Quality Measures & Standards Booklet for Physicians

Quality Measures & Standards Booklet

Guidelines for Setting Select Goals for 2023

1. For each metric, prior CI year performance is obtained as close as possible to the close of that year.

2. The prior year performance will be compared with the prior year goal and HEDIS benchmarks (mean, P50, P75 and P90).

3. If prior year performance meets or exceeds HEDIS P90, the new goal will be set at HEDIS P90.

4. If prior year performance falls below P75 (below P50 for new MHN measures), the new goal will be to improve prior year performance by 5% (unless the situation in #5 below exists).

5. If the 5% improvement calculation results in a new goal that is less than the prior year goal, the prior year goal shall be maintained.

Table of Contents

Commercial ACO Focus

1.1

2.3

2.4

2.5

01 Pediatric Care

Well-Child Exams in the First 30 Months of Life (W30)

What Is the Measure?

This measure looks at the percentage of enrolled patients who had six or more Well Care Visits on different dates of service with a PCP during their first 30 months of life.

Patients must turn 30 months old during the measurement year. The Well Care Visit must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child.

Documentation

Documentation in the patient’s medical record must include evidence of all of the following:

• Health history

• Both a physical and mental developmental history

• Physical exam

• Health education/anticipatory guidance

Eligible Codes

1.1

How to Improve Score

• Review care gap reports and attribution lists and outreach to the patients’ parents/guardians to schedule their Well Care Visit.

• Integrate screening reminders into the EHR.

• Conduct or schedule Well Care Visits when patients present themselves for illness, or other events such as school physicals, accidental injuries or colds.

• Offer evening hours to improve patient access.

Pediatric Care: Well-Child Exams in the First 30 Months of Life (W30)

Child & Adolescent Well Care Visits (WCV)

What Is the Measure?

This measure looks at the percentage of children 3 to 11 years of age and adolescents 12 to 21 years of age who have had at least one comprehensive Well Care Visit with a PCP or an OB/GYN practitioner during the measurement year.

Documentation

Documentation in the patient’s medical record must include evidence of all of the following:

• Health history

• Both a physical and mental developmental history

• Physical exam

• Health education/anticipatory guidance

Eligible Codes

Well Care Visit

Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9

How to Improve Score

• Review care gap reports and attribution lists and outreach to the patients’ parents/guardians to schedule their Well Care Visit.

• Conduct or schedule Well Care Visits when patients present themselves for illness, or other events such as school physicals, accidental injuries or colds.

• Offer evening hours to improve patient access.

• Integrate screening reminders into the EHRs.

99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461

02 Chronic Disease Management

Breast Cancer Screening (BCS)

What Is the Measure?

This measure looks at the percentage of women 50 to 74 years of age who had a mammography study performed any time during the measurement period (October 1st two years prior to measurement year through December 31st of measurement year).

Eligible Codes

2.1

2.2

2.3

2.4

2.5

Exclusions

• Bilateral mastectomy or unilateral mastectomy with a bilateral modifier at any time during their history through the end of the measurement year

• Hospice care

• Palliative care during the measurement year

• Members 66 years of age and older as of December 31st of the measurement year, with frailty and advanced illness (must meet both frailty and advanced illness for exclusion)

• Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period and a dispensed medication for dementia (cholinesterase inhibitors or central nervous system agents) during the measurement period or the year prior to the measurement period

History of breast cancer without a bilateral mastectomy is not an exclusion for this measure. Patient refusal is not an exclusion for this measure.

How to Improve Score

• Discuss the importance of breast cancer screening and ensure your patients are up to date with their annual mammogram.

• Document the screening for breast cancer in the medical record. The medical record must indicate specific date and result of the screening. MRIs, ultrasounds, or biopsies do not count in this measure.

• Document medical and surgical history of the breast in the medical record, including dates.

• Submit the appropriate diagnosis and procedure codes for the services rendered.

• Submit claims and encounter data in an accurate and timely manner.

For Broward Guardian Providers

• It is required that you document the date and results of the most recent mammogram.

2.6

2.7

2.8

2.9

2.10

Cervical Cancer Screening (CCS)

What Is the Measure?

This measure looks at the percentage of women 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:

• Women age 21 to 64 years of age who had cervical cytology performed every 3 years (measurement year through 2 years prior to measurement year)

• Women age 30 to 64 who had cervical cytology and human papillomavirus (HPV) co-testing performed every 5 years (measurement year through 4 years prior to measurement year)

Documentation

Biopsies are not valid because they are diagnostic and therapeutic; they are not appropriate for primary cervical cancer screening.

Eligible Codes

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

• History of hysterectomy with no residual cervix; documentation may state “complete,” “total,” or “radical” abdominal or vaginal hysterectomy

• Cervical agenesis or acquired absence of cervix

• Hospice care

Hysterectomy alone does not meet exclusion criteria because it is not sufficient documentation that the cervix was removed. Patient refusal does not exclude patient from the measure.

How to Improve Score

• Review care gap reports and outreach to eligible patients.

• Document any exclusion criteria completely and appropriately.

• Discuss importance of cervical cancer screening with patients.

2.9

2.10

Chlamydia Screening in Women (CHL)

What Is the Measure?

This measure looks at the percentage of sexually active women 16 to 24 years of age who had at least one urine test for chlamydia during the measurement year

Documentation

Methods for identifying sexually active women

• Pharmacy data

• Medical claims/encounter data

Eligible Codes

How to Improve Score

• Review care gap reports and attribution lists to facilitate patient outreach for wellness visits and screenings.

• Integrate screening reminders into the EHR.

• Ensure proper billing codes are submitted via claims.

• Emphasize importance of screening to prevent infections and lifelong complications.

Colorectal Cancer Screening (COL)

What Is the Measure?

This measure looks at the percentage of enrolled patients 45 to 75 years of age who have had appropriate screening for colorectal cancer.

Documentation

Documentation in the medical record must include a note indicating the date the colorectal cancer screening was performed. A result is required. This ensures that the screening was performed and not just ordered. Patientreported colorectal cancer screenings are acceptable if the screening is documented in the patient’s medical history.

Eligible Codes

The patient must have undergone one of the following screening procedures during the indicated dates in order to satisfy this measure:

Exclusions

• Hospice care

• History of a total colectomy

• Living in long-term institutional settings

Patient refusal does not exclude patient from the measure.

Common Errors

• Not report a result

How to Improve Score

• Integrate screening reminders into EHRs

• Review care gap reports and outreach to eligible patients

• Educate patients regarding benefits of screening (i.e., early detection)

• Discuss available options with patient, including less invasive options (e.g., FOBT, Cologuard)

• Offer assistance with scheduling screening procedures

Diabetes Care – HbA1c Control (<8.0) (HBD)

What Is the Measure?

The measure assesses the percentage of members 18 to 75 years of age with a diagnosis of diabetes (type 1 and type 2) whose hemoglobin A1c (HbA1c) was below 8 during the measurement year.

Documentation

Evidence of an HbA1c test and the most recent HbA1C level performed during the measurement year. At a minimum, documentation in the medical record must include a note indicating the date when the HbA1c test was performed AND the result.

*This is an inverse measure; the goal is to be less than 8.0% (meets all measures).

Eligible Codes

Exclusions

Patients are excluded from the measure if they meet the following criteria:

• Hospice care

• Palliative care anytime during the measurement year

• Medicare patients 66 years of age and older as of December 31st of the measurement year who are either enrolled in an institutional special needs plan (I-SNP) or living long-term in an institution

• Patients 66 years of age and older as of December 31st of the measurement year who meet both frailty and advanced illness criteria

• Diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes during measurement year or the year prior to measurement year and do not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year

How to Improve Score

• Frequency of visits should depend on level of A1c control; patients with elevated A1c levels need to be seen more frequently

• Monitor diabetic patients for changes and schedule follow-up testing

• For point-of-care HbA1c testing, document the date of the in-office test with the result; the office must submit the CPT code for the test performed in addition to CPTII codes to report A1C result value

Diabetes Care – Eye Exam (EED)

What Is the Measure?

This measure looks at the percentage of enrolled members 18-75 years of age with type 1 or type 2 diabetes who had a comprehensive eye exam to screen/monitor for diabetic retinal disease using either of the following criteria:

• A retinal or dilated eye exam in the current measurement year

• A negative retinal or dilated eye exam (negative for retinopathy) in the year prior to measurement year

• Bilateral eye enucleation any time during the patient’s history through December 31 of the measurement year

Eye exam must be done by an eye care professional (optometrist or ophthalmologist).

Documentation

Documentation of retinal exam must be obtained from eye care provider if patient advises they have completed an eye exam. At a minimum, documentation in the medical record must include one of the following:

• A note or letter from an ophthalmologist, optometrist, PCP, or other health care professional indicating that an ophthalmoscopic exam was completed, the date when the procedure was performed, and the results.

• A chart or photograph indicating the date when the fundus photography was performed and that an optometrist or ophthalmologist reviewed the results.

• Documentation of a negative retinal or dilated eye exam by an optometrist or ophthalmologist in the year prior to the measurement year, results indicating retinopathy was not present.

• Documentation anytime in the member’s history of bilateral eye enucleation or acquired absence of both eyes

Eligible Codes

92250 or 92227 or 92228

Must be submitted via claims by an eye care professional (optometrist or ophthalmologist); if submitted by PCP then must also apply a CPTII code as shown in the adjacent column. →

2.6

2.7

2.8

2022F, 2024F, 2026F (2023F and 2025F are current year codes to be used for when the member is without evidence of retinopathy. Thus, they meet numerator compliance for current year and the following year.)

2.9

2.10

To be used only for eye exams read by a system that provides an artificial intelligence (AI) interpretation of results.

Exclusions

• Hospice care

• Palliative care anytime in the measurement year

• Medicare patients 66 years of age and older as of December 31st of the measurement year who are either enrolled in an institutional special needs plan (I-SNP) or living long-term in an institution

• Patients 66 years of age and older as of December 31st of the measurement year who meet both frailty and advanced illness criteria

How to Improve Score

• Review chart notes to find evidence of retinal eye exam or statement from patient that they have completed within the year or year prior.

• Educate patient regarding importance of eye exam, especially with diabetes.

• Prepare standing referral to eye care professional; assist patient in making appointment if needed.

• Ensure proper billing codes are submitted by eye care professional.

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2 of 2

Diabetes Care – Medical Attention for Nephropathy

What Is the Measure?

This measure looks at the percentage of patients 18 to 75 years of age with type 1 or type 2 diabetes who had nephropathy screening during the measurement year.

Documentation

Diabetic patients must have at least one of the following during the measurement year:

• Test for urine protein, urine albumin, or urine microalbumin

• Evidence of Stage 4 chronic kidney disease (must be documented in the medical record)

• Evidence of kidney transplantation (must be documented in the medical record)

• A visit/consult with a nephrologist

• Evidence of treatment with an ACE Inhibitor or Angiotensin II Inhibitor (ARB)

How to Improve Score

• Review care gap reports and outreach to diabetic patients to ensure they have received the appropriate screening and follow-up.

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10

Controlling High Blood Pressure (CBP)

What Is the Measure?

This measure looks at the percentage of enrolled patients 18 to 85 years of age with a diagnosis of hypertension reported on an outpatient claim and whose blood pressure is adequately controlled. Blood pressure control is defined as having the most recent blood pressure below 140/90 mmHg during the measurement year.

In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. The patient must be part of an outpatient visit, telephone visit, e-visit or virtual check-in for the BP reading to count.

Eligible Codes

• It is required that you document the date and most recent results of the blood pressure readings and use the codes above based on BP ranges.

Exclusions

• Evidence of end-stage renal disease (ESRD), dialysis, nephrectomy or renal transplant before or during the measurement period

• Diagnosis of pregnancy during the measurement period

• Patients 66 years of age and older who are either enrolled in an institutional special needs pans (I-SNP) or living long-term in an institution

• Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a dispensed medication for dementia (cholinesterase inhibitors or miscellaneous central nervous system agents) during the measurement period or the year prior to the measurement period

• Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND either one acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or non-acute inpatient encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior to the measurement period

How to Improve Score

• Include appropriate CPTII codes when submitting claims.

• Counsel patients to take their blood pressure medication as prescribed and not to skip doses or discontinue unless advised to do so by their provider.

• Encourage patients to obtain a home blood pressure monitor. This may be covered under the member’s insurance benefit in some cases. If so, an order/prescription will be required for coverage.

• If no blood pressure is recorded during the measurement period, the patient’s blood pressure is assumed “not controlled.”

• In your office, if your team records a BP that is out of range,(higher than 140/90) the BP should be repeated and if the original and repeat are still high, the provider should be notified.

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10

Cesarian Section Rate

What Is the Measure?

This measure looks at the primary c-section rate across all deliveries.

The numerator consists of patients with a primary c-section delivery. Patients with a previous c-section are excluded from this measure

The denominator consists of patients with a delivery DRG.

2.8

2.9

2.10

Episiotomy Rate

What Is the Measure?

The purpose is to reduce the rate of routine episiotomies.

Evidence-based guidelines recommend against routine episiotomy, as studies fail to show maternal benefit.

Efficiency

MHN Efficiency Metrics

3.1 Generic Medication Usage

This measure looks at the ratio of generic prescriptions divided by the total prescriptions (brand and generic) authorized for MHN-attributed members during the measurement year (2022).

• Inpatient orders are not included in this measure.

• Goal: Varies by specialty and is based upon historical performance

• Exclusion: Branded Levothyroxine products

• Threshold: 25 total outpatient prescriptions

3.2 ED Visits per 1,000

This measures the ED utilization of all members seen by the practice and is calculated by taking the number of ED visits during the measurement year (2022) divided by the number of member months per practice multiplied by 12,000.

