HPH Quality and Performance Evaluation Program … periodontists, and oral surgeons will be...

HPH Quality and Performance Evaluation Program 2009-2010 Prescribing Pattern Measure Specification

Formulary First-Tier Prescribing Version 1.00 for Program Guide

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For use by HMSA HPH health centers participating in the Q&P program

Measure Formulary First-Tier Prescribing (“First Tier”) Target > 72.00% Measure Rationale

The purpose of this measure is to increase prescribing of HMSA formulary first-tier drugs. Select formulary first-tier drugs consist of all First Databank generics and certain branded generics, the latter of which are brand name drugs offered to members at a generic co-payment. Currently, the list of first-tier drugs includes preferred brand insulins.

Denominator Denominator Definition

The sum of all normalized scripts (in all select formulary tiers) filled by HPH members for the current reporting period. Prescriptions written by dentists and dental-type specialties including endodontists, periodontists, and oral surgeons will be excluded. Prescription counts are normalized based on the days supply provided. Script – Days’ Supply Normalization:

if days’ supply is > 0 and ≤ 30 days, script count = 1 If days’ supply is between 31 and 60 days, script count = 2

If days’ supply is between 61 and 90 days, script count = 3 If days’ supply is between 91 and 120 days, script count = 4 If days’ supply is between 121 and 150 days, script count = 5 Only drug claims with HMSA as the primary payer will be incorporated into measurement.

Denominator Encounters/Claims Criteria

Filled prescriptions for HPH members during the current reporting period, where the prescribing provider’s reimbursement specialty is NOT:

o Oral Surgery (019) o Pharmacy (105) o Dentist (120) o Pedodontist (121) o Periodontist (122) o Prosthodontist (123) o Endodontist (124) o Orthodontist (125) o Specialty Pharmacy (127) o Non-Submitting Provider (200)

Denominator Member

Members of an HPH health center at any time during the current reporting period.

HPH Quality and Performance Evaluation Program 2009-2010 Prescribing Pattern Measure Specification

Formulary First-Tier Prescribing Version 1.00 for Program Guide

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Demographics No continuous enrollment criteria are applied.

Denominator Exclusion Denominator Exclusion Definition

None.

Denominator Exclusion Claims Criteria

N/A

Numerator Numerator Definition

Number of normalized (based on days supply) scripts for first-tier drugs filled during the current reporting period.

Numerator Claims Criteria

All prescriptions for HPH members where the Select Formulary tier = Generic. Prescription counts will be normalized based on days supply.

Reporting note: Reporting for this measure is member-driven. Prescriptions written by out-of-Health Center providers are included in measurement. Thus any prescription activity for a health center member will be traced back to the member’s health center (and PCP).

HPH Quality and Performance Evaluation Program 2009-2010 Clinical Measure Specification

Inappropriate Utilization of Antibiotic Medications for URIs or Acute Bronchitis Version 1.00 for Program Guide

Codes Source: 2009 HEDIS V1.00 09-10 Q&P Spec

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Measure Inappropriate Utilization of Antibiotics for URIs or Acute Bronchitis (“Antiburi”) Target < 23.00 Note that this is an inverse measure in which a lower rate indicates

better performance. Clinical Intent

To ensure that members with viral URIs and Acute Bronchitis are treated appropriately, without the use of antibiotic medications.


Continuously enrolled members ages 3 months to 64 years as of the start of the reporting period who were identified as having a common cold, URI, or acute bronchitis during the current reporting period, up to 7 days before the end of the period. Members are required to be continuously enrolled with both medical and pharmacy benefits. The final denominator (reported to health centers and used in scoring) for this measure will contain just one episode per member, selected as the earliest/first episode per member during the current reporting period.


Episodes for which members have at least one diagnosis of common cold, URI, or acute bronchitis during an Outpatient or Emergency Department visit within the current reporting period, up to 7 days before the end of the period.

Common cold, URI, acute bronchitis Code Type Code ICD-9 460, 465.xx, 466.xx

Denominator Member Demographics

Members must be ages 3 months to 64 years as of the start of the reporting period. For the 2009-10 program year, this is a DOB range from 4/1/2009 (0.25 yrs) to 7/2/1944 (64.99 yrs), inclusive.

Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final report measurement are required to be continuously enrolled within the same HPH Health Center during the reporting period, as specified below:




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1. Patient Intervention Report 1 (aggregate rates): continuously enrolled in a Q&P – eligible health center from 7/1/09 to 9/30/09, with no gaps allowed



4. Final Report: continuously enrolled in a Q&P – eligible health center from 7/1/09 to 6/30/10, with no gaps allowed

Members are also required to be continuously enrolled with pharmacy benefits for the same time periods as given above.


Episode dates for which the member had any diagnosis for a comorbid condition between 0 and 365 days prior to the episode date. Or, episode dates for which the member had at least one confounding diagnosis within 30 days prior to 7 days after the episode date. Or, episode dates for which the member had at least one prescription for an antibiotic filled 30 days prior to the episode date.


Episodes for which members had at least one diagnosis of a comorbid condition between 0 to 365 days prior to the index Episode date of the URI or acute bronchitis diagnosis.

