Tag: #hedismeasures

Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Use of Imaging Studies for Low Back Pain

Posted on by KR2Medical Billing

HEDIS Measures get updated every year. In this post we will discuss the proper coding and billing for HEDIS Measure: Use of Imaging Studies for Lower Back Pain; and list the changes for the upcoming 2022 year. This measure applies to all types of insurances: Medicare, Commercial, and Medicaid.

Background:

One out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.  Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.

What causes back pain?

HEDIS Measure: Use of Imaging Studies for Low Back Pain Definition-
Members 18-50 years of age with a new primary diagnosis of low back pain in an outpatient or ED visit who did not have an x-ray, CT or MRI within 28 days of the primary diagnosis. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur)

Proper Medical Coding:

CPT codes for imaging Studies-

List of Proper DX codes:

Measure Exclusions:

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Proper Exclusions Coding:

Improve the score for this HEDIS Measure:

-Avoid ordering diagnostic studies within 30 days of a diagnosis of new-onset back pain in the absence of red flags (e.g., cancer, recent trauma, neurologic impairment,
or IV drug abuse).
• Provide patient education on comfort measures, e.g., pain relief, stretching exercises, and activity level.
• Use correct exclusion codes if applicable (e.g., cancer).
• Look for other reason for visits for low back pain (e.g., depression, anxiety, narcotic dependency, psychosocial stressors, etc.).
• Document and code/bill all comorbidities (e.g. MVA, fall, trauma, etc.

HEDIS Measure: Use of Imaging Studies for Low Back Pain 2022 Changes:

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HEDIS Measure: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

Posted on by KR2Medical Billing

HEDIS is always a hot topic of discussion. In this blog post we will discuss the HEDIS measure WCC or Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents.

Background/Research Data:

The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

The purpose of this HEDIS Measure:

This HEDIS measure looks at the percentage of patients between the 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

  • Body mass index (BMI) percentile (percentage, not value)
  • Counseling for nutrition
  • Counseling for physical activity

This HEDIS Measure (WCC) requires the following documentation:

  • When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
  • When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
  • Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Source: Progress on Childhood Obesity | VitalSigns | CDC

Proper Coding and Billing:

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HEDIS® Measures: W30 and WCV (well child visits)

Posted on by KR2Medical Billing

Well-child visits in the first 30 months of life (W30):
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:

  1. Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
  2. Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.

Child and adolescent well-care visits:
Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

In order to complete these measures AAP developed a comprehensive schedule.

In order for Providers to comply with AAP, the providers should follow AAP recommendations: eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure.  Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures. 

For Empire BCBS NY Child Well Care visit coverage:

BCBS Empire NY offers complete coverage for well-child visits regardless of when visit is received:

Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.