• Applicable to primary care providers only

• For group practices: The practice rate will be used, NOT individual physician

3.3 Average Length of Stay

This measure reports the arithmetic average length of stay for all cases attributed to a provider over a rolling 12-month period.

• Value indicates the provider’s average length of stay for cases with the Memorial Healthcare System

• For the adult population, the Crimson Cohort “All Hospitals” will be used as a comparison

• For the pediatric population, the Crimson Pediatric Cohort “Hospitals with Pediatric Beds” will be used as a comparison

• Attributed only to the “responsible” physician on the case, not all providers in the practice

• Threshold: 10 cases

• Population: All inpatients regardless of payor

3.4 30-Day All-Cause Readmission Ratio

This measures the MHN Network performance as a whole, not individual physician performance.

• Applies to all patients regardless of payor

• For the all-cause readmissions, pediatrics and adults will be broken out into two separate scores

• Physicians will be measured on a system total, NOT individual performance

• Goal: To have the observed rate over the expected rate be > 1.0

3.1

3.2

3.3

3.4

COMMERCIAL ACO FOCUS

MHN Citizen Metrics

4.1 Clinical Integration Education/One CI Program Update Session

• In-person sessions offered throughout Memorial Healthcare System for convenience

• Attendance at one MHN CI Program Update Session in person or online is required to remain in good standing

• Goal: One full point will be awarded to physicians compliant with this metric

4.2 MHN Second Education Topic

• Attendance at one MHN-related topic session in person or online per calendar year

• Topic to be determined by the MHN Quality/IT Committee

• Goal: One full point will be awarded to physicians compliant with this metric

4.3 MHN Physician Survey

• Provides MHN physicians the opportunity to share their opinions and suggestions with MHN administration

• Goal: One full point will be awarded to physicians who complete the survey during the measurement year (2022)

4.4 Clinical Integration Education/Office Manager Symposium

• Provides targeted MHN Network information to office administrative staff

• Attendance at one CI Education Session in-person or online per calendar year by at least one member of the office staff

• Goal: One full point will be awarded to physicians compliant with this metric

4.5 Specialty-Specific MHN Meeting

• Provides targeted information to physicians in the specific specialty

• Attendance at the annual meeting is required (either in-person or online)

• Goal: One full point will be awarded to physicians compliant with this metric

4.6 Extended Hours/Bonus

• Encourages physicians to expand office hours, accommodating same-day appointments in order to reduce visits to emergency departments and out-of-network providers

• Extended hours defined as at least one hour per week that meets at least one of the following requirements listed below.

Appointments must be available during these times.

a) Any office hours on Saturday or Sunday

b) Additional office hours on Monday through Friday before 8 AM or after 6 PM

• Must complete After Hours Access Attestation form indicating availability of appointments during the hours stated above

• Goal: One bonus point will be awarded to office-based physicians compliant with this metric

4.1

4.2

4.3

4.4

4.5

4.6

HEDIS Type Reporting Measures

Hemoglobin A1c Poor Control >9% DM – 2 (ACO – 27)

Controlling High Blood Pressure HTN – 2 (ACO – 28)

Instructions

• A diagnosis of diabetes (active or history of) during the measurement period or year prior to the measurement period AND

• The date and value of the most recent HbA1c test performed during the measurement period and code.

• A diagnosis of essential hypertension within the first six months of the measurement period or at any time prior to the measurement period.

AND

• The date and value of the most recent systolic and diastolic blood pressure readings during the measurement period. If there are multiple blood pressure readings on the same date of service, use the lowest systolic and lowest diastolic reading as the most recent blood pressure reading.

• Code 3074F < 130, 3075F 130-139 3077F > 140 and 3078F < 80, 3079F 80-89, 3080F > 90

• Documentation of exclusion criteria

5.2

5.3

5.4

5.5

5.6

5.7

Breast Cancer Screening Prev – 5 (ACO – 20)

Colorectal Cancer Screening Prev – 6 (ACO – 19)

• Date the mammogram was performed and results (October 1, 2019–December 31, 2021).

• Documentation of exclusion criteria.

• Indication of current colorectal cancer screening as evidenced by the completion of one of the above-mentioned tests or procedures with in its corresponding time frame, the date the screening was performed and the result.

• Documentation of exclusion criteria.

Prevention Type Reporting Measures Instructions

5.1

Future Fall Risk Screening Care – 2 (ACO – 23)

Preventive Care and Screening for Influenza PREV – 7 (ACO – 14)

• Documentation of assessment of whether the patient has experienced a fall or problems with gait or balance performed during the measurement period. Documentation of no falls is sufficient. OR

• Documentation of exclusion criteria.

• Indication the patient received an influenza immunization between August 1, of the prior year and March 31, of the current year OR

• Documentation of the reason why the Quality Action is not performed due to an exception.

5.2

5.3

5.4

5.5

Tobacco Use: Screening and Cessation Intervention Prev – 10 (ACO – 17)

• The date and results of a query of the patient’s use of tobacco. If identified as a tobacco user, documentation of cessation intervention. OR

• Documentation of the reason why the Quality Action is not performed due to an exception.

5.6

5.7

Preventive care and Screening: Depression and follow up Plan Prev – 12 (ACO – 18)

• The date and results of a named age appropriate standardized depression screening tool. If screening results are positive, documentation of discussion of a follow-up plan on the date of the positive screen. The follow-up plan must be specified as an intervention that pertains to depression. OR

• Documentation of the reason why the Quality Action is not performed due to an exception. OR

• Documentation of exclusion criteria.

PREV-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Statin Therapy Info Found in: _________________

1. Was patient ever diagnosed with ASCVD: YES NO

Qualifier: (Please select one)

Acute Coronary Syndromes

History of MI

Stable or Unstable Angina

Coronary or other arterial revascularization (i.e., PCI, CABG

Stroke of TIA

PAD or atherosclerotic orgin

Other:

2. Has patient EVER had a fasting or direct LDL-C > 190 mg/dL with a history or current diagnosis of familial or pure cholesterolemia:

YES NO

3. Age 40-75 years with a diagnosis of diabetes and had LDL-C level between 70-189 mg/dL (in 2019 to 2021):

YES NO

4. Was patient prescribed or taking statin therapy in 2001: YES NO

Qualifier: (Please select one)

Lipitor/Atorvastatin

Crestor/Rosuvastatin

Zocor/Simvastatin

Livalo/Pitavastatin

Pravachol/Pravastatin

Other:

Exclusion: (Please select one if applicable)

Adverse effect, allergy, or intolerance to statin

Palliative care

Active liver disease, hepatic disease or insufficiency (i.e., Hepatitis)

ESRD

Diabetes who have the most recent fasting or direct LDL-C < 70 and are not taking statin therapy

Diagnosis of rhabdomyolysis

Instructions

• For Question #1 only: An active diagnosis or history of clinical atherosclerotic cardiovascular disease (ASCVD). (If Q1 is yes, then update the qualifier and go to Q4.)

OR

• For Question #2 only: The date and value of a fasting or direct low-density lipoprotein cholesterol (LDL-C) level greater than or equal to 190 mg/dL (any time in the patient’s history— but prior to the end of the measurement period) OR documentation of a history of or active diagnosis of familial or pure hypercholesterolemia.

OR

• For Question #3 only: Adults aged 40-75 years with a documented diagnosis of diabetes and the date and value of a fasting or direct LDL-C level of 70-189 mg/dL (during the measurement period or two years prior to the beginning of the measurement period).

• And for the corresponding question,documentation of an active prescription for statin therapy anytime during the measurement period

OR

• Documentation of the reason why the Quality Action is not performed due to an exception. OR

• Documentation of exclusion criteria.

5.1

5.2

5.3

5.4

5.5

5.6

5.7

Prevention Type Reporting Measures

MH-1 (ACO-40) Depression Remission at 12 Months

Depression Remission (MH) Info Found in: _________________

1. Mental Health Diagnosis (11/01/2019 - 10/31/2020)? YES NO

Exclusion: (Please select one if applicable)

Patient deceased

Received palliative or hospice care

Permanent nursing home resident

Diagnosis of Bipolar Disorder

Diagnosis of Personality Disorder

2. PHQ-9 Test Performed (11/01/2019 - 10/31/2020)?

YES NO

3. PHQ-9 Date: _______________________

4. PHQ-9 Score (0-27): _______________________

5. Diagnosis of Dysthymia or Depression

YES NO

6. PHQ-9 Follow-Up Test Performed (2021 - 12 months after initial +/- 30 days):

YES NO

7. PHQ-9 Follow-Up Date: _______________________

8. PHQ-9 Follow-Up Score (0-27): _______________________

Instructions

• A diagnosis of major depression or dysthymia during the measurement period (November the prior year to October of this year) AND

• A PHQ-9 scoregreater than 9 between (November the prior year to October of this year) AND

• A follow-up PHQ-9 scoreless than 5 at 12 months (+/- 60 days)after theinitial PHQ-9 score greater than 9. OR

• Documentation of exclusion criteria.

5.1

5.2

5.3

5.4

5.5

5.6

5.7

Annual Wellness Visit (AWV)

What Is the Measure?

This measure looks at the percentage of patients who had one Annual Wellness Visit as of December 31st of the measurement year. At the Annual Wellness Visit (AWV), physicians can create a personalized prevention plan to inform preventive care decisions for the next five to 10 years.

The plan may include:1

• Age-appropriate preventive services

• Recommendations offered by the U.S. Preventive Services Task Force

• Health advice, taking the patient’s risk factors into consideration

• Referrals and relevant programs

Types of Annual Wellness Visits

1 2 3

5.1 5.2

5.3

5.4

5.5

Initial Preventive Physical Examination (IPPE)

A one-time physical exam performed within the first 12 months of a patient’s enrollment under Part B Medicare

Initial AWV

Provided 12 months after the initial enrollment or 12 months after the IPPE

Subsequent AWV

Performed annually after first two types have been documented

Annual Wellness Visit Components

Information Gathering

• Illnesses

• Hospital stays

• Operations

• Allergies

• Injuries and treatments

• Medication and supplement utilization (including vitamins)

• Opioid use

• Behavioral risks

• Activities of daily living (ADLs)

• Instrumental ADLs (IADLs)

• Fall risk

• Home safety

• List of current providers and suppliers regularly involved in the patient’s care

Exam/Assessment

• Vital signs

• Pain assessment

• Cognitive function assessment

• Risk factors for depression or other mood disorders

• End-of-life planning (if patient agrees)

• Cognitive impairment detection

Counseling

• Establish a written screening schedule, such as a checklist for the next 5 to 10 years, as appropriate.

• Establish a list of risk factors and conditions for which interventions are recommended or underway.

• Furnish personalized health advice and a referral as appropriate to health education or preventive counseling services or programs.

5.6

5.7

Medicare Preventive Services Link AAFP Medicare Wellness Link

Eligible Codes

Description

G0402

G0403

Initial preventive physical examination includes face-to-face visit; services limited to new beneficiary during the first 12 months of Medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Common Errors

Details Initial

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405

G0404

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV; Only valid when billed with location code 50, for our contracted FQHC providers

• Not allowing enough time for a patient visit to meet all the necessary criteria required by CMS

• Completing a yearly physical instead of a Medicare Annual Wellness Visit (AWV)

• Creating a new visit appointment just for annual wellness visit criteria that is not on patient’s regular follow-up schedule set by the medical provider

How to Improve Score

• Develop protocols on how to best schedule appointments and workflow due to the many components required for AWV completion

• Understand that in addition to a physician, a qualified non-physician practitioner (NPP) such as a physician assistant (PA), nurse practitioner (NP) or certified clinical nurse specialist (CCNS) can complete an annual wellness visit

• Have set forms or templates within the EMR or paper forms where providers document and attest to their findings

• Ask patients to bring a wide array of information to the visit including medical records, immunizations, detailed family health histories, complete list of medications, complete list of care providers and suppliers, list of durable medical equipment, the completed health risk assessment (HRA), and a list of their questions or concerns

• Include medical staff patients such as medical assistants and nurses to begin to assist in documentation of histories and concerns

• Research alternative methods and processes for completing the AWV such as virtual care or enlisting AWV nurses

Find Medicare Health Risk Assessment in the Assessment Tools section of this guide.

References:

1. Cuenca, A. E., & Kapsner, S. (2019, April 1). Medicare Wellness Visits: Reassessing their value to your patients and your practice. American Academy of Family Physicians. Retrieved April 29, 2022, from https://www.aafp.org/fpm/2019/0300/p25.html

2. Hughes, C. (2011, August 1). Medicare annual wellness visits made easier. Family Practice Management. Retrieved April 29, 2022, from https://www.aafp.org/fpm/2011/0700/p10.html#fpm20110700p10-bt1

3. Center for Medicare and Medicaid Services (CMS). (2021, February 1). Medicare Wellness Visits . Retrieved April 29, 2022, from https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

Fall Risk Screening

What Is the Measure?

Assessment of whether an individual has experienced a fall or has problems with gait or balance. A specific screening tool is not required for this measure. However, potential screening tools include the Morse Fall Scale and the Timed Up and Go test. A clinician with appropriate skills and experience may perform the screening.

Tobacco Use Cessation Intervention: Includes brief counseling (3 minutes or less), and/or pharmacotherapy.

Documentation

A clinician with appropriate skills and experience may perform the screening

• Medical record must include documentation of screening performed

• Any history of falls during the measurement period is acceptable as meeting the intent of the measure

• A gait or balance assessment meets the intent of the measure

Eligible Codes

Exclusions

• Non-ambulatory patient (at the most recent encounter during the measurement period)

• Bed-ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair

How to Improve Score

• Complete screening for future fall risk either in person or during a telehealth encounter

• Document any falls in the past 12 months.