Comorbid conditions Code Type Code Code Desc ICD-9 dx 010.xx-018.xx Tuberculosis 042.xx, V08.xx HIV disease; asymptomatic HIV 277.0x Cystic fibrosis 279.xx Disorders of the immune

system 140.xx-208.xx Malignancy neoplasms 491.xx Chronic bronchitis 492.xx Emphysema 494.xx Bronchiectasis 495.xx Extrinsic allergic alveolitis 493.2x, 496.xx Chronic airway obstruction,

chronic obstructive asthma 500.xx- 508.xx Pneumoconiosis and other lung

disease due to external agents 510.xx-519.xx Other diseases of the




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respiratory system OR Episodes for which members had at least one competing diagnosis between 30 days prior to 7 days after the index Episode date of the URI or acute bronchitis diagnosis.

Competing diagnoses Code Type Code Code Desc ICD-9 dx 001.xx to

009.xx Intestinal infections

033.xx Pertussis 041.9x Bacterial infection unspecified 088.xx Lyme disease and other

arthropod-borne diseases 382.xx Otitis media 461.xx Acute sinusitis 034.0x,

462.xx Acute pharyngitis

463.xx Acute tonsillitis 473.xx Chronic sinusitis 464.1x to

464.3x, 474, 478.21 to 478.24, 478.29, 478.71, 478.79, 478.9x

Infections of the pharynx, larynx, tonsils, adenoids

601.xx Prostatitis 383.xx,

681.xx, 682.xx, 730.xx

Cellulitis, mastoiditis, other bone infections

683.xx Acute lymphadenitis 684.xx Impetigo 686.xx Skin staph infections 078.88,

079.88, 079.98

Chlamydia

090.xx to 097.xx

Syphilis

098.xx, Gonococcal infections and




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099.xx, V01.6x, V02.7x, V02.8x

venereal diseases

481.xx to 486.xx

Pneumonia (non-viral)

590.xx Infections of the kidney 595.xx,

599.0x Cystitis or Urinary Tract Infection

614.xx to 616.xx, 131.xx

Inflammatory diseases (female reproductive organs)

OR Episodes for which members had at least one antibiotic prescription during the 30 days prior to the index Episode date (do not include the episode date). Note: this exclusion uses the same drug lists provided for use in the numerator of this measure.


Episodes in the denominator wherein the member filled an antibiotic prescription within 0 to 3 days of the denominator episode date


The numerator will be positive when the member fills an antibiotic prescription within 0 to 3 days of the denominator episode date

Appropriate numerator drugs are identified via two drug lists updated on an annual basis by NCQA for use in the HEDIS measures “Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis” and ”Appropriate Treatment for Children with URI.”

Antibiotics List (Source: 2009 HEDIS)

Description Prescription

5-aminosalicylates sulfasalazine

Aminoglycosides amikacin gentamicin

kanamycin neomycin

streptomycin tobramycin

Aminopenicillins amoxicillin ampicillin

Antipseudomonal penicillins

piperacillin ticarcillin

Beta-lactamase inhibitors

amoxicillin-clavulanate

ampicillin-sulbactam

piperacillin-tazobactam

ticarcillin-clavulanate




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First generation cephalosporins

cefadroxil cefazolin

cephalexin cephradine

Fourth generation cephalosporins

cefepime

Ketolides telithromycin

Lincomycin derivatives clindamycin lincomycin

Macrolides azithromycin clarithromycin

erythromycin erythromycin

ethylsuccinate

erythromycin lactobionate

erythromycin stearate

Miscellaneous antibiotics

aztreonam chloramphenicol dalfopristin-

quinupristin

daptomycin erythromycin-

sulfisoxazole linezolid

metronidazole vancomycin

Sulfamethoxazole-trimethoprim DS

sulfamethoxazole-trimethoprim

Natural penicillins penicillin G benzathine-procaine

penicillin G potassium

penicillin G procaine

penicillin G sodium

penicillin V potassium

Penicillinase resistant penicillins

dicloxacillin nafcillin oxacillin

Quinolones ciprofloxacin gatifloxacin gemifloxacin

levofloxacin lomefloxacin moxifloxacin

norfloxacin ofloxacin sparfloxacin

Rifamycin derivatives rifampin

Second generation cephalosporin

cefaclor cefotetan

cefoxitin cefprozil

cefuroxime loracarbef

sulfadiazine sulfisoxazole Sulfonamides

sulfamethoxazole-trimethoprim

Tetracyclines doxycycline minocycline tetracycline

Third generation cephalosporins

cefdinir cefditoren cefixime

cefotaxime cefpodoxime ceftazidime

ceftibuten ceftizoxime ceftriaxone

fosfomycin nitrofurantoin

nitrofurantoin macrocrystals-monohydrate

trimethoprim

Urinary anti-infectives

nitrofurantoin macrocrystals


Breast Cancer Screening (mammo) Version 1.00 for Program Guide

Source: 2009 HEDIS V1.00 09-10 Q&P Spec

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Measure Breast Cancer Screening (“mammo”) Target > 76.00% Clinical Intent

To ensure that all eligible women age 40-69 (41 to 69 as of the start of program year) receive a mammogram during the program year or year prior.


