83701, 83704, 83715, 83716, 83721
CERVICAL CANCER SCREENING
88141-88143, 88147-88148, 88150, 88152-88155, 88164-88167, 88174-88175 87110, 87270, 87320, 87490, 87491, 87492, 87810 99201-99205, 99211-99215, 99241-99245, 99271-99275
CHLAMYDIA SCREENING PRENATAL POSTPARTUM
NY HEDIS QRC 8/08
MEASURES PRENATAL POSTPARTUM (cont’d)
REQUIRED SERVICE Postpartum care must be on or between 21st and 56th days after delivery. Ages 42-69. Mammogram should be done 1-2 years Member 18 or older diagnosed with major depression. Three outpatient follow-up visits within 84 days (12 weeks) after the prescription of antidepressant medication. One of the three visits can be via telephone. Member must remain on medication the entire 84 days (12 weeks) and continue for at least 180 days (6 months)
ACCEPTABLE CPT CODES 59430, 57170, 58300, 88141-88145, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 76083, 76090-76092, 77055-77057 Face to face visit CPT CODES 99221-99223, 99231- 99233, 99238-99239, 99251-99255, 99261-99263 Telephone visit CPT CODES 99371-99373
BREAST CANCER SCREENING ANTIDEPRESSANT MEDICATION MANAGEMENT
USE OF APPROPRIATE MEDICATION FOR PEOPLE WITH ASTHMA
Member identified as having persistent asthma (ages 5-56) and was prescribed asthma medication
ASTHMA ICD-9-CM DIAGNOSIS CODE 493 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341,-99345, 99347-99350, 99382-99386, 99392-99396, 99401-99404, 99411,99412, 99420, 99429,99499
CHILDREN WITH PHARYNGITIS CHILDHOOD IMMUNIZATIONS
Children ages 2-18 years of age and received a group A streptococcus (strep) test with a diagnosis of pharyngitis Complete vaccination on or before the child’s 2nd birthday
87070,87071,87081,87430, 87650-87652, 87880 DTaP 90698, 90700, 90721, 90723 Diphtheria and Tetanus 90702 Diphtheria 90719, Tetanus 90703 IPV 90698,90713, 90723 MMR 90707, 90710 Measles and Rubella 90708 Measles 90705, Mumps 90704 Rubella 90706, HiB 90645-90648, 90698, 90721, 90748 Hepatitis B 90723, 90740, 90744, 90747, 90748, VZV 90710, 90716 Pneumococcal conjugate 90669 83655
LEAD
One capillary or venous blood test on or before the child’s 2nd birthday
MEASURES WELL CHILD VISIT 0-15 MONTHS WELL CHILD VISIT 3-6 YRS ADOLESCENT WELL-CARE USE OF APPROPRIATE MEDICATION FOR PEOPLE WITH ASTHMA
REQUIRED SERVICE Six or more well visits from birth to 15 months One or more well child (3-6 years) visit in one year One or more adolescent well care visit (12-21 years) in one year Member identified as having persistent asthma (ages 5-56) and was prescribed asthma medication
ACCEPTABLE CPT CODES 99381, 99382, 99391, 99392, 99432, 99382, 99383, 99392, 99393 99383-99385, 99393-99395 ASTHMA ICD-9-CM DIAGNOSIS CODE 493 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99382-99386, 99392-99396, 99401-99404, 99411,99412, 99420, 99429,99499
APPROPRIATE TREATMENT FOR CHILDREN WITH UPPER RESPIRATORY INFECTION
Children ages 3 month to 18 year of age given a diagnosis of upper respiratory infection and were not dispensed an antibiotic prescription
ACUTE NASOPHARYGITIS ICD-9-CM DIAGNOSIS CODE 460 URI ICD-9-CM DIAGNOSIS CODE 465 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99381-99385, 99391-99395, 99401-99404, 99411, 99412, 99420, 99429, 99499
FOLLOW UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION
Children ages 6-12 prescribed with ADHD medication should have one follow-up visit in the first 30 days then 2 follow up visits within 2 to 9 months of prescription start date. One visit can be a telephone visit
90804-90815, 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383, 99384, 99393, 99394, 99401-99404, 99411, 99412, 99510, 99801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99251,-99255, 99261-99263