• Discuss falls or problems with balance or walking and recommend how to prevent falls.

• Treat balance or walking problems.

Find Fall Risk Assessment Tool in the Assessment Tools section of this guide.

Tobacco Use Screening & Smoking Cessation Counseling

What Is the Measure?

This measure looks at the percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco use cessation intervention if identified as a tobacco user during the measurement period.

Tobacco use cessation intervention consists of brief counseling (3 minutes or less) and/or pharmacotherapy.

Eligible Codes

For CMS Sampling Use Only / Annual Wellness Visit:

Exclusions

• Diagnosis of limited life expectancy

Depression Screening

What Is the Measure?

This measure refers to the percentage of patients 12 years of age and older who were screened for clinical depression and, if screened positive, received follow-up care.

Depression Screening (DSF): The percentage of patients who were screened for clinical depression using a standardized instrument.

Follow-Up on Positive Screen: The percentage of patients who received follow-up care within 30 days of a positive depression screen finding.

Depression Remission Screening (DRR): The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age and older, with major depression or dysthymia, who reached remission 12 months (+/- 60 days) after an index event.

Documentation

A standard assessment instrument is defined as having been normalized and validated for the appropriate patient population. Eligible screening instruments with thresholds for positive findings include:

Instruments for Adolescents (≤17 years) Positive Finding

Patient Health Questionnaire (PHQ-9)®

Patient Health Questionnaire Modified for Teens (PHQ- 9M)®

Patient Health Questionnaire-2 (PHQ-2)

Total Score ≥10

Total Score ≥10

Total Score ≥3

Instruments for Adolescents (18+ years) Positive Finding

Patient Health Questionnaire (PHQ-9)®

Patient Health Questionnaire-2 (PHQ-2)

Eligible Codes

Total Score ≥10

Total Score ≥3

Eligible Codes (continued)

Documented within the encounter record

Exclusions

Rx Drug Class

5.1

• Additional evaluation (referral)

• Suicide risk assessment

• Referral to a practitioner who is qualified to diagnose and treat depression

• Pharmacological interventions

• Other interventions or follow-up for the diagnosis of depression

• Antidepressants

• Antidepressants/MAO Inhibitors

• OTC (5-Hydroxytryptophan)

• Bipolar disorder in the year prior to the measurement year

• Depression that starts during the year prior to the measurement year

• Personality disorder

• Psychotic disorder

• Pervasive developmental disorder

• Alzheimer’s disease or dementia

• Hospice care

• Palliative care during the measurement year

• Patient refuses to participate in screening assessment

5.2

5.3

5.4

5.5

5.6

5.7

F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.1, F34.81, F34.89, F43.21, F43.23, F53.0, F53.1, O90.6, O99.340, O99.341, O99.342, O99.343, O99.345

G8433

Screening for clinical depression not documented. Medical record documents that the patient is not eligible/appropriate.

G8940

Screening for clinical depression documented as positive. A follow-up plan not documented. Medical record documents that the patient is not eligible/appropriate.

Common Errors

• Not labeling PHQ-2 or PHQ-9 clearly in the EMR appropriately

• Physicians not totaling overall questionnaire score and certifying their findings in the note

• Screening exclusion criteria not appropriately documented within the medical record

• If patient refuses/declines to have depression screening, not properly marking in the encounter

How to Improve Score

• Have set forms within the EMR or paper forms where providers document and attest to their findings.

• Document exclusion criteria appropriately in the medical record.

• Document exclusion diagnosis as an active problem within the patient’s problem list.

Find Depression Screening Patient Health Questionnaire in the Assessment Tools section of this guide.

5.1

5.2

5.3

5.4

5.5

5.6

5.7

Influenza Vaccination (FVO)

What Is the Measure?

Percentage of adults aged 6 months and older seen for a visit between October 1st and March 31st of the measurement year, who received an influenza immunization or who reported previous receipt of an influenza immunization.

Definition of Previous Receipt: Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

Performance Met: Influenza immunization administered or previously received (G8482)

Denominator Exception: Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) (G8483)

Performance Not Met: Influenza immunization was not administered, reason not given (G8484)

Eligible Codes

Administration of influenza virus vaccine

Influenza virus vaccine, split virus, for intramuscular use (agriflu)

Influenza virus vaccine, split virus, when administered to individuals

3 years of age and older, for intramuscular use (afluria)

Influenza virus vaccine, split virus, when administered to individuals

3 years of age and older, for intramuscular use (flulaval)

Influenza virus vaccine, split virus, when administered to individuals

3 years of age and older, for intramuscular use (fluvirin)

Influenza virus vaccine, split virus, when administered to individuals

3 years of age and older, for intramuscular use (fluzone)

Influenza virus vaccine, split virus, when administered to individuals

3 years of age and older, for intramuscular use (not otherwise specified)

Exclusions

• Allergy to eggs

• Anaphylactic reaction due to eggs

• Patient declined vaccine

• Vaccine not available or other systemic reasons

• Hospice care

5.1

5.2

5.3

5.4

5.5

5.6

5.7

Social Determinants of Health (SDoH)

What Is the Measure?

This measure refers to all patients 18 and older with a primary care provider (PCP) screened for social determinants of health (SDoH).

Screening patients to understand their social context is the gateway to addressing barriers and improving health.

Eligible Codes

Description

SDoH Screening Performed

HCPCS

Problems related to education and literacy (Z55)

Problems related to employment and unemployment (Z56)

ICD-10

Code(s)

G9920 - Screening Performed and Negative

G9919 - Screening Performed and Positive and Provision of Recommendations

Z55.0 - Illiteracy and low-level literacy

Z55.1 - Schooling unavailable and unattainable

Z55.2 - Failed school examinations

Z55.3 - Underachievement in school

Z55.4 - Educational maladjustment and discord with teachers and classmates

Z55.5 - Less than a high school diploma

Z55.8 - Other problems related to education and literacy

Z55.9 - Problems related to education and literacy, unspecified

Z56.0 - Unemployment, unspecified

Z56.1 - Change of job

Z56.2 - Threat of job loss

Z56.3 - Stressful work schedule

Z56.4 - Discord with boss and workmates

ICD-10

Z56.5 - Uncongenial work environment

Z56.6 - Other physical and mental strain related to work

Z56.81 - Sexual harassment on the job

Z56.82 - Military deployment status

Z56.89 - Other problems related to employment

Z56.9 - Unspecified problems related to employment

Z57.0 - Occupational exposure to noise

Z57.2 - Occupational exposure to dust

Z57.31 - Occupational exposure to environmental tobacco smoke

5.1 5.2 5.3 5.4 5.5 5.6

5.7

Occupational exposure to risk factors (Z57)

Problems related to physical environment (Z58)

ICD-10

Z57.39 - Occupational exposure to other air contaminants

Z57.4 - Occupational exposure to toxic agents in agriculture

Z57.5 - Occupational exposure to toxic agents in other industries

Z57.8 - Occupational exposure to other risk factors

ICD-10

Z58.6 - Inadequate drinking-water supply

Z59.0 - Homelessness

Z59.1 - Inadequate housing

Z59.2 - Discord with neighbors, lodgers and landlord

Z59.3 - Problems related to living in residential institutions

Problems related to housing and economic circumstances (Z59)

ICD-10

Z59.4 - Lack of adequate food and safe drinking water

Z59.5 - Extreme poverty

Z59.6 - Low income

Z59.7 - Insufficient social insurance and welfare support

Z59.8 - Other problems related to housing and economic circumstances

(Please use this code to identify when transportation limits the patient’s healthcare access)

Eligible Codes (continued)

Description System Code(s)

Z60.0 - Problems of adjustment to life-cycle transitions

Z60.2 - Problems related to living alone

5.1

Problems related to social environment (Z60)

5.2

ICD-10

Z60.3 - Acculturation difficulty

Z60.4 - Social exclusion and rejection

Z60.5 - Target of (perceived) adverse discrimination and persecution

Z60.8 - Other problems related to social environment

Z62.0 - Inadequate parental supervision and control

Z62.1 - Parental overprotection

Z62.2 - Upbringing away from parents

Z62.21 - Child in welfare custody

Z62.22 - Institutional upbringing

Z62.3 - Hostility towards and scapegoating of child

5.3

Problems related to upbringing (Z62)

Other problems related to primary support group, including family circumstances (Z63)

Problems related to certain psychosocial circumstances (Z64)

Problems related to other psychosocial circumstances (Z65)

Problems related to medical facilities and other health care (Z75)

Common Errors

ICD-10

Z62.6 - Inappropriate (excessive) parental pressure

Z62.810 - Personal history of physical and sexual abuse in childhood

Z62.811 - Personal history of psychological abuse in childhood

Z62.812 - Personal history of neglect in childhood

Z62.819 - Personal history of unspecified abuse in childhood

Z62.82 - Parent-child conflict

Z62.822 - Parent-foster child conflict

Z63.0 - Problems in relationship with spouse or partner

Z63.3 - Absence of family member

Z63.4 - Disappearance and death of family member

Z63.5 - Disruption of family by separation and divorce

5.4 5.5

5.6

ICD-10

5.7

Z63.6 - Dependent relative needing care at home

Z63.7 - Other stressful life events affecting family and household

Z63.72 - Alcoholism and drug addiction in family

Z63.8 - Other specified problems related to primary support group

Z64.0 - Problems related to unwanted pregnancy

ICD-10

Z64.1 - Problems related to multiparity

Z64.4 - Discord with counselors

Z65.0 - Conviction in civil and criminal proceedings without imprisonment

Z65.1 - Imprisonment and other incarceration

Z65.2 - Problems related to release from prison

ICD-10

Z65.3 - Problems related to other legal circumstances

Z65.4 - Victim of crime and terrorism

Z65.5 - Exposure to disaster, war and other hostilities

Z65.8 - Other specified problems related to psychosocial circumstances

Z75.0 - Medical services not available in home

ICD-10

Z75.3 - Unavailability and inaccessibility of health care facilities

Z75.4 - Unavailability and inaccessibility of other helping agencies

• Not training or informing staff of the importance of SDoH and their role in assisting screening

• Not updating social history yearly

• Not utilizing waiting period during office visits as a moment to conduct SDoH survey

How to Improve Score

• SDoH screening should not be the sole job of the physician. Screening should be a team-based effort integrated with patient care management workflows. Successful practices have created or employed nurses, medical assistants, care coordinators, patient navigators, health coaches, community health workers who assist in streamlining and directing screening processes as well as coordination of care.

How to Improve Score (continued)

• Staff member can have patient self-administer surveys while they wait for physicians and staff can input results in real-time in social history sections of the EHR so the provider has an updated view to address any concerns to create a care plan.

• Practices should have a list of referral resources to connect patients to needed services in the community, such as meal programs or utility assistance programs.

Find SDoH screening in the Assessment Tools section of this guide.

5.1

5.2

5.3

5.4

5.5

5.6

References:

1. Editors, F. P. M. (2018, June 27). Three tools for screening for Social Determinants of Health. AAFP Quick Tips. Retrieved May 3, 2022, from https://www.aafp.org/journals/fpm/blogs/inpractice/entry/social_determinants.html

2. McMacken, M. (2022, March 29). ICD-10 Codes to Identify Social Determinants of Health. Johns Hopkins Medicine Provider Update. Retrieved May 3, 2022, from https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/

3. O’Gurek, D. T., & Henke, C. (2018, June 1). A practical approach to screening for Social Determinants of Health. Family Practice Management. Retrieved May 3, 2022, from https://www.aafp.org/fpm/2018/0500/p7.html#fpm20180500p7-b15

Annual Wellness Focus: Social Determinants of Health (SDoH)

5.7 3 of 3

Patient Experience (CAHPS Survey)

What Is the Measure?

The Consumer Assessment of Healthcare Providers & Systems (CAHPS®) is an industry standard survey tool used to evaluate the experiences of healthcare consumers. The National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS) require health plans to conduct CAHPS surveys on an annual basis and the survey results are used to measure and compare plan performance, determine quality rating performance and quality bonus payment (as applicable), and to publicly report data via plan shopping tools such as CMS Medicare Plan Finder and State and Federal exchanges.

The CAHPS surveys are mailed out in February and March with a telephonic follow-up for patients who do not respond to the mailed surveys. The results are usually available in July and August.

Patient-Focused Question Domains

• Friendliness of provider

• Explanations offered to patient

• Level of concern shown

• Efforts made by provider to include patient in decisions

• Information provided to patient about medications

• Instructions provided to patient about follow-up care

• Clarity

• Amount of time spent with patient

• Patient’s confidence in provider

• Likelihood of your recommending provider to others

How to Improve Score

• Make scheduling appointments easy by reducing call wait times, offering a call back feature and self-service booking options.

• Reduce appointment wait times by offering same-day, weekend, and early morning/evening appointment slots.

• Offer wait-list options when fully booked.

• Offer telehealth as an alternative to in-person appointments.

• Prepare the patients’ records and review them ahead of time, and get prior authorizations if necessary, to expedite care.

• Inform patients if there are likely to be long wait times or if lab work needs to be completed.

• Do your best to see patients within 15 minutes of their appointment time.

• Check patients’ prescriptions, ensure they understand their medications, and alert them of possible adverse drug interactions.

• Let patients know when their results will be available and follow up to to discuss results.

• Provide patients with the opportunity to ask questions and voice concerns about their care.

• Schedule follow-up appointments to ensure continuity of care.

• Account for follow-up care by referring patients to in-network providers/facilities, informing patients of any authorization requirements.

