Category: HEDIS Measures

Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, Cinga Insurance, EmblemHealth NY, HEDIS Measures, NY Providers, Training

HEDIS Measure: Immunizations for Adolescent

Posted on by KR2Medical Billing

This measure represents the percentage of children who turned 13 years old and received the following immunizations before their 13th birthday.

  • One dose of meningococcal vaccine
  • One tetanus, diphtheria toxoids and one acellular pertussis vaccine (Tdap): and
  • Completed the human papillomavirus (HPV) series.*

*HPV requires 2 shots, at least 146 days apart.

Meningococcal recombinant (serogroup B) (MenB) vaccines- DO NOT COUNT towards the HEDIS measure.

For Meningococcal Serogroups A, C, W, Y:

  • At least one meningococcal serogroups A, C, W, Y vaccine, with a date of service on or between the member’s eleventh and 13th birthdays
  • Anaphylaxis due to the meningococcal vaccine any time on or before the member’s 13th birthday meets criteria

For Tdap: generic documentation (Tdap/Td) can be counted towards this HEDIS measure.

  • At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, with a date of service on or between the member’s tenth and 13th birthdays.
  • If patient has anaphylaxis due to Tdap vaccine during or before pt turns 13 years old
  • Encephalitis due to the tetanus, diphtheria, or pertussis vaccine

For HPV:

  • At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart
  • At least 3 HPV vaccines – w/ different DOS before or on the date when patient turns 13 years of age
  • Anaphylaxis due to the HPV vaccine any time on or before the member’s 13th birthday meets criteria

Accepted documentation:

  • A note with the specific antigen/vaccine and the date of administration of the vaccine
  • A certificate of immunization prepared by an authorized health care provider or agency with information of each vaccine and their administration dates

Not accepted documentation:

A note that says the member is up to date and does not have the actual vaccines listed w/ administration dates

Via Anthem (NY) provider news.

PROVIDERS-some things you can do in your practice in order to meet this measure:

  • Have standing orders for adolescent vaccines- the visit can be performed by a Nurse
  • Use appointment reminders to schedule vaccine appointments
  • For HPV  vaccines make sure to schedule a f/u appt for the next dosage.
  • Educate parents on the importance of the vaccines and their on time administration.

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Posted in HEDIS Measures, Training

Hedis Measure: the Pharmacotherapy Management of COPD Exacerbation Measure

Posted on by KR2Medical Billing

This measure assesses chronic obstructive pulmonary disease (COPD) exacerbations for adults 40 years of age and older who had appropriate medication therapy to manage an exacerbation.

COPD is a debilitating lung condition that affects one in eight Americans age 45 and older.

A COPD exacerbation is defined as an acute inpatient discharge or emergency department visit with a primary discharge diagnosis of COPD.

There are 2 rates that are reported for this measure:

  • Dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event
  • Dispensed a bronchodilator (or there is evidence of an active prescription) within 30 days of the COPD exacerbation event

Providers are encouraged to have a COPD action plan: that is a personalized patient tool that includes the important steps to help manage COPD. This plan includes medications, exercise, diet, and avoidance of triggers, such as tobacco products and other inhaled irritants.

To achieve this measure providers should follow these helpful steps:

  1. Schedule a f/u appt after the COPD exacerbation event.
  2. Review the list of medications and reconcile the medications that were given to the patient during the discharge
  3. Document any barriers that prevent the patient from obtaining the medications for the COPD
  4. Assure the patient with COPD is up to date with the vaccinations, including flu vaccine and Pnuemoccoccal vaccine.

Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Comprehensive Diabetes Care

Posted on by KR2Medical Billing

In this blog post we will explore the Comprehensive Diabetes Care HEDIS measure. .

What is New for 2020?

New measure Kidney Health Evaluation for Patient with Diabetes measure was added in 2020. This is a new measure. It evaluates the percent of members that are between 18 and 85 years of age that have diabetes and who received a kidney health evaluation, including estimated glomerular filtration gate test (eGFR) and a urine albumin-creating ration.

What is Comprehensive Diabetes Care Measure?

Measure that evaluates percentage of adult members between ages of 18 and 75 years of age (looks at both type 1 and type 2 diabetes) and who had each of the following:

  1. HbA1c testing
  2. HbA1c poor control (>9%)
  3. HbA1c control of (<8%)
  4. Retinal Eye Exam performed
  5. Blood Pressure Control (<140/90 mm/Hg)\

Documentation:

Record your efforts: document results of, all of the above mentioned test, in the patient’s medical record.

How to meet this measure?

  • Provide reminders to patients for upcoming appointments and screenings.
  • Draw labs in your office if available or refer patients to a local lab for screenings.
  • Refer patients to participating eye professionals for annual retinal eye exams.
  • Follow up on lab test, eye exams and specialist referrals and document in your chart.
  • Telephone visits, e-visits and virtual check-ins are acceptable settings for blood pressure readings and should be recorded in the chart.
  • Include Category II reporting codes on claims to reduce the burden of HEDIS medical record review.
  • Educate patients on topics (for example, home monitoring of blood sugar and blood pressure, taking medications as prescribed, and other healthy lifestyle education like diet, exercise, and smoking cessation).

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