Continuously enrolled women ages 41-69 years as of the start of the current reporting period. (Minimum member age is adjusted to reflect the two year periodicity of measurement).


N/A


Female members must be ages 41-69 years as of the start of the reporting period. For the 2009-10 program year, this is a DOB range from 7/2/1939 through 7/1/1968, inclusive. Only female members are eligible for this measure. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled during the current reporting period and the prior 12-month program year. This enrollment must be within the same HPH health center during the periods specified below:


2. Patient Intervention Report 2 (aggregate rates): continuously enrolled in a Q&P–eligible health center from 7/1/08 to 12/31/09, with no gaps allowed



Denominator Exclusion Denominator Members with two unilateral mastectomies or one bilateral mastectomy




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Exclusion Definition

at any time in the member’s history prior to the end of the current reporting period.* *Note: data regarding procedures performed and/or diagnoses made

prior to 1999, or data elements pertaining to an individual prior to the individual becoming an HMSA member, are not available for analysis.


Members will be excluded if they have at least two unilateral mastectomies on different dates of service at any time in the member’s history through the end of the current reporting period. Unilateral mastectomy codes CPT-4 19180, 19200, 19220, 19240, or 19303-19307 OR ICD-9 Surgical Procedure codes

85.41, 85.43, 85.45, 85.47

NOTE: Codes retired Jan 2007 (keep for history): [19180, 19200, 19220, or 19240]

OR Members will be excluded if they have at least one bilateral mastectomy at any time in the member’s history through the end of the current reporting period. Bilateral procedures may be coded in any of the following ways:

Bilateral mastectomy codes ICD-9 Surgical Procedure

85.42, 85.44, 85.46, 85.48

Bilateral mastectomy may also be coded using 09950 CPT code.

Bilateral mastectomy codes CPT-4* [19180, 19200, 19220, 19240, or 19303-19307]

AND 09950* on same claim

NOTE: Codes retired Jan 2007 (keep for history): [19180, 19200, 19220, or 19240]

*Note: .CPT code 00950, when appearing on the same claim as a CPT code for mastectomy, indicates that the mastectomy was a bilateral procedure.




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Bilateral mastectomy may also be coded as LT and RT procedures on the same date of service. Bilateral mastectomy codes (D) CPT-4 19180LT, 19200LT, 19220LT, 19240LT,

19303LT, 19304LT, 19305LT, 19306LT, or 19307LT AND on same date of service: 19180RT, 19200RT, 19220RT, 19240RT 19303RT, 19304RT, 19305RT, 19306RT, or 19307RT

Bilateral mastectomies may also be coded using the .50 modifier code.

Bilateral mastectomy codes (E) CPT-4* 19180, 19200, 19220, 19240, 19303, 19304,

19305, 19306, 19307 AND Modifier Code

50

*Note: .50 is a modifier code which indicates the procedure was bilateral and performed during the same operative session.


Members will be counted towards the numerator if they received at least one mammogram during the current reporting period or the prior 12-month program year.


At least one mammogram during the current reporting period or the prior 12-month program year. For the 2009-10 program year, the numerator window encompasses dates of service from July 1, 2008 through the end of the reporting period (Sept 30, 2009; Dec 31, 2009; March 31, 2010; or June 30, 2010). Mammogram codes: CPT-4 76083, 76090-76092, or 77055-77057 OR HCPCS G0202, G0204 (diagnostic), or G0206

(diagnostic) OR ICD-9 Surgical Procedure

87.36, 87.37




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OR ICD-9 status V-codes

V76.11, V76.12

OR UB-92 Revenue 0401* (keep for historical reporting), 0403, also

as 401*, 403 OR HMSA Z-codes* (for history)

Z5026, Z5027, Z5030

Notes: * indicates a retired code appropriate for retrospective analysis


Cervical Cancer Screening (pap) Version 1.00

Codes Source: 2009 HEDIS 09-10 v1.00 Q&P Spec

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Measure Cervical Cancer Screening (“pap”) Target > 76.00% Clinical Intent

To ensure that all women ages 21-64 (23 to 64 as of the start of the program year) receive a cervical cancer screening test during the program year or the 2 years prior.


Continuously enrolled female members ages 23 – 64 years as of the start of the current reporting period. (Minimum member age is adjusted to reflect the three year periodicity of measurement.)


N/A


Female members ages 23-64 years as of the start of the reporting period. For the 2009-10 program year, this is a DOB range from 7/1/1986 (23.00 yrs) to 7/2/1944 (64.99 yrs), inclusive. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled during the current reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled within the same HPH health center during the current reporting period, as specified below:






Members will be excluded from the denominator if they had a hysterectomy with no residual cervix at any time in the member’s history* through the end of the reporting period.




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*Note: data regarding procedures performed and/or diagnoses made

prior to 1999, or data elements pertaining to an individual prior to the individual becoming an HMSA member, are not available for analysis.