• Encourage patients to use the patient portal to access health records and request prescription refills.

• Share health records with patient’s care team.

Health Outcomes Survey (HOS)

What Is the Measure?

This measure provides a general indication of how well a Medicare organization manages the physical and mental health of its patients. The survey measures each patient’s physical and mental health status at the beginning and at the end of a two-year period.

A two-year change score is calculated and each patient’s physical and mental health status is categorized as better, the same, or worse than expected (considering risk adjustment factors). Organization-specific results are assigned as percentages.

How to Improve Score

• Promote the Annual Wellness Visit. The measure may be directly and positively impacted by the support of AWVs.

• Recall an AWV is meant to include mental health considerations as well as risk factors for overall decline.

6.1

6.2

Medicare Health Risk Assessment (HRA)

Patient Name: DOB: Today’s Date

Physical Activity/Exercise

How many days a week do you usually exercise?

__________days per week

How intense is your typical exercise?

c Light (stretching or slow walking)

c Very heavy (running or stair climbing)

Smoking Status

c Moderate (brisk walking)

amount of time spent exercising

c I am currently not exercising

Do you currently smoke cigarettes or use other types of tobacco?

c Current smoker

Alcohol Use

c Former smoker

c Never a smoker

c Heavy (jogging or swimming)

In a typical week, how often do you have 1 or more alcoholic drinks on one occasion?

c No alcohol use

c Social drinker

c Moderate (Men: 2 per day or less; Women: 1 per day or less)

c Alcohol use (3 or more per day)

Nutrition

Do you eat fiber, fruits and vegetables?

Oral Health

Do you see a dentist yearly?

Hearing

Do you have difficulty hearing when someone speaks in a whisper?

Do you have hearing problems when in a crowd?

Does a hearing problem cause you to argue with family members?

Sleep

How many hours of sleep do you get each night?

Activities of Daily Living

c Yes c No

c Yes c No

c Yes

c No

c Yes c No

c Yes c No

Do you feel that you need assistance with dressing, feeding or bathing? c Yes c No

Do you have feelings of unsteadiness including balance? c Yes c No

Over the past year you have: c Not experienced a fall c Had one fall with injury

c Had two or more falls

Do you need assistance with shopping, food preparation, housekeeping, laundry or transportation?

Do you need help with your medications?

c Yes c No

Do you need assistance with handling financial affairs?

c Yes c No

c Yes c No

Motor Vehicle Safety

Do you wear a seatbelt every time you are in an automobile? c Yes c No

Sun Exposure

When outdoors, do you wear sunscreen? c Yes c No

Home Safety

Do you have working smoke and fire detectors in your home? c Yes c No

High Stress

How well do you handle the stress in your life?

c I’m usually able to cope effectively. c At times I have problems coping. c I often have problems coping.

How often is stress a problem for you?

c Never/Rarely c Sometimes c Often c Always

General Well-being

In general, how would you describe your health?

Depression

c Excellent c Very good c Good c Fair c Poor

Over the past 2 weeks how often, have you experienced loss of pleasure from your usual activities?

c Not at all c Several days c More than half the days c Nearly every day

Over the past 2 weeks how often have you been bothered by feelings of sadness, depression or helplessness?

c Not at all c Several days c More than half the days c Nearly every day

Have your feelings caused you distress or interfered with your ability to interact socially with friends?

c Yes c No

Generally, how satisfied are you with your life?

c Very satisfied

c Satisfied

Social/Emotional Support

c Dissatisfied

c Very dissatisfied

How often do you get the social and emotional support you need?

c Always c Usually c Sometimes c Rarely c Never

Fall Risk Assessment Tool

Fall Risk Factor Category

Scoring not completed for the following reason(s) (check any that apply). Enter risk category (i.e. Low/High) on flow sheet based on box selected.

__ Complete paralysis, or completely immobilized. Implement basic safety (low fall risk) interventions.

__ Patient has a history of more than one fall within 6 months before admission. Implement high fall risk interventions throughout hospitalization.

Patient has experienced a fall during this hospitalization. Implement high fall risk interventions throughout hospitalization.

__ Patient is deemed high fall-risk per protocol (e.g. seizure precautions). Implement high fall-risk interventions per protocol.

Complete the following and calculate Fall Risk Score. If no box is checked, score for category is 0. Points

Age (Select one.)

__ 60–69 years (1 point)

__ 70–79 years (2 points)

__ ≥80 years (3 points)

Fall History (Select one.)

__ One fall within 6 months before admission (5 points)

Elimination, Bowel and Urine (Select one.)

__ Incontinence (2 points)

__ Urgency or frequency (2 points)

__ Urgency/frequency and incontinence (4 points)

Medications Includes PCA/opiates, anti-convulsants, anti-hypertensives, diuretics, hypnotics, laxatives, sedatives and psychotropics (Select one.)

__ On 1 high fall risk drug (3 point)

__ On 2 or more high fall risk drugs (5 points)

__ Sedated procedure within past 24 hours (7 points)

Patient Care Equipment Any equipment that tethers patient (e.g., IV infusion, chest tube, indwelling catheters, SCDS) (Select one.)

__ 1 present (1 point)

__ 2 present (2 points)

__ 3 or more present (3 points)

Mobility (Choose all that apply and add points together)

__ Requires assistance or supervision for mobility, transfer, or ambulation (2 points)

__ Unsteady gait (2 points)

__ Visual or auditory impairment affecting mobility (2 points)

Cognition (Choose all that apply and add points together)

__ Altered awareness of immediate physical environment (1 point)

__ Impulsive (2 points)

__ Lack of understanding of one’s physical and cognitive limitations (4 points)

Total Points

Moderate risk = 6–13 Total Points

High risk > 13 Total Points

Depression Screening (PHQ2 and PHQ9)

The PHQ 2 and the PHQ9 have been shown to be effective in screening for depression. When conducting the questionnaire, begin by asking about the presence of a symptom. Then, determine the persistence and severity of symptoms.

• Consider Major Depressive Disorder:

- If there are at least 5 positives in the shaded area (one of which corresponds to Question #1 or #2)

• Consider Other Depressive Disorder

- If there are 2-4 positives in the shaded area (one of which corresponds to Question #1 or #2)

Interpretation of Total Score

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc.

Patient Health Questionnaire (PHQ-9)

Name:

Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “a” to indicate your answer)

5.

6. Feeling bad about yourself —or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite — being so figety or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead, or of hurting yourself

(Healthcare professional: For interpretation of TOTAL, please refer to accompanying scoring card).

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Date:

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD © is a trademark of Pfizer Inc.

A2663B 10-04-2005

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. Assessment

Social Determinants of Health Assessment Tools

Patients’ social needs can create significant obstacles to high-quality care and contribute to poor health. Screening for SDoH without first equipping the practice to address identified needs would be ineffective and unethical. Several brief screening tools can be effective in primary care practices as part of a workflow designed to address social needs with referrals to community-based resources.

• Personal Characteristics

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

• Family & Home

• Money & Resources

• Social & Emotional Health

• Housing

• Food

• Transportation

• Utilities

The American Academy of Family Physicians Social Needs Screening Tool

The Accountable Health Communities Health-Related Social Needs (AHC-HRSN) Screening Tool

• Child Care

• Employment

• Education

• Finances

• Personal Safety

• Assistance

• Living Situation

• Food

• Transportation

• Utilities

• Safety

• Financial Strain

• Employment

• Family & Community Support

• Education

• Physical Activity

• Substance Use

• Mental Health

• Disabilities

https://prapare.org/wp-content/uploads/2021/10/PRAPAREEnglish.pdf

Short: https://www.aafp.org/dam/AAFP/documents/patient_care/ everyone_project/patient-short-print.pdf

Long:

https://www.aafp.org/dam/AAFP/documents/patient_care/ everyone_project/patient-long-print.pdf

https://innovation.cms.gov/Files/worksheets/ahcmscreeningtool.pdf

Care for Older Adults Assessment Form

Patient Name: DOB:

Functional Status

Activities of Daily Living:

Completely Independent: Y / N (if NO, circle type of assistance required below)

Assistance with ADLs: Bathing / Dressing / Eating / Transferring / Toileting / Walking

Assistance with IADLs: Shopping / Driving OR Using Public Transportation / Using the Phone / Meal Preparation / Housework / Home Repair / Laundry / Taking Medications / Handling Finances

Caregiver is present: Y / N N/A

Functionally Independent:

Currently Working: Y / N Able to perform a job: Y / N Able to Exercise: Y / N

Cognitive Status:

Intact Not Oriented: Person, Place, Time (circle)

Ambulation Status:

Normal/Good Fair Poor Independent: Y / N Non Ambulatory: Y / N

Needs assistive device: Y / N Cane Walker Wheel Chair Scooter

Sensory Ability:

Hearing: Good Fair Poor Impaired: Deaf Use of Hearing Aids/ Device

Speech: Unimpaired Impaired: Language Barrier Present: Y / N: __________

Vision: Good Fair Poor Impaired: Uses Glasses/contacts Cataracts Glaucoma Macular Degeneration DM Retinopathy Blind

Advance Care Planning (ACP)

Does the patient have: Advance Directives: Y / N Living Will: Y / N Surrogate Decision Letter: Y / N

Medication Review/List

Medication Review Completed: Y / N

*Please attach copy of current medications.

Comprehensive Pain Assessment

Pain: Y / N (must select option Y or N)

Indicate level of pain (1 for no pain; 10 for worst pain) _______

Location(s) of Pain ____________________________________________________________________________________________________________________________

Physician’s Name: ______________________________________ Print Physician’s Name (if other):

Physician’s Signature: _________________________________________________ Date Assessment Completed: Comments:

(HCCs)

HCC Coding Quick Reference

ICD-10-CM Codes Impacting the HCC Models

The following represents common conditions. For a comprehensive list, please refer to the ICD-10-CM codebook for correct coding and reporting.

Cancer (CA) & Other Neoplasms

Blood & Immune Disorders (Cont.)

These codes classify unspecified or type 2 DM. See the ICD-10-CM codebook for othr types.

DM with dermatitis

DM with foot ulcer, right

DM with foot ulcer, left

DM with acanthosis nigricans

DM with periodontal disease

DM with hyperglycemia

DM with hyperlipidemia

DM, poorly controlled

DM, use this code only for a controlled DM without any complication

+ I50.9

+ L97.919

+ L97.929

+ L83

+ E78.5

The following represents common conditions. For a comprehensive list, please refer to the ICD-10-CM codebook for correct coding and reporting.

Other Endocrine, Nutritional & Metabolic Diseases

The following represents common conditions. For a comprehensive list, please refer to the ICD-10-CM codebook for correct coding and reporting.

Other Circulatory Diseases

Respiratory Conditions

Skin Diseases

Pressure ulcers, only stages 2, 3, 4, and unstageable impact the HCC models. See codes under category L89-

Non-pressure ulcers, see L97- & L98.4-. Also, if known, code the underlying condition like DM or arteriosclerosis.

Nervous System Diseases

The following represents common conditions. For a comprehensive list, please refer to the ICD-10-CM codebook for correct coding and reporting.

Mental Health

Codes that impact the HCC models are in bold CRA-only codes are in blue

Pregnancy, most codes impact the CRA HCC model, see O codes, Z34- or Z33.1

Hand & arm, see Z89.1- and Z89.2Leg, AKA, Z89.61-, BKA, Z89.5-, Ankle, Z89.44-, Foot, Z89.43Great toe, Z89.41-, Other Toes, Z89.42-

Ostomies

All artificial openings impact the HCC models, see category Z93-

Most of transplants impact the HCC models, see category Z94-

Codes with a dash (-), i.e., E11-, require additional characters. See ICD-10-CM codebook.

HIV (Z21) or AIDS (B20)

Overlooked Conditions

Diagnosis, Clinical Documentation & Coding

Identifying and evaluating diagnoses is critical for a successful provider HCC performance. Assessing and reporting all diagnoses that coexist reflects the actual patient panel’s health status. The following are conditions that providers may miss when evaluating their patients.

Evaluating Echo Results

The following are 4 conditions that impact the HCC models:

Heart Failure, I50.9

EF <45% or normal EF with S&S and left atrium/ventricular enlargement, engorged inferior vena cava, elevated E/e filling velocity; or elevated brain natriuretic peptide (BNP)

Pulmonary Hypertension, I27.20

Pulmonary artery pressure >35

Arteriosclerotic or Calcified Aorta, I70.0

If tortuous, use I77.1; If only the aortic arch, use Q25.46

Cardiomyopathy, I42.9

Moderate to severe left hypertrophy or valve disease

Labs/Results

Two GFRs between 30-59, 90 days apart

Two WBCs < 4.0 (ANC < 1500)

Elevated/low PTH

Two platelets < 140

Two platelets > 450

Elevated homocysteine in urine or blood

Senile Purpura, D69.2

Pulmonary Fibrosis, J84.10

Imaging studies with terms such as calcified granuloma, diffuse idiopathic interstitial, or scarring tissue

Chronic Respiratory Failure, J96.10

Patients using supplemental oxygen at home

Conditions/Codes

CKD stage 3 (N18.30), stage 3a (N18.31), or stage 3b (N18.32)

Neutropenia, D70.9

Hyperparathyroidism, E21.3 or Hypoparathyroidism, E20.9

Thrombocytopenia, D69.6

Thrombocytosis, D47.3

Homocysteinemia or homocystinuria, E72.11

Characterized by irregularly-shaped macules, 1-4 cm in diameter, that are dark purple with well-defined margins1

Malnutrition, E46

Patients with a BMI <19 and anemia, substance use disorder or another chronic condition

Sacroiliitis, M46.1

Degeneration of the sacroiliac joint2

Spinal Enthesopathy, M46.00

Enlargement, hypertrophy or calcification of the ligamentum flavum

In order to bill/report a code, the documentation must indicate that the diagnosis requires or affects patient care treatment or management.