Hysterectomy with no residual cervix is defined using the following codes:

Hysterectomy with no residual cervix CPT-4 51925, 56308, 58150, 58152, 58200,

58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58550—58554, 58570—58573, 58951, 58953, 58954, 58956, 59135

OR ICD-9 V-codes V67.01, V76.47 OR ICD-9 Diagnosis 618.5x OR ICD-9 Surg Procedure

68.4x-68.8x


Members who had at least 1 cervical cancer screening test during the current reporting period or within the 2 years prior to the current program year. (Window in 2009-10 program year is from July 1, 2007 through June 30, 2010, for a total period of 3 years).


Members who had at least 1 pap smear during the current reporting period or within the 2 years prior to the current program year (3 years total).

Cervical cancer screening (Pap smear) CPT-4 88141-88143, 88144*, 88145*, 88147,

88148, 88150, 88152-88155, 88164-88167, 88174, 88175

OR HCPCS G0123, G0124, G0141, G0143, G0144,

G0145, G0147, G0148, P3000, P3001, Q0091

OR ICD-9 Surg Procedure

91.46

OR




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ICD-9 V-codes V72.32, V76.2x OR UB-92 Revenue 0923, also as 923 OR HMSA Z-Codes Z5012, Z5018, Z5031

*Codes have been retired but are still appropriate for retrospective analysis.


Childhood Immunization Status: Combinations 2 and 3 Version 2.00 for Program Guide


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Measure Childhood Immunization Status: Combination 2 and 3 (“Combo2”) Target > TBD; no scoring target for 2009-2010 Clinical Intent

To ensure that eligible children turning two years old during the program year receive recommended vaccinations prior to their second birthday.


Continuously enrolled children turning two years old during the program year.


N/A


The denominator measures continuously enrolled children turning 2 during the 12 month program year. For the 2009-10 program year, this is a date of birth range from 7/1/2007 (turns 2 at start of year) to 6/30/2008 (turns 2 at end of year), inclusive. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled in the same HPH Health Center for the 12 months prior to the child’s second birthday. No gaps will be allowed.


Children in the denominator with a contraindication to a vaccination at any time in the member’s history prior to or on the child’s 2nd birthday (the index date). Children who had a contraindication for any specific vaccine should be excluded from the denominator for all antigen rates and combination rates.


Members with any HEDIS-specified contraindication for MMR and VZV vaccines at any time in the member’s history prior to or on the member’s 2nd birthday (the index date).

Vaccine contraindications – MMR and VZV Code Type

Code Description

ICD-9 dx 999.4 Anaphylactic reaction to vaccine ICD-9 dx 279.xx Immunodeficiency, including genetic

(congenital) immunodeficiency syndromes




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042, V08 ICD-9 dx HIV-infected or asymptomatic HIV ICD-9 dx 200.xx to

202.xx Cancer of lymphoreticular or histiocytic tissue

ICD-9 dx 203.xx Multiple myeloma ICD-9 dx 204.xx to

208.xx Leukemia

OR Members with the HEDIS-specified contraindication for DTaP vaccines at any time in the member’s history prior to or on the member’s 2nd birthday.

Encephalopathy: ICD-9 diagnosis code(s): 323.5 (NO 5th digit prior to Oct 1, 2006) or 323.51 AND Poisoning resulting from the tetanus, diphtheria, or pertussis vaccine: ICD-9 diagnosis code(s): E948.4, E948.5, E948.6


The numerator is based on 2010 HEDIS vaccination requirements for the Childhood Immunization Status measure. Members in the denominator who received at least the following vaccines on or before the child’s 2nd birthday (the index date): HEDIS-based Combo 2:

A) 4 DTaP (diphtheria, tetanus, and acellular pertussis) vaccines on different dates of service, between 42 days after birth and the child’s 2nd birthday (the index date), inclusive.

AND B) 3 IPV (polio) vaccines on different dates of service, between 42 days

after birth and the child’s 2nd birthday (the index date), inclusive. AND C) 3 Hib (H influenza type B) vaccines on different dates of service,

between 42 days after birth and the child’s 2nd birthday (the index date), inclusive.

AND D) 2 Hep B (hepatitis B) vaccines on different dates of service on or before

the child’s 2nd birthday (the index date), inclusive. Evidence of the disease may also count.

AND E) 1 VZV (chicken pox) vaccine on or before the child’s 2nd birthday (the

index date), inclusive. Evidence of the illness may also count. AND F) 1 MMR (measles, mumps, and rubella) vaccine on or before the child’s




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2nd birthday (the index date), inclusive. Evidence of the disease(s) may also count.

HEDIS-based Combo 3:

G) All vaccines listed above for Combo 2, plus 4 PCV (pneumococcal conjugate vaccinations) on different dates of service, between 42 days after birth and the child’s 2nd birthday (the index date), inclusive.

Additional vaccines measured by HEDIS 2010:

H) 2 Hepatitis A (HepA) vaccinations on different dates of service on or before the child’s 2nd birthday (the index date), inclusive. Evidence of hepatitis A disease may also count.

I) 2 or 3 (depending on vaccine schedule) Rotavirus vaccinations on different dates of service, between 42 days after birth and the child’s 2nd birthday (the index date), inclusive.

J) 2 Influenza vaccinations on different dates of service, between 6 months after birth and the child’s 2nd birthday (the index date), inclusive.