Morbid Obesity, E66.01

BMI greater than 40, but also a BMI greater than 35 with at least one obesity-related condition3. Some obesity-related conditions are hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, sleep apnea, or degenerative arthritis of weight-bearing joints4

Hyperglycemia in Diabetes, E11.65

Persistent blood glucose levels over 140mg/dL or an A1c level over 8%7

Immunodeficiency (Immunocompromised)5

-Due to other conditions, D84.81

Patients with DM and recurrent infections or ulcers that don’t heal

-Due to chemotherapy or drugs, D84.821

Other drugs could be immunosuppressant, prednisone, corticosteroid, betamethasone, or DMARDs

-Due to radiotherapy, D84.822

Secondary Hypercoagulable State, D68.69

Acquired disorder in patients with underlying systemic diseases or clinical conditions known to be associated with an increased risk of thrombosis. For example: malignancy, pregnancy, use of oral contraceptives, myeloproliferative disorders, hyperlipidemia, diabetes mellitus, history of DVTs, A-fib, and abnormalities of blood vessels and rheology6

Calcified Basal Ganglia, G23.8 or Degeneration in CT/MRI brain studies, G23.9

Functional Quadriplegia, R53.2

Complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord. Patients usually do not have the mental ability to move themselves and require “total care,” such as turning every one or two hours and full assistance with feeding, elimination and hygiene8.

Ostomies (Current)

• Colostomy, Z93.3; Cystostomy, Z93.50

• Cutaneous-vesicostomy, Z93.51

• Gastrostomy (PEG), Z93.1

• Ileostomy, Z93.2; Tracheostomy, Z93.0

Transplants Status

• Kidney, Z94.0; Heart, Z94.1; Lung, Z94.2; Both, Z94.3; Liver, Z94.4

• Bone marrow, Z94.81

• Intestines, Z94.82; Pancreas, Z94.83

• Stem cells, Z94.84

References and Additional Notes:

The following are common causes:

• Late-stage Alzheimer’s disease (AD), G30.9 and F02.80

-For other types of advanced-stage dementias, see ICD-10-CM codebook

• Multiple sclerosis, G35

• Amyotrophic lateral sclerosis (ALS), G12.21

• Huntington’s disease, G10

• Severe intellectual disability, F72

• Other similar conditions that impair basic activities of daily living

Amputations

• Right hand, Z89.111; Left hand, Z89.112; Right arm Z89.201; Left arm, Z89.202

• Above left knee amputation (AKA), Z89.612; Above right knee amputation (AKA), Z89.611

• Below left knee amputation (BKA), Z89.512; Below right knee amputation (BKA), Z89.511

• Left ankle, Z89.442; Left foot, Z89.432; Left great toe, Z89.412; Other left toe, Z89.412

• Right ankle, Z89.441; Right foot, Z89.431; Right great toe, Z89.411; Right toe, Z89.411

* This tool is not intended to diagnose, evaluate, or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s care. Always refer to the ICD-10-CM codebook for correct coding and more information about coding guidelines at: cdc.gov/nchs/icd/icd10cm.htm

1. DermNet: dermnetnz.org/topics/senile-purpura/

2. AHA Coding Clinic for ICD-10-CM/PCS. 2020 Number 2 Second Quarter Volume 7: codingclinicadvisor.com

3 . Obesity Medicine Association. Anna Welcome. 2019. What Is Morbid Obesity? Not What You Might Think. Excerpted from: obesitymedicine.org/what-is-morbid-obesity/

4. First Coast Services Options, Inc. 2019. Local Coverage Determination Surgical Management of Morbid Obesity (L33411). Excerpted from: cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33411&ver=29&DocID=L33411&bc=AAAAAAIAAAAA&

5. AHA Coding Clinic for ICD-10-CM/PCS. 2021 Number 1 First Quarter Volume 8: codingclinicadvisor.com

6. US National Library of Medicine, National Institute of Health. 1985. The hypercoagulable states. Excerpted from: ncbi.nlm.nih.gov/pubmed/3158262

7. Mayo Clinic. Hyperglycemia. Excerpted: mayoclinic.org/diseases-conditions/hyperglycemia/basics/tests-diagnosis/con-20034795

8. Pinson, R., MD. (2012, May 15). Functional quadriplegia (American College of Physicians, Ed.). Retrieved August 1, 2019, from: acphospitalist.org/archives/2012/05/coding.htm

Malignancy

The ICD-10-CM provides two code sets to classify cancer (CA):

Categories C00-D09 are for active cancer or requiring active treatment. These categories include primary and secondary malignant neoplasms, and carcinoma-in-situs.

In order to use these categories, the clinical documentation must include:

• The term “active” and whether it is primary, secondary (metastasis) or in situ

• OR active treatment such as chemotherapy, radiation, immunotherapy or hormone therapy (e.g., Tamoxifen)

• OR if the patient refuses treatment, the term “watchful waiting” or that it is a contraindication due to age or other medical circumstance

Use the following codes as the first-listed or principal code when the encounter is solely for the administration of 1:

• Antineoplastic radiation therapy, Z51.0

• Antineoplastic chemotherapy, Z51.11

• And/or antineoplastic immunotherapy Z51.12

The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis.

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site only, the metastatic site is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code1

Codes under these categories (C00-D09) also have an impact in the Risk Adjustment Factor methodology. Here are the hierarchical conditions categories (HCCs):

1 2

This HCC (12) also includes certain nonmalignant neoplasms mainly related to the nervous system.

Categories Z85 and Z86 for history of a malignant neoplasm or carcinoma-in-situs

Use these categories when the CA has been eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing malignancy. Also, these categories should be used when the documentation does not support an active code (above codes)1

If applicable, code first Z08 for follow-up examinations after active treatment including routine surveillance for recurrence of a previously treated malignancy.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate, or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s care. Always refer to the ICD-10-CM codebook for correct coding and more information about coding guidelines at: cdc.gov/nchs/icd/icd10cm.htm

1. RAF weight is based on a community-nondual-aged member, please refer to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors Optum360, LLC. (2019). ICD-10-CM Expert for Hospitals

Cellulitis, UTI & Sepsis

According to the Centers for Disease Control and Prevention (CDC), cellulitis is a common bacterial skin infection. If untreated, it can spread to other tissues and organs. As a result, patients may develop sepsis, suppurative arthritis, osteomyelitis, and endocarditis, among other serious health complications.

Clinical Documentation

• Location

• Infectious

• Risk factors like injuries, chronic skin conditions, edema, obesity, and others.

ICD-10-CM coding

This is a limited list, see the codebook for more options.

• L03.011, Cellulitis of right finger

• L03.012, Cellulitis of left finger

• L03.111, Cellulitis of right axilla

• L03.112, Cellulitis of left axilla

• L03.115, Cellulitis of right lower limb

• L03.116, Cellulitis of left lower limb

• L03.211, Cellulitis of face

• L03.311, Cellulitis of abdominal wall

Use an additional code from categories B95-B97 to specify infectious agent, e.g., group A strep

• L03.312, Cellulitis of back

• L03.313, Cellulitis of chest wall

• L03.314, Cellulitis of groin

• L03.315, Cellulitis of perineum

• L03.317, Cellulitis of buttock

• L03.811, Cellulitis of head

• L03.90, Cellulitis, unspecified

Cellulitis in the risk adjustment methodology

The skin infection per se does not impact the methodology. However, its potential complications such as sepsis and osteomyelitis do.

Urinary Tract Infection (UTI)

UTIs are common infections when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract. UTI is a general term used to encompass infections in different locations in the urinary system; however, the most common site is the bladder (cystitis).

Clinical Documentation

• Location

• Infectious

• Risk factors like previous infections, pregnancy, enlarged prostate, and others.

ICD-10-CM coding

This is a limited list, see the codebook for more options.

Use an additional code from categories B95-B97 to specify infectious agent, e.g., E. Coli

• N30.00, Acute cystitis without hematuria

• N30.10, Interstitial cystitis (chronic) without hematuria

• N34.2, Other urethritis

• N39.0 Urinary tract infection, site not specified

UTIs do not have an impact on the risk adjustment methodology

According to CDC, sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency managed and treated in a facility setting. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Sepsis can rapidly lead to tissue damage, organ failure, and death without timely treatment. This direr stage is called severe sepsis. However, the most stringent level of sepsis is a septic shock which is diagnosed when the patient suffers from hypotension (Sepsis Alliance, 2022)

Bacterial infections are the most common cause, but other infections can also cause sepsis, such as COVID-19 and influenza. The infections are often in the lungs, stomach, kidneys, or bladder. Sepsis can begin with a small cut that gets infected or an infection that develops after surgery. Sometimes, sepsis can occur in people who did not even know that they had an infection (NIH, 2022).

The minimum clinical documentation requirements for ICD-10-CM code assignment:

• The term “sepsis”

• The infectious organism

• Whether it is severe, including organ dysfunctions

• And whether the patient is suffering from a septic

Who is at risk?

• Adults 65 or older

• People with chronic conditions suchs as diabetes, lung disease, cancer, and kidney disease

• Sepsis survivors

Common infective organisms that cause sepsis are escherichia coli and klebsiella pneumoniae. However, the deadliest is methicillin-resistant staphylococcus aureus.

General coding guidelines

If the type of causal organism is not specified in the documentation, the coder should use code A41.9, Sepsis, unspecified organism. For severe sepsis, at least two codes are required:

• Code identifying the infection, the sepsis per se. Use code A41.9 if the organism is not specified.

• Code R65.20, classifying sepsis as a severe process. However, if the patient is in a septic shock, code R65.21 should be used instead.

• Code associated organ dysfunctions such as acute kidney, respiratory or heart failures

Sepsis in the risk adjustment methodology

All types of sepsis impact the methodology and are classified under the hierarchy (HCC) 2**. The HCC 2 has a score of 0.352.

• Most related organ dysfunctions like acute kidney failure and acute respiratory failure also impact the methodology.

Coding example

A patient with chronic cystitis with hematuria is admitted due to severe sepsis. The organism responsible for the infection is escherichia coli. The patient suffered from acute renal and liver failures during the hospital stay. In addition, the patient has diabetes complicated with chronic kidney disease stage 4 and a history of recurrent UTIs.

• A41.51, Sepsis due to Escherichia coli [E. coli]

• R65.20, Severe sepsis without septic shock

• N17.9, Acute kidney failure, unspecified

• K72.00, Acute and subacute hepatic failure without coma

• E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

• N18.4 Chronic kidney disease, stage 4 (severe)

• N30.21 Other chronic cystitis with hematuria

• Z87.440 Personal history of urinary (tract) infections

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care.

** CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees.

• CDC, 2022.

- Cellulitis, https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html#:~:text=Cellulitis%20is%20a%20common%20bacterial,Many%20Bacteria%20Can%20Cause%20Cellulitis - Sepsis, https://www.cdc.gov/sepsis/what-is-sepsis.html#:~:text=Sepsis%20is%20the%20body’s%20extreme,%2C%20skin%2C%20or%20gastrointestinal%20tract - UTI, https://www.cdc.gov/antibiotic-use/uti.html#:~:text=UTIs%20are%20common%20infections%20that,is%20another%20type%20of%20UTI

• NIH, 2022. https://medlineplus.gov/sepsis.html

• Sepsis Alliance, 2022. https://www.sepsis.org/sepsis-basics/what-is-sepsis/ 2 of 2

Chronic Kidney Disease

Patients with CKD or ESRD?*

The principle aim is to identify individuals at risk of progressive chronic kidney disease (CKD) in the primary care setting:

• Lab test to identify and monitor proteinuria, serum creatinine levels and hematuria

• Control the underlying disease if applicable, like hypertension or diabetes (DM)

• Assess for any urinary obstruction

• Medication review to identify nephrotoxic drugs and drugs that may need to be adjusted

• Assess for anemia, hemoglobin levels

• If progression is identified, it may be necessarily to refer the patient to a nephrologist

Same as above plus:

• Potassium, bicarbonate, calcium and phosphate levels

• Assess for water fluid retention

• If applicable, assess AV fistula/shunt site, use in addition code Z99.2

• Evaluate patient every 3 months

CKD 5 requiring dialysis is considered the end stage of the disease (ESRD). Use in addition code Z99.2 to identify patients requiring dialysis.

• Patients refusing dialysis, use code Z91.15

• Kidney transplant status, use code Z94.0

30 million people or 15% of adults in the U.S. are estimated to have CKD. Most (96%) people with kidney damage or mildly reduced kidney function are not aware of having CKD. Those with diabetes, high blood pressure, or both have a higher risk of developing CKD than those without these diseases. Other risk factors for CKD include heart disease, obesity, and a family history of CKD4

Patient with CKD may develop hyperparathyroidism. It is a very early disease and its diagnosis and treatment is crucial in the management of the patient. It has been demonstrated that the PTH starts to increase as early as the beginning of CKD stage 3, along with normal levels of serum calcium and phosphorus5

• Related to CKD or another renal disease, N25.81

• Due to other condition, E21.1

• Primary, E21.0

Patients who have undergone kidney transplant may still have some form of CKD3. Therefore, assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0.

Monitor periodically these conditions and their plan of treatment. Some patients do not adhere to medications, diet or care plan. We recommend scheduling one face-to-face visit before July 1st, and one before December 31st.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. ** CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees.

1. CDC. National Chronic Kidney Disease Fact Sheet, 2021. Excerpted: https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html

2. The Renal Association. The UK eCKD Guide. 2017. Excerpted: https://ukkidney.org/health-professionals/information-resources/uk-eckd-guide

3. RAF weight is based on a community-nondual-aged member, please refer to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

4. CMS. ICD-10-CM Official Guidelines for Coding and Reporting FY 2021. Excerpted: https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf

Coronary Artery Disease (CAD)

Patients with CAD?*

Coronary artery disease (CAD) is the most common type of heart disease. CAD can lead to angina, heart attacks and failures and arrhythmias. It is the leading cause of death in the United States.1

Arrhythmias

• Atrial Fibrillation I48.91

• Atrial flutter I48.92

• Atrial tachycardia I47.1

• Atrioventricular block, complete I44.2

• Paroxysmal ventricular tachycardia I47.2

• Supraventricular tachycardia I47.1

• Sick Sinus Syndrome I49.5

• Ventricular tachycardia I47.2

• Ventricular fibrillation I49.01, treated in a facility setting

• Ventricular flutter I49.02, treated in a facility setting

Patients at risk of developing the disease may suffer from: hypertension, high cholesterol, smoking, poor diet, obesity, inactivity, and other health conditions such as diabetes.2 Patients should be screened for a cardiovascular disease every 5 years.3

CAD I25.10 with

Angina pectoris I25.119

Treatment: rest and/or nitroglycerin4

Unstable angina I25.110

It should be treated as an emergency since the patient could be having a heart attack.4

Acute myocardium infarction (AMI) I21.9

Subsequent AMI I22.9

Treatment may include: anticoagulants, lipid-lowering medications, pacemaker, and others

• For AMI between 0-28 days (or 4 weeks) use category I21.- Use I25.2 (Old MI) for more than 28 days (4 weeks) AMIs or when the timeframe is unknown.

• Use category I22.- to identify a subsequent AMI during the acute timeframe of the first unspecified or type 1 AMI. Subsequent AMIs do not extend the original AMI’s timeframe; therefore, once the 28 days (4 weeks) are over the MIs should be coded as old I25.2.

• For subsequent type 2 AMIs assign only code I21.A1. For subsequent type 4 or type 5 AMIs, assign only code I21.A9

Monitor periodically these conditions and their plan of treatment. Some patients do not adhere to medications, diet or care plan. We recommend scheduling one face-to-face visit before July 1st, and one before December 31st.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. ** CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees.

1. US National Library of Medicine. Coronary Artery Disease. Excerpted: https://medlineplus.gov/coronaryarterydisease.html

2. American Academy of Family Physicians. CAD. Excerpted: https://familydoctor.org/condition/coronary-artery-disease-cad/?adfree=true

3. Medicare Claims Processing Manual Chap. 18 - Preventive and Screening Services. Excerpted: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

4. American Heart association. Angina Pectoris (Stable Angina). Excerpted: https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/angina-pectoris-stable-angina HCCs:

Cerebrovascular Accident (CVA)

Patients that suffered from a CVA?*

Yes

Acute cerebrovascular accident (CVA)

Cerebrovascular accidents (CVAs), strokes or brain infarcts are a medical emergency. Quick treatment is needed, patients should be sent to ER.4 The correct code for an acute episode of the condition is I63.9.1 If this code is used in an office setting, documentation must support the acute episode. The physician may require additional testing to establish the diagnosis, code signs and symptoms if the diagnosis is uncertain.

Speech and language deficits

• Aphasia I69.320

• Dysphasia I69.321

• Dysarthria I69.322

Monoplegia of lower limbs

• Right dominant side I69.341

• Left dominant side I69.342

• Right non-dominant side I69.343

• Left non-dominant side I69.344

• Unspecified side I69.349

No

Many common medical conditions can increase the chance of suffering a CVA. These are hypertension, high cholesterol, heart disease, diabetes, others. If the patient had a transient ischemic attack (TIA) already, the risk of having a CVA is even higher.2

Hemiparesis or hemiplegia

• Right dominant side I69.351

• Left dominant side I69.352

• Right non-dominant side I69.353

• Left non-dominant side I69.354

• Unspecified side I69.359

Other paralytic syndromes

• Right dominant side I69.361

• Left dominant side I69.362

• Right non-dominant side I69.363

• Left non-dominant side I69.364

• Unspecified side I69.369

• Use additional code for: Paraplegia G82.20 or Quadriplegia G82.50

Sequelae management3

• Rehabilitation like physical therapy and swallowing and respiratory therapy

• Drug therapy

• Psychological treatment such as antidepressant and counseling

• Skin breakdown prevention

• Limb contractures prevention

• Other treatments

Stroke is the fifth leading cause of death in the United States and is a major cause of serious disability for adults. About 795,000 people in the United States have a stroke each year.2

The sequela may be apparent early, or it may occur months or years later. There is no timeframe to code a sequela5

Monitor periodically these conditions and their plan of treatment. Some patients do not adhere to medications, diet or care plan. We recommend scheduling one face-to-face visit before July 1st, and one before December 31st.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. Always refer to the ICD-10-CM codebook for correct coding and more information about coding guidelines at: cdc.gov/nchs/icd/icd10cm.htm

1. CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees

2. CDC Accidents Cerebrovascular 2016. Excerpted: https://www.cdc.gov/stroke/risk_factors.htm

3. American Stroke Association. Let’s talk about Complications after stroke. Excerpted: https://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/documents/downloadable/ucm_309717.pdf

4. US National Library of Medicine. Stroke. Excerpted: https://medlineplus.gov/ency/article/000726.htm

5. CMS. ICD-10-CM Official Guidelines for Coding and Reporting FY 2021

HCCs: Cerebrovascular Accident (CVA)

Heart Failure

Patients with heart failure (HF)?*

About 5.7 million people in the United States have HF. It is a leading cause of hospital stays among people on Medicare2

Types of HFs I50.9:

Systolic I50.20

• Acute I50.21

• Chronic I50.22

• Acute on chronic I50.23

Diastolic I50.30

• Acute I50.31

• Chronic I50.42

• Acute on chronic I50.33

Combined systolic and diastolic I50.40

• Acute I50.41

• Chronic I50.42

• Acute on chronic I50.43

Other types of HFs

• End stage (D) I50.84

• Biventricular I50.82

• High output I50.83

• Right side I50.810

- Acute I50.811

- Chronic I50.812

- Acute on chronic I50.813

- Secondary to left HF I50.814

Due to HTN, code first: I11.01

Left HF I50.1

A normal heart’s ejection fraction (EF) is between 50% and 70%. However, patients with a normal EF may still have HF. It is called HF with preserved ejection fraction (HFpEF), I50.30. This happens when the heart muscle has become so thick and stiff that the ventricle holds a smaller than usual volume of blood, it might still seem to pump out a normal percentage of the blood that enters it. Though, the total amount of blood pumped is not enough to meet body’s needs. Contradictory, an EF higher than 75% may indicate a heart condition such as hypertrophic cardiomyopathy5, I42.2

Heart failure develops over time as the heart’s pumping action grows weaker. The most common signs and symptoms of heart failure are: shortness of breath (SOB), fatigue (tiredness), swelling in the ankles, feet, legs, abdomen, and veins in the neck2

Coronary artery disease (CAD) is the most common cause of HF. Other underlying conditions are hypertension (HTN), heart valves disorders, cardiomyopathy, diabetes, HIV, hyperthyroidism, and hypothyroidism3.

Acute HF is defined as a rapid onset of new or worsening signs and symptoms of HF. It is often a potentially life-threatening condition, requiring hospitalization, and emergency treatment is aimed predominantly at managing fluid overload and hemodynamic compromise4.

1 out of every 500 people has a hypertrophic

Types of cardiomyopathy I42.9

• Hypertrophic I42.2

• Hypertrophic obstructive I42.1

• Hypertensive I11.9 and I43

• Dilated I42.0

• Restrictive I42.5

• Diabetic E11.59 and I43

• Due to alcoholism I42.6 and F10.20

Monitor periodically these conditions and their plan of treatment. Some patients do not adhere to medications, diet or care plan. We recommend scheduling one face-to-face visit before July 1st, and one before December 31st.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care.

1. RAF weight is based on a community-nondual-aged member, please refer to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

2. NIH. Heart Failure. Excerpted: https://www.nhlbi.nih.gov/health-topics/heart-failure

3. Mayo Clinic. Heart Failure. Excerpted: https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142

4. NIH. Acute Heart Failure: Definition, Classification and Epidemiology. Excerpted: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597697/

5. AHA. Ejection Fraction Heart Failure Measurement. Excerpted: http://www.heart.org/en/health-topics/heart-failure/diagnosing-heart-failure/ejection-fraction-heart-failure-measurement

type5

Diabetes

Diagnosis, Clinical Documentation & HCC Coding

According to the Centers for Disease Control and Prevention (CDC), 34.2 million Americans have diabetes (DM). However, 7.3 million are undiagnosed. Type 2 DM accounts for 90% to 95% of all diabetes cases.1

• A1C 6.5% or above

• Fasting plasma glucose (FPG) 126 or abovea

Two abnormal results from these tests required to establish the diagnosis.*

Hyperglycemia, E11.65 Persistent blood glucose levels over 140mg/dL or an A1c level over 8%2

• Oral glucose tolerance test (OGTT) 200 or aboveab

• Random plasma glucose test (RPG) 200 or abovea

a - Glucose values are in milligrams per deciliter, or mg/dL

b - At 2 hours after drinking 75 grams of glucose

Other terms that support code E11.65: poorly controlled/out of control DM

In the long term, persistent hyperglycemia, even if not severe, can lead to complications affecting eyes, kidneys, nerves, and other parts of the body.2

Kidney Complications

DM with nephropathy, E11.21

DM with CKD 1, E11.22 and N18.1

DM with CKD 2, E11.22 and N18.2

DM with CKD 3, E11.22 and N18.30

Circulatory Complications

DM with PVD or PAD, E11.51

DM with peripheral angiopathy, E11.51

DM with CKD 4, E11.22 and N18.4

DM with CKD 5, E11.22 and N18.5

DM with ESRD, E11.22 and N18.6

Code also: Requiring dialysis, Z99.2

Patient refuses dialysis, Z91.15 AV fistula/shunt in place, Z99.2

Eye & Nerve Complications

DM with neuropathy, E11.4

DM with polyneuropathy E11.42

DM with cardiomyopathy, E11.59 and I43

DM with heart failure, E11.59 and I50.9

Amputations

DM with cataracts, E11.36

DM with retinopathy, E11.319

DM with proliferative retinopathy, E11.3599

Amputations may be present in DM patients due to vascular and nerve complications. See the following subcategories in the codebook:

Great toe, Z89.41Other toes, Z89.42Foot, Z89.43-

HCCs: Diabetes

Ankle, Z89.44Below knee, BKA, Z89.51-

No knee, Z89.52Above knee, AKA, Z89.61-

See the ICD-10-CM codebook for more specific retinopathy options.

Skin Complications Other Complications

DM with dermatitis, E11.620

DM with acanthosis nigricans, E11.628 and L83

DM with foot ulcers, E11.621 plus:

RT foot, L97.919

LT foot, L97.929

See code E11.622 and category L97 for more specific ulcer options.

DM with periodontal disease, E11.630

DM with xerostomia, E11.638 and K11.7

DM with erectile dysfunction (ED), E11.69 and N52.1

If it is documented as related to nerve or vascular damage, use the corresponding code category.

DM with hypertriglyceridemia, E11.69 and E78.1

DM with hyperlipidemia, E11.69 and E78.5

The most common lipid abnormalities in type 2 diabetes patients are hyper-triglyceridemia and reduced high-density lipoprotein (HDL) cholesterol levels.3

Documentation & Coding Guidelines

• Diagnoses must be documented in the medical record in words; do not use codes. If the electronic health record uses the code description in lieu of a diagnostic statement, avoid code descriptions with ambiguous terms like “other,” “unspecified,” “without,” or “in disease classified elsewhere.” However, further clarification in the same note may be required if these terms are used, like an open-text notation describing the diagnosis better.

• Use relationship terms when documenting diabetes and its complications such as “with,” “due to,” or “diabetic.”

• In order to support a code, the documentation must include treatment for every diagnosis or a statement describing how the diagnosis is affecting patient care. For example:

- Oral hypoglycemic drugs, use code Z79.84 for long-term use

- Insulin, use code Z79.4 for long-term use

- Non-insulin injectables, use code Z79.899 for long-term use

- Diet and exercise

- Referral to other healthcare providers

- A statement indicating the status, evaluation, or how the diagnosis is affecting patient care like “controlled blood glucose” or “a therapy or procedure cannot be performed because the patient has diabetes.” Some coders use acronyms MEAT and TAMPER™ to apply this guideline better.**

• Use as many codes as necessary to translate the diagnostic statement.

• Category E11 is used to classify unspecified or type 2 DM; see ICD-10-CM codebook to code correctly other types of diabetes.

• Codes with a dash (-) are incomplete and require additional characters.

• Code E11.9 is used when the documentation does not specify any diabetic complication. Do not use this code with other diabetes codes or when the documentation supports a more specific code.

• Code E11.8 is used when the documentation does not specify the diabetic complication, i.e., “complicated diabetes” without further specifications. Query the providers in these instances.