Notes:

Per HEDIS 2010: For MMR, hepatitis B, VZV, and hepatitis A, count any of the following.

Evidence of the antigen or combination vaccine, or Documented history of the illness, or A seropositive test result

For 2010 HEDIS, only 2 Hib shots are required due to a vaccine shortage. However, as the shortage eases, the HEDIS requirement will likely revert to 3 Hib shots. For Hepatitis B vaccination, the standard recommendation is for 3 shots prior to the child’s 2nd birthday. The first shot, now frequently administered in the hospital prior to discharge, may not always be captured via claims data. We will therefore assume the presence of the first shot when service dates are present for two of the three required administrations.


2010 HEDIS-based Childhood Immunization requirements for children turning 2.

HEDIS-based Combo 2 All vaccines must be administered on or before the child's 2nd birthday.

Vaccine type Required vaccinations Constraints

Evidence of disease

DTaP

At least four DTaP vaccinations on different dates of service

Administered no earlier than 42 days after birth




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IPV

At least three IPV vaccinations on different dates of service


MMR At least one MMR vaccination

Counts towards numerator

HiB

At least three HiB vaccinations on different dates of service*


Hepatitis B

At least two hepatitis B vaccinations on different dates of service**


VZV At least one VZV vaccination Counts towards numerator

* HEDIS 2010 requires only 2 HiB due to vaccine shortage **HEDIS 2010 requires 3 Hep B; HMSA will assume the first dose is given at birth if two other service dates are present

Combo 2 codes:

Combo 2: Codes to Identify Childhood Immunizations

Immunization CPT HCPCS ICD-9 Proc Code

DTaP 90698, 90700, 90721, 90723 99.39 IPV 90698, 90713, 90723 99.41 MMR 90707, 90710 99.48 Measles and rubella 90708 Measles 90705 99.45 Mumps 90704 99.46 Rubella 90706 99.47 HiB 90645-90648, 90698, 90721, 90748 Hepatitis B 90723, 90740, 90744, 90747, 90748 G0010 VZV 90710, 90716

Combo 3 requirements:

HEDIS Combo 3: All Combo 2, plus PCV All vaccines must be administered on or before the child's 2nd birthday.


Evidence of disease

PCV

At least four pneumococcal conjugate vaccinations on different dates of service





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Combo 3 codes: All combo 2 shots, plus the following PCV vaccinations are required for Combo 3.

Combo 3: Codes to Identify Childhood Immunizations


Pneumococcal conjugate 90669 G0009

Other 2010 HEDIS vaccinations:

Other vaccines required by 2010 HEDIS All vaccines must be administered on or before the child's 2nd birthday.


Evidence of disease

Hepatitis A Two hepatitis A vaccinations on different dates of service


Rotavirus

2 or 3 doses, depending on vaccine type, on different dates of service


Influenza Two influenza vaccinations on different dates of service

Administered no earlier than 6 months after birth

Other HEDIS 2010 vaccination codes:

Codes to Identify Childhood Immunizations


Hepatitis A 90633 Rotavirus (2 dose schedule) 90681 Rotavirus (3 dose schedule) 90680 Influenza 90655, 90657, 90661, 90662 G0008 99.52

Per HEDIS, evidence of the disease counts towards the numerator for the following conditions:




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Codes to Identify Evidence of Disease Immunization ICD-9 Dx Code Measles 055 Mumps 072 Rubella 056 Hepatitis B 070.2, 070.3, V02.61 VZV 052, 053 Hepatitis A 070.0, 070.1


Chlamydia Screening for Women Version 1.00


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Measure Chlamydia Screening for Women Target > 60.00% Clinical Intent

To ensure that sexually active women 16-24 years of age receive at least one screening test for chlamydia during the program year.


Continuously enrolled, sexually active female members ages 16-24 as of the start of the reporting period.


Female members identified as sexually active during the current reporting period. Female members are identified as being sexually active if they have: At least one claim for pregnancy, delivery, or sexually transmitted diseases at any time during the current reporting period. Pregnancy, delivery, or STIs Code Type Code Description ICD-9 Dx 042 Human immunodeficiency virus (HIV)

disease ICD-9 Dx 054.1X Genital herpes ICD-9 Dx 078.11 ICD-9 Dx 078.88 Other specified diseases due to

Chlamydiae ICD-9 Dx 079.4 Human papillomavirus ICD-9 Dx 079.51-

079.53 Human T-cell lymphotrophic virus, type I, or type II, or Human immunodeficiency virus, type 2

ICD-9 Dx 079.88 Other specified chlamydial infection ICD-9 Dx 079.98 Unspecified chlamydial infection ICD-9 Dx 091.XX-

097.XX Syphilis

ICD-9 Dx 098.0X Gonococcal infections (through 098.8X) ICD-9 Dx 098.10 ICD-9 Dx 098.11 ICD-9 Dx 098.15-

098.19, 098.2, 098.30, 098.31, 098.35-098.8X

ICD-9 Dx 099.XX Other venereal diseases




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ICD-9 Dx 131.XX Urogenital trichomoniasis ICD-9 Dx 614.XX-

616.XX Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum; uterus, except cervix; cervix, vagina, and vulva

ICD-9 Dx 622.3X Noninflammatory disorders of cervix; old laceration of cervix

ICD-9 Dx 623.4X Noninflammatory disorders of vagina; old vaginal laceration

ICD-9 Dx 626.7X Postcoital bleeding ICD-9 Dx 628.XX Infertility, female ICD-9 Dx 630.XX to

677.XX Pregnancy and childbirth

ICD-9 Dx 795.0X Abnormal pap smear of cervix and cervical HPV

ICD-9 Dx 996.32 Mechanical complication of nervous system device, implant, and graft; due to intrauterine contraceptive device

ICD-9 Dx V01.6X Venereal diseases ICD-9 Dx V02.7X Carrier or suspected carrier of infectious

disease; Gonorrhea ICD-9 Dx V02.8X Carrier or suspected carrier of infectious

disease; other venereal diseases ICD-9 Dx V08.XX Asymptomatic human immunodeficiency

virus (HIV) infection status ICD-9 Dx V15.7X Other personal history presenting

hazards to health; contraception ICD-9 Dx V22.XX Normal pregnancy ICD-9 Dx V23.XX Supervision of high-risk pregnancy ICD-9 Dx V24.XX Postpartum care and examination ICD-9 Dx V25.XX Encounter for contraceptive management ICD-9 Dx V26.XX Procreative management ICD-9 Dx V27.XX Outcome of delivery ICD-9 Dx V28.XX Antenatal screening ICD-9 Dx V45.5X Presence of contraceptive device ICD-9 Dx V61.5X-

V61.7X Multiparity; Illegitimacy or illegitimate pregnancy; Other unwanted pregnancy

ICD-9 Dx V69.2X Problems related to lifestyle; High risk sexual behavior

ICD-9 Dx V72.3X Gynecological examination ICD-9 Dx V72.4X Pregnancy examination or test,

pregnancy unconfirmed ICD-9 Dx V73.81 Human papillomavirus ICD-9 Dx V73.88 Other specified chlamydial diseases ICD-9 Dx V73.98 Unspecified chlamydial disease




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ICD-9 Dx V74.5X Special screening examination for bacterial and spirochetal diseases; Venereal disease

ICD-9 Dx V76.2X Special screening for malignant neoplasms; Cervix

ICD-9 Surg Proc

69.01, 69.02, 69.51, 69.52, 69.7, 72.XX-75.XX, 97.24, 97.71, 97.73

HCPCS G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, H1000, H1001, H1003-H1005, P3000, P3001, Q0091, S0180, S4981, S8055

Rev 0112, 0122, 0132, 0142, 0152, 0720-0722, 0724, 0729, 0923, 0925, or 112, 122, 132, 142, 152, 720-722, 724, 729, 923, 925

OR Member has at least one claim indicating an injection of contraceptives, child delivery, prenatal care, or postpartum care at any time during the current reporting period.

Denominator Procedure Identification Codes CPT-4 Code Description 11975-11977 Insertion/removal, implantable contraceptive

capsules 57022 Incision and drainage of vaginal hemtoma;

obstetrical/postpartum 57170 Diaphragm or cervical cap fitting with instructions 58300-58301 Insertion/removal of intrauterine device (IUD) 58600, 58605, 58611

Ligation or transaction of fallopian tube(s)

58615 Occlusion of fallopian tube(s) 58970 Follicle puncture for oocyte retrieval 58974 Embryo transfer, intrauterine 58976 Gamete, zygote, or embryo intrafallopian transfer 59000-59001 Amniocentesis 59012 Cordocentesis (intrauterine) 59015 Chronic villus sampling 59020 Fetal contraction stress test 59025 Fetal non-stress test 59030 Fetal scalp blood sampling 59050-59051 Fetal monitoring during labor 59070 Transabdominal amnioinfusion, including ultrasound

guidance 59072 Fetal umbilical cord occlusion, including ultrasound




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guidance 59074 Fetal fluid drainage, including ultrasound guidance 59076 Fetal shunt placement, including ultrasound

guidance 59100 Hysterotomy, abdominal 59120-59121 Surgical treatment of ectopic pregnancy 59130 Abdominal pregnancy 59135 Interstitial, uterine pregnancy requiring total

hysterectomy 59136 Interstitial, uterine pregnancy with partial resection of

uterus 59140 Cervical, with evacuation 59150-59151 Laparoscopic treatment of ectopic pregnancy 59160 Curettage, postpartum 59200 Insertion of cervical dilator 59300 Episiotomy or vaginal repair 59320, 59325 Cerclage of cervix, during pregnancy; vaginal,

cervical 59350 Hysterorrhaphy of ruptured uterus 59400 Routine obstetric care including antepartum care,

vaginal delivery and postpartum care 59409 Vaginal delivery only 59410 Including postpartum care 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate delivery) 59425 Antepartum care only; 4-6 visits 59426 Antepartum care; 7 or more visits 59430 Postpartum care only 59510 Routine obstetric care including antepartum care,

cesarean delivery, and postpartum care 59514 Cesarean delivery only 59515 Cesarean delivery, including postpartum care 59525 Subtotal or total hysterectomy after cesarean

delivery 59610 Routine obstetric care including antepartum care,

vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59612 Vaginal delivery only, after previous cesarean delivery