References and additional notes:

This tool is not intended to diagnose, evaluate, or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s care. Always refer to the ICD-10-CM codebook for correct coding and more information about coding guidelines at: cdc.gov/nchs/icd/icd10cm.htm

*Based on the American Diabetes Association guidelines, please refer to the official source: care.diabetesjournals.org/content/43/Supplement_1

**TAMPER is a trademark of ionhealthcare.com/

1. CDC. 2020 National Diabetes Statistics Report: cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

2. Mayo Clinic. Hyperglycemia. Excerpted from: mayoclinic.org/diseases-conditions/hyperglycemia/basics/tests-diagnosis/con-20034795

3. American Family Physicians. Hyperlipidemia in Patients with Type 2 Diabetes: aafp.org/afp/1999/0315/p1666.html

Epilepsy and Seizures Disorders*

3.4 million people nationwide have epilepsy, making it one of the most common neurological disease globally, and people with epilepsy are up to three times more likely to die prematurely than those without it. Causes of epilepsy can include anything from head trauma or drug or alcohol intoxication of fever, stroke and metabolic disturbances.1

Epilepsy and recurrent seizures2

• G40.0-, Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset;

• G40.1-, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures;

• G40.2-, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures;

• G40.3-, Generalized idiopathic epilepsy and epileptic syndromes;

• G40.A-, Absence epileptic syndrome;

• G40.B-, Juvenile myoclonic epilepsy (impulsive petit mal)

• G40.4-, Other generalized epilepsy and epileptic syndromes

• G40.5-, Epileptic seizures related to external causes

• G40.8-, Other epilepsy and recurrent seizures

• G40.9-Epilepsy, unspecified.

Test & Treatment

Blood tests, neurological exams, and lumbar punctures help to diagnose any infections, metabolic imbalances, or genetic conditions that could be the cause of a seizure and, in doing so, helps to indicate the likelihood of recurrence. EEGs also help by providing doctors with details regarding any possible patterns in the seizure activity. CT scans, MRIs, and PET scans can also reveal the existence of any lesions or abnormalities that could be attributed to a cause.

Depending on whatever cause is determined, possible treatments include surgical intervention, anti-seizure medications, neurostimulation, and dietary therapies to improve seizure control.

Documentation must confirm:

• Intractable or not –intractable

• With or without status epilepticus

Seizures / Convulsions2

• R56.0- Febrile convulsions

• R56.00- Simple febrile convulsions NOS

• R56.01- Complex febrile convulsions

• R56.1- Post traumatic seizures

• R56.9- Unspecified convulsions (includes seizures NOS).

Current vs. History of Documentation

• Avoid using the descriptor “history of” to describe a present diagnosis as it suggests the condition occurred in the past and is no longer current.

• To meet the M.E.A.T documentation values for patients with a chronic condition that is not actively showing symptoms, a provider may use descriptors such as inactive, quiescent, dormant, etc.

• It is possible for a patient on maintenance therapy to achieve long-term seizure-free status, while still having epilepsy. The two are not mutually exclusive, so ensure that conditions are documented clearly.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care.

** CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees.

1. Center of Disease Control, https://www.cdc.gov/epilepsy/data/index.html

2. Optum360, LLC. (2022). ICD-10-CM Expert for Hospitals

HCCs: Epilepsy and Seizure Disorders

Morbid Obesity

Obesity and overweight are conditions based on a person’s weight in relation to their height and body mass index (BMI). BMI is a valuable screening tool for physicians in the evaluation of weight and nutritional status. A BMI of 25 or greater is considered higher than normal, but a physician or other qualified health care provider is required to make a diagnosis of overweight or obese.

Morbid obesity is defined by the CDC simply as a BMI ≥ 40. The National Institutes of Health (NIH) indicates that morbid obesity should be identified as a severe obesity that includes patients with a BMI ≥ 40 or BMI = 35.0-39.9 who have at least one significant comorbidity related to obesity. The ICD-10-CM guidelines section I (C.21.c.3) states, “physicians have the discretion to align their weight diagnosis with their assessment of the patient’s weight and comorbidities.”

Morbid obesity greatly increases the patient’s risk for other disorders. Significant comorbid conditions include type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease (coronary artery disease, peripheral vascular disease, carotid artery disease, and abdominal aortic aneurysm), obstructive sleep apnea and obesity-hyperventilation syndrome. Any diagnosis of obese or morbidly obese should be documented for any encounter in which the condition is observed.

Morbidly Obese

= 18.5 - 24.9

= 25 - 29.9

ICD-10 Codes for Overweight, Obesity, Morbid Obesity and BMI

ICD-10 CM Description

E66.01 Morbid (severe) obesity due to excess calories

E66.09 Other obesity due to excess calories

E66.1 Drug-induced obesity

E66.2 Morbid (severe) obesity with alveolar hypotension

E66.3 Overweight

E66.8 Other obesity

E66.9 Obesity, unspecified

Z68.35 Body mass index (BMI) 35.0 – 35.9, adult

Z68.36 Body mass index (BMI) 36.0 – 36.9, adult

Z68.37 Body mass index (BMI) 37.0 – 37.9, adult

Z68.38 Body mass index (BMI) 38.0 – 38.9, adult

Z68.39 Body mass index (BMI) 39.0 – 39.9, adult

Z68.41 Body mass index (BMI) 40.0 – 44.9, adult

Z68.42 Body mass index (BMI) 45.0 – 49.9, adult

Z68.43 Body mass index (BMI) 50.0 – 59.9, adult

Z68.44 Body mass index (BMI) 60.0 – 69.9, adult

Z68.45 Body mass index (BMI) 70 or greater, adult

Documentation and Coding Example

Assessment/Plan

Morbid obesity recorded BMI is 40.2 –patient admits to overeating. Discussed dietary changes and reduced caloric intake at length. Will schedule consult appointment with our registered dietician. Type 2 Diabetes without complications: A1c within normal limits. Continue current medication.

ICD-10-CM Codes

• E66.01 – Morbid (severe) obesity due to excess calories

• Z68.41 – BMI 40.0 - 44.9, adult

• E11.9 – Type 2 Diabetes mellitus without complications

• Z71.3 – Dietary counseling and surveillance

BMI Chart - What is your BMI?

Percutaneous Coronary Intervention (PCI)*

Outpatient Coding for PCI

CPT codes 92920 -92944

• They’re reported by major coronary arteries and their branches. Modifiers must be used to identify each, otherwise, the payer may deny the service.

– Left main coronary (modifier LM)

– Left anterior descending artery (LD)

– Left circumflex (LC)

– Right coronary artery (RC)

– Ramus intermedium artery (RI)

• This is a variant coronary artery resulting from trifurcation of the left main coronary artery. It is present in ~20% (range 15-30%) of the population.

Coding CPT example:

• A balloon was used for a main right coronary artery, a stent in the posterior descending of the artery, and a second stent was placed in the left circumflex

Code 92928-RC (percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery of branch.)

– plus 92921 –RC

– 92928- LC (percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch.)

Documentation for CPT/HCPCS

Make sure that documentation includes every component of the code’s description

• Plus: any other regulations like LCD/NCDs

What is included in the PCI code?

Make sure that documentation includes every component of the code’s description

PCI coding hierarchy

Stent

• 92928, 92929 or 92933, 92934

Atherectomy

• 92924 and 92925

Just the Balloon

• 92920 and 92921

• Each code in the family, including balloon angioplasty and when it was performed.

• Diagnostic coronary angiography codes (93454-93461) and injection procedure codes (93563-93564) should not be used with percutaneous coronary revascularization services (92920-92944) to report:

Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for the coronary intervention

Vessel measurement for the coronary intervention

Post-coronary angioplasty/stent/atherectomy angiography, as this work is captured in the percutaneous coronary revascularization services codes (92920-92944).

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care.

** CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees.

Substance Use Disorder*

Diagnostic Criteria, Documentation and Coding

According to the National Institute of Health (NIH), addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain. However, addiction is not a specific diagnosis in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which is the diagnostic manual used to establish mental disorders. The DSM-5 has replaced categories of substance abuse and substance dependence with a single category: substance use disorder, with three sub classifications—mild, moderate, and severe1. Although some healthcare professionals along with the ICD-10-CM are still using the obsolete terms, dependence or addiction.

Take into consideration the following criteria when establishing the diagnosis: 3,4,5

General Criteria:

1. Substance is often taken in larger amounts and/or over a longer period than the patient intended.

2. Persistent attempts were made, or one or more unsuccessful efforts, to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects.

4. Craving or strong desire or urge to use the substance.

5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued substance use despite having persistent or recurrent social or interpersonal problem caused or exacerbated by the effects of the substance.

7. Important social, occupational or recreational activities given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous.

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance

11. Withdrawal

More than one in four adults living with serious mental health problems also has a substance use problem. Substance use problems occur more frequently with certain mental health conditions, including2: Schizophrenia F20.9 (0.524), bipolar disorder F31.9 (0.309), and personality disorders F60.9 (0.309)**

Refer to the ICD-10-CM manual for more coding options for other complications like intoxication and withdrawal.

Substitute the last F code’s characters with the following characters if the patient suffers from any substance-related or induced problem:

Mood Disorder Characters - 14 Characters - 24

Deliriums Characters - 150 Characters - 250

Hallucinations

Sexual dysfunction

Characters - 151 Characters - 251

Characters - 181 Characters - 281

Sleep disorder Characters - 182 Characters - 282 1

Substance Use Disorder in Remission5

• Early remission: None of the criteria for substance use disorder have been met for at least 3 months but for less than 12 months

• Sustained remission: None of the criteria for substance use disorder have been met at any time during a period of 12 months or longer

The ICD-10-CM classifies both types of remissions under the same coding characters. Use the appropriate substance F code with .11 for mild disorders in remission and characters .21 for moderate and severe severities. Also, ICD-10-CM classifies “history of drug dependence” as “in remission”.

Substance use that does not meet criteria, 0-1 of the 11 criteria

The ICD-10-CM provides coding options for substance use that does not meet the severity criteria. However, these codes are to be used only when the substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the healthcare professional. These codes must never be used to identify recreational or social substance use without any related problem. These subcategories are: F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9- o F19.9-.

Caffeine Use Disorder

The caffeine use disorder should only be established if the use of this substance is causing any impairment in the patient’s health or require or affect patient care treatment or management. Examples include:

• “Patient suffers of insomnia and cannot decrease caffeine consumption…”.

• “Patient on bupropion, 30 days under the therapy, indicates that sometimes feels more anxious than normal and is harder to fall asleep since taking the drug. He was educated to cut down the caffeine consumption (currently 4-5 caffeine drinks a day) to only one drink. We will monitor…”.

• Limited or discontinue use of caffeine should be encouraged in patients with certain conditions like: hypertension, insomnia, anxiety, gastroesophageal reflux, gastritis, kidney problems, and others. Caffeine may also interact with certain prescribed drugs such as antidepressants and thyroid medications7, 8, 9, 11 .

Patient Treatment and Management10

• Toxic habits evaluation and medication reconciliation must be done to identify potential interactions and better course of treatment

• Behavioral counseling and psychotherapy

• Medication such as methadone and nicotine replacement therapies

• Medical devices and applications used to treat withdrawal symptoms or deliver skills training

• Evaluation and treatment for co-occurring mental health issues such as depression and anxiety

• Long-term follow-up to prevent relapse

HEDIS and Stars Rating programs recommend a patient evaluation within 14 days of the first intervention of the diagnosis, and two or more additional services within 30 days of the initial visit. This recommendation does not apply for patients with history or remission of the disorder6.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. Always refer to the ICD-10-CM manual for appropriate code assignment.

** HCC information and RAF weight is based on a community-nondual-aged member, please refer to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

1. NHI (rev. 2018, July). The Science of Drug Abuse and Addiction: The Basics. Retrieved from: https://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics

2. HHS. (2013, March 14). Mental Health and Substance Use Disorders. Retrieved from: https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders

3. Striley, C. L., Griffiths, R. R., & Cottler, L. B. (2011, Diciembre). Evaluating Dependence Criteria for Caffeine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621326/

4. Ogawa, N., & Ueki, H. (2007). Clinical importance of caffeine dependence and abuse. Psychiatry and Clinical Neurosciences, 61(3), 263-268. doi:10.1111/j.1440-1819.2007.01652.x.

Retrieved from: http://www.recoveryonpurpose.com/upload/Clinical%20Importance%20of%20Caffeine%20Dependence%20and%20Abuse.pdf

5. APA. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, Londres: American Psychiatric Association.

6. HEDIS (2018). Washington, DC: National Committee for Quality Assurance.

7. Sagon, C. (n.d.). Coffee for Health - Positive and Negative Effects of Caffeine. Retrieved from https://www.aarp.org/health/healthy-living/info-10-2013/coffee-for-health.html

8. Caffeine & Sleep Problems. (n.d.). Retrieved from https://www.sleepfoundation.org/articles/caffeine-and-sleep

9. Sheldon G. Sheps, M. (2019, January 26). What caffeine does to blood pressure.

Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/blood-pressure/faq-20058543

10. National Institute on Drug Abuse. (n.d.). Treatment Approaches for Drug Addiction.

Retrieved from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction

11. PDR. (n.d.). Bupropion hydrochloride - Drug Summary. Retrieved from: https://www.pdr.net/drug-summary/Wellbutrin-bupropion-hydrochloride-237

The patient may have cravings or a strong desire or urge to use the substance, but still considered to be in remission5

E/M and Level of Medical Decision Making (MDM) Quick Reference

Elements of Medical Decision Making

• 2 or more stable chronic illness or

• 1 undiagnosed new problem with uncertain prognosis or

• 1 acute illness w/systemic sym. or

• 1 acute complicated injury

Limited (Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

• Review of prior external notes

• Order tests,

• Review of test result(s) or Category 2: Assessment requiring an independent historian(s)

Moderate (Must meet the requirements of at least 1 of the 3 categories)

Category 1: Tests, documents, or independent historian(s)

(Any combination of 3 from the following)

• Review of test result(s)

• Order tests

• Review prior external notes

• Assessment requiring anindependent historian(s) or Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another provider or Category 3: Discussion of management or test interpretation

• Discussion of mgmt. or test interpretation with external provider

Moderate risk

Example only:

• Prescription drug management

• Minor surgery w/ risk factors

• Decision for major surgery w/o risk factors

• Diagnosis treatment significantly limited by Social Determinants

• 1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment or

• 1 acute or chronic illness or injury that poses a threat to life of bodily functions

Extensive (Must meet the requirements of at least 2 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

(Any combination of 3 from the following)

• Review of test result(s)

• Order tests

• Review prior external notes

• Assessment requiring anindependent historian(s) or

Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another provider or Category 3: Discussion of management or test interpretation

• Discussion of mgmt. or test interpretation with external provider

High risk

Example only:

• Drug monitoring for toxicity

• Major surgery with risk factors

• Decision for emergency major surg.