59614 Including postpartum care 59618 Routine obstetric care including antepartum care,

cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery




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59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;

59622 Cesarean delivery, including postpartum care 59812 Treatment of incomplete abortion, any trimester,

completed surgically 59820, 59821, 59830

Treatment of missed abortion, completed surgically; first trimester

59840, 59841, 59850

Induced abortion

59851 Induced abortion, with dilation and curettage and/or evacuation

59852 Induced abortion, with hysterotomy 59855, 59856, 59857

Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation, with hysterectomy

59866 Multifetal pregnancy reduction(s) (MPR) 59870-59871 Uterine evacuation and curettage for hydatidiform

mole 59897 Unlisted fetal invasive procedure, including

ultrasound guidance 59898 Unlisted laparoscopy procedure, maternity care and

delivery 59899 Unlisted procedure, maternity care and delivery 76801 Ultrasound, pregnant uterus, real time with image

documentation, first trimester; single/first gestation 76805, 76811, 76813, 76815, 76816

Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete, limited, repeat

76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818-76819 Fetal biophysical profile 76820, 76821

Doppler velocimetry, fetal; umbilical artery or middle cerebral artery

76825-76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76827-76828 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral display; complete

76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation




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76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation

76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation

80055 Obstetric panel 82105 Alpha-fetoprotein; serum 82106 amniotic fluid 82143 Amniotic fluid scan 82731 Fetal fibronectin, cervicovaginal secretions, semi-

quantitative 83632 Lactogen, human placental human chorionic

somatomammotropin 83661-83664 Fetal lung maturity assessment;

L/S ratio Foam stability test Fluorescence polarization Lamellar body density

84163 Pregnancy associated plasma protein-A 86592-86593 Syphilis test; qualitative; quantitative 86631 Chlamydia 86632 Chlamydia, IgM 87110 Culture, chlamydia, any source 87164 Dark field examination, any source (eg, penile,

vaginal, oral, skin); includes specimen collection 87166 “ - without collection 87270 Chlamydia trachomatis 87320 Chlamydia trachomatis 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87492 Chlamydia trachomatis, quantification 87590-87592 Neisseria gonorrhea; direct probe technique,

amplified probe technique, quantification 87620-87622 Papillomavirus, human; direct probe technique,

amplified probe technique, quantification 87660 Trichomonas vaginalis, direct probe technique 87800, 87801

Infectious agent detection by nucleic acid, multiple organisms; direct probe technique, amplified probe technique

87808 Infectious agent detection by immunoassay with direct optical observation; trichomonas vaginalis

87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis

87850 Gonorrhea detection 88141-88145 Cytopathology, cervical or vaginal (88144, 88145 are

retired codes kept in for historical reporting)




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88147, 88148 Cytopathology smears, cervical or vaginal 88150, 88152-88155

Cytopathology, slides, cervical or vaginal

88164-88167 Cytopathology, slides, cervical or vaginal (the Bethesda system)

88174-88175 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid

88235 Amniotic fluid or chorionic villus cells 88267 Chromosome analysis, amniotic fluid or chorionis

villus, count 15 cells, 1 karyotype, with banding 88269 Chromosome analysis, in situ for amniotic fluid cells,

count cells from 6-12 colonies, 1 karotype, with banding

OR Member has a pregnancy test during the current reporting period.

Denominator Pregnancy Test codes Code Type

Code Code Description

CPT 81025 Urine pregnancy test, by visual color comparison methods

CPT 84702-84703

Gonadotropin, chorionic (hCG); quantitative, qualitative

Rev 0925 or 925

Other diagnostic services: Pregnancy Test

OR Member has at least one claim for a contraceptive prescription during the current reporting period.

Denominator Contraceptive Drugs (NCQA/HEDIS)

Description Prescription

Contraceptives desogestrel-ethinyl estradiol

drospirenone-ethinyl estradiol

estradiol-medroxyprogesterone

ethinyl estradiol-ethynodiol

ethinyl estradiol-etonogestrel

ethinyl estradiol-levonorgestrel

ethinyl estradiol-norgestimate

ethinyl estradiol-norgestrel etonogestrel levonorgestrel levonorgestrel-

medroxyprogesterone medroxyprogesterone mestranol-norethindrone




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ethinyl estradiol-norelgestromin

ethinyl estradiol-norethindrone

Diaphragm diaphragm

Spermicide nonxynol 9


Female members ages 16-24 years old as of the start of the reporting period (July 1, 2009). For the 2009-10 program year, this is a DOB range from 7/1/1993 (16.00 yrs) to 7/2/1984 (24.99 yrs), inclusive. Only female members are eligible for this measure. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled within the same HPH health center during the current reporting period, as specified below:






Members whose only means of identification for the denominator was a pregnancy test, and whose pregnancy test was followed within 0 to 7 days by either an x-ray or the filling of an Accutane prescription.* *Note: A member will be excluded from the denominator only if all of the following conditions are met: 1) Her only method of denominator identification is via a pregnancy test(s). (Meaning the member did not have any other qualifying services or contraceptive prescriptions during the program year). AND




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2) A member will be excluded from the denominator only if each pregnancy test is followed, within 0 to 7 days, by either an X-Ray or a prescription for Accutane. If there is any pregnancy test without a subsequent X-Ray or Accutane prescription, the member does not qualify for the denominator exclusion.