• Decision for hospitalization

• Decision DNR or to deescalate because of poor prognosis

PROLONGED SERVICES

(Must meet time components and 15 minutes or more. Each unit must reach 15 minutes to bill for prolonged services.) +99417 (Comm. payers) (99205) Each additional 15 minutes after 74 minutes on day of encounter

Each additional 15 minutes after 54 minutes on day of encounter

Each additional 15 minutes after 89 minutes on day of encounter

Medicare

Each additional 15 minutes after 69 minutes on day of encounter

TIME-BASED CODING ELEMENTS

(When performed and documented. **Time-based coding is based on total time spent on date of the encounter)

• Reviewing patient’s record prior to visit

• Documenting clinical information in the patient’s electronic health record

• Obtaining/review history from someone other than patient

• Independently interpreting results

• Performing a medically appropriate history and exam

• Communicating results to the patient/family/caregiver

• Counseling/educating the patient/family/caregiver

• Coordination of care for the patient

• Referring and communicating with another healthcare provider(s) when not separately reported during the visit

• Ordering prescription medications, tests, or procedures

IMPORTANT NOTES:

• E/M code 99201 is deleted in 2021 due to low utilization.

• History and exam will not be counted as an element, but medical necessity must be established by documenting risk and medical decision making relevant to management of patient’s condition.

• Interpretation of tests or discussion of management with another qualified healthcare professional is considered only when not separately reported

Additional Measures

Use of Imaging Studies for Low Back Pain (LBP)

What Is the Measure?

This measure looks at the percentage of enrolled patients 18 to 50 years of age diagnosed with uncomplicated low back pain during the measurement period who did not have an imaging study (X-ray, MRI, or CT scan) within 28 days after the diagnosis.

Eligible Codes

9.1

9.2

9.3

Description Code(s)

Uncomplicated low back pain

Exclusions

Patients with any of the following conditions are excluded from the measure:

• Cancer

• HIV

• Major organ transplant

• Recent trauma within 3 months prior to episode date to 28 days after the episode date

• Previous diagnosis of low back pain within 6 months prior to episode date

• History of Intravenous drug abuse within 12 months prior to episode date

• Neurologic impairment (cauda equina syndrome) within 12 months prior to episode date

• Spinal infection within 12 months prior to the episode date

• Prolonged treatment (>_ 90 consecutive days) with corticosteroids within 12 months prior to the episode date

• Hospice patients

How to Improve Score

• Document all comorbid conditions and relevant medical history in the patients’ medical record.

• Educate patients and their caregivers that imaging studies are not necessary for confirmation of most uncomplicated low back pain diagnoses. In the majority of cases, low back pain resolves within 6 weeks.

• Teach patients about ways to alleviate symptoms at home, and when they should seek additional treatment.

9.4

9.5

Additional Measures: Use of Imaging Studies for Low Back Pain (LBP)

Asthma Medication Ratio (AMR)

What Is the Measure?

The measure looks at the percentage of patients 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Asthma is a treatable, manageable, condition that affects more than 25 million people in the United States. The prevalence and cost of asthma have increased over the past decade, demonstrating the need for better access to care and medication. Appropriate medication management for patients with asthma could reduce the need for rescue medication—as well as the costs associated with ER visits, inpatient admissions and missed days of work or school.

Documentation

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 with a principal diagnosis of Asthma

• At least one acute inpatient encounter, with a principal diagnosis of asthma without telehealth

• At least one acute inpatient discharge with a principal diagnosis of asthma (Asthma Value Set) on the discharge claim

• At least four outpatient visits, observation visits, telephone visits or e-visits or virtual check-ins, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events for any controller or reliever medication

• At least four asthma medication dispensing events for any controller or reliever medication

The ratio for the AMR measure is calculated by totaling the units of Controller Medications and dividing into the total of all Asthma Medications for the year.

Units of medications defined as an amount lasting 30 days or less, as one medication unit. One medication unit equals one inhaler canister, one injection, one infusion, or a 30-day or less supply of an oral medication.

Exclusions

• Emphysema

• COPD

• Obstructive chronic bronchitis

• Chronic respiratory conditions due to fumes or vapors

• Cystic fibrosis

• Acute respiratory failure

• No asthma controller or reliever medications dispensed during the measurement year

• Hospice care during the measurement year

Common Errors

• Not listing all competing or comorbid diagnosis codes on claim when ordering asthma medications and submitting documentation which could disqualify encounter allowing encounter to be improperly counted.

9.1

9.2

9.3

9.4

9.5

How to Improve Score

• Develop asthma action plans with patients and education on reduction of asthma triggers.

• Collaborate with the patient and customize the treatment to meet health goals.

• Provide simple and clear instructions as low health literacy can impact a patient’s health.

• Simplify treatment regimen.

• Involve family in treatment planning if patient needs additional support.

• Advise patients to incorporate inhalers into daily routine.

• Offer assistance with utilizing inhalers when first prescribed.

• Educate on potential side effects of controller medications and how to manage side effects.

9.1

9.2

9.3

9.4

9.5

References:

1. NCQA. HEDIS 2022 Technical Specifications for Health Plans, Volume 2, Washington, D.C., 2022.

2. Centers for Disease Control and Prevention (CDC). 2011. “CDC Vital Signs: Asthma in the US.” http://www.cdc.gov/vitalsigns/pdf/2011-05-vitalsigns.pdf

3. Geisinger Health Plan. (2022). HEDIS Information Guide 2022. Scranton; Geisinger Health Plan.

4. Aetna of Pennsylvania. (2020). Asthma Medication Ratio (AMR). Aetnabetterhealth.com. Retrieved May 23, 2022, from https://www.aetnabetterhealth.com/pennsylvania/providers

Additional Measures: Asthma Medication Ration (AMR)

Use of Opioids from Multiple Providers (UOP)

What Is the Measure?

The percentage of adult patients, who have been receiving prescription opioids from multiple providers for 15 or more days during the measurement year. A member who had more than one opioid medication dispensing event during the measurement year with the sum of all the days on opioids 15 or greater is eligible for this measure.

Opioid Medication

• Benzhydrocodone

• Buprenorphine

• Butorphanol

• Codeine

• Dihydrocodeine

• Fentanyl

• Hydrocodone

• Hydromorphone

• Levorphanol

Exclusions

9.1

9.2

9.3

• Meperidine

• Methadone

• Morphine

• Opium

• Oxycodone

• Oxymorphone

• Pentazocine

• Tapentadol

• Tramadol

• Hospice care during the measurement year

How to Improve Score

• Perform a primary care follow up visit after the patient’s follow-up visit with a behavioral health provider, performing a behavioral health assessment and identifying a treatment plan.

• Inform the patient about the Substance Use Hotline: 877-326-2458

9.4

9.5

Additional Measures: Use of Opioids from Multiple Providers (UOP)

Follow-Up After ED Visit for People With Multiple High-Risk Chronic Conditions (FMC)

What Is the Measure?

The measures looks at the percentage of emergency department (ED) visits for patients 18 years of age and older who have multiple high-risk chronic conditions who had a follow-up service within 7 days of the ED visit (8 days total).

Studies show that communication challenges and adverse health outcomes persist because hospitals, including ED providers, face few repercussions for failing to send medical records to patients’ outpatient providers upon admission and following discharge.1

Documentation

Eligible patients refers to those who are 18 years or older on the date of the ED visit AND have two or more chronic conditions diagnosed prior to the ED visit AND visited the ED on or between January 1 and December 24 of the measurement year.

Members may have more than one ED visit. Identify all ED visits between January 1 and December 24 of the measurement year. If a member has more than one ED visit in an 8-day period, include only the first eligible ED visit. Identify ED visits where the member had a chronic condition prior to the ED visit. The following are eligible chronic condition diagnoses.

Description

COPD and asthma

Heart failure

Alzheimer’s disease and related disorders

Acute myocardial infarction

Chronic kidney disease

Atrial fibrillation

Depression

Stroke and transient ischemic attack

9.1

9.2

9.3

9.4

9.5

Code(s)

A follow-up service within 7 days after the ED visit (8 total days). Include visits that occur on the date of the ED visit. The following meet criteria for follow-up:

• An outpatient visit

• A telehealth visit

• Transitional care management services

• Case management visit

• Complex care management services

• An outpatient or telehealth behavioral health visit

• An intensive outpatient encounter or partial hospitalization

• A community mental health center visit

• Electroconvulsive therapy

• A substance use disorder service

• A substance use disorder service

Additional Measures: Follow-Up After ED Visit for People With Multiple High-Risk Chronic Conditions (FMC)

Eligible Codes

Description

Substance Use Disorder Service

E-Visit or Virtual Check-In

Exclusions

• ED visits that result in an inpatient stay

CPT 99408, 99409

HCPCS

Code(s)

G0396, G0397, G04443, H0001, H0005, H0007, H0015, H0016, H0022, H0047, H0050, H2035, H2036, T1006, T1012

CPT 99423, 99444, 99457

POS G0071, G2010, G2012, G2061, G2062, G2063

9.1 9.2 9.3 9.4 9.5

• ED visits followed by admission to an acute or non-acute inpatient care setting on the date of the ED visit or within 7 days after the ED visit, regardless of the principal diagnosis for admission

Note: An ED visit billed on the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay

Common Errors

• Communication challenges or not actively checking and receiving ED medical records upon admission and following discharge

• Not having an established transition of care protocol within the practice

• Reviewing ED status weekly or waiting for claims data notification

How to Improve Score

• Sign up for the Florida Health Information Exchange service, through Audacious Inquiry, to receive real-time updates when a patient is seen at an emergency department within the state of Florida.

• Utilize EPIC Remote Access to monitor daily patients who are in the ED or have been admitted to the hospital.

• Schedule post ED follow-up visit within 3-5 days after discharge.

• Provide a visit summary with what was discussed during the PCP transition visit and clear instructions on changes that need immediate attention.

• Establish a care transition workflow as part of daily process within your practice along with a Transition Coach role (a specially trained nurse/ MA).

• Establish templates or order sets within EHR system for specific visit type and attributable codes.

References:

1. Health Affairs. 2012. Health Policy Brief: Care Transitions. September 13, 2012. Retrieved July 12, 2016, from https://www.healthaffairs.org/do/10.1377/hpb20120913.327236/full/healthpolicybrief_76.pdf

2. Staff, N. C. Q. A. (2020, December 28).

Follow-up after emergency department visit for people with high-risk multiple chronic conditions. NCQA. Retrieved May 4, 2022, from https://www.ncqa.org/hedis/measures/follow-up-after-emergency-department-visit-for-people-with-high-risk-multiple-chronic-conditions/

Additional Measures: Follow-Up After ED Visit for People With Multiple High-Risk Chronic Conditions (FMC)

Transitions of Care (TRC)

What Is the Measure?

The measure assesses the percentage of discharges (acute and/or non-acute) between January 1 and December 1 for patients age 18 or older who had each of four reported indicators during the measurement year:

• Notification of inpatient admission

• Receipt of discharge information

• Patient engagement after inpatient discharge

• Medication reconciliation post-discharge

Note: Patients may be in the measure more than once if there are multiple admissions.

Documentation

Notification of Impatient Admission

Admission refers to the date of inpatient admission or date of admission for an observation stay that turns into an inpatient admission. Documentation in the outpatient medical record must include evidence of receipt of notification of inpatient admission on the day of admission through two days after admission (3 days total) with a date and timestamp.

Discharge Information

Documentation must include evidence of receipt of discharge information on the day of discharge through two days after discharge, with date and timestamp. Discharge information may be included in a discharge summary or summary of care record or located in structured fields in an electronic health record.

After Inpatient Discharge

Documentation must include evidence of patient engagement within 30 days after discharge. Any of the following meets criteria:

• An outpatient visit, including office visits and home visits

• A telephone visit

• A synchronous telehealth visit where real-time interaction occurred between the member and provider using audio and video communication

• An e-visit or virtual check-in

• Transitional care management services

Do not include patient engagement that occurs on the same date of discharge. If the member is unable to communicate with the provider, interaction between the member’s caregiver and the provider meets criteria.

Post-Discharge Medication Reconciliation

Medication reconciliation conducted by a prescribing practitioner, physician assistant, or registered nurse, as documented through either administrative data or medical record review on the date of discharge through 30 days after discharge (total of 31 days). Documentation must include evidence of medication reconciliation and the date it was performed.

Any of the following will meet documentation criteria:

• Documentation of the current medications with a notation that the provider reconciled the current and discharge medications

• Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications)

• Documentation of the member’s current medications with a notation that the discharge medications were reviewed

• Documentation of a current medication list, a discharge medication list and notation that both lists were received on the same date of service

9.1

9.2

9.3

9.4 9.5

Eligible Codes