Exclude each episode during the current reporting period where a member received a pregnancy test which was followed within 0 to 7 days by either an X-ray or a filled prescription for Accutane. Pregnancy tests are defined with the same codes used in the denominator criteria.

Pregnancy Test codes Code Type


CPT 81025 Urine pregnancy test, by visual color comparison methods

CPT 84702-84703

Gonadotropin, chorionic (hCG); quantitative, qualitative

Rev 0925 or 925

Other diagnostic services: Pregnancy Test

AND Member had a claim for an X-ray or Accutane prescription within 0-7

days after the pregnancy test.

Diagnostic Radiology (X-Ray) defined as: CPT-4 codes: 70010-76499 UB Revenue codes: 032X or 32X

OR Prescription for Accutane Qualifying NDCs are identified via an NQCA/HEDIS exclusion drug list which is updated on an annual basis for the HEDIS measure “Chlamydia Screening in Women.”

AND Only exclude women who are ONLY present in the denominator due to a pregnancy test. That is, women who qualify for the denominator in any identification step other than a pregnancy test alone are not eligible to be considered for the denominator exclusion.




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Members in the denominator who had at least one screening test for Chlamydia (i.e. Chlamydia trachomatis tests, Chlamydia species test, Chlamydia trachomatis and neiserria gonorrhea tests) during the current reporting period.


Members in the denominator who had at least one screening test for Chlamydia during the current reporting period. Chlamydia screening defined as: CPT-4 codes: 87110, 87270, 87320, 87490, 87491, 87492, 87810


Diabetic Retinal Exam Version 1.00 for Program Guide


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Measure Diabetic Retinal Exam (“Retinal”) Target > 60.00% Clinical Intent

To ensure that all diabetic members ages 18-75 receive a diabetic retinopathy screening test at a clinically appropriate frequency.


Continuously enrolled members ages 18-75 years as of the start of the reporting period who were identified as having diabetes during the current reporting period or the prior 12-month program year. Members are identified as having diabetes via prescription drug and diagnosis histories.


Members are identified as having diabetes by satisfying at least one of the following criteria: Members who were dispensed at least one insulin and/or oral hypoglycemics/antihyperglycemic drug on an ambulatory basis during the current reporting period or the prior 12-month program year. Appropriate denominator drugs are identified via a drug list updated on an annual basis by NCQA for use in the HEDIS measure “Comprehensive Diabetes Care.”

2009 HEDIS: Prescriptions to Identify Members with Diabetes Description Prescription

Alpha-glucosidase inhibitors

acarbose miglitol

Amylin analogs pramlinitide Antidiabetic combinations

glimepiride-pioglitazone glimepiride-rosiglitazone glipizide-metformin glyburide-metformin

metformin-pioglitazone

metformin-rosiglitazone

metformin-sitagliptin Insulin insulin aspart

insulin aspart-insulin aspart protamine

insulin detemir insulin glargine insulin glulisine insulin inhalation insulin isophane beef-

pork insulin isophane human insulin isophane pork

insulin lispro insulin lispro-insulin

lispro protamine insulin regular beef-

pork insulin regular human insulin regular pork insulin zinc beef-pork insulin zinc extended

human insulin zinc human




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insulin isophane-insulin regular

insulin zinc pork

Meglitinides nateglinide repaglinide Miscellaneous antidiabetic agents

exenatide pramlintide sitagliptin

Sulfonylureas acetohexamide chlorpropamide glimepiride

glipizide glyburide

tolazamide tolbutamide

Thiazolidinediones pioglitazone rosiglitazone Note: Per HEDIS 2009, glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis coding only.

OR Members who had at least two face-to-face encounters with a diagnosis of diabetes in an outpatient setting or non-acute inpatient setting on different dates of service during the current reporting period or prior 12-month program year. (Diagnosis may be in primary or additional dx positions).

Diagnosis of diabetes Code Type Code ICD-9 dx 250.XX, 357.2X, 362.0X, 366.41, or 648.0X

OR Members who, during the current reporting period or prior 12-month program year, had at least one face-to-face encounter in an acute inpatient or emergency room setting with any diagnosis of diabetes on the same claim. See above for diabetes diagnosis codes.


Members must be ages 18-75 years old as of the start of the reporting period. For the 2009-10 program year, this is a DOB range from 7/1/1991 (18.00 yrs) to 7/2/1933 (75.99 yrs), inclusive. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled within the same HPH health center during the current reporting period, as specified below:




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Members in the denominator with a diagnosis of polycystic ovaries at any time in the member’s history prior to the end of the current reporting period who did NOT receive a diagnosis of diabetes during the current reporting period or prior 12-month program year. OR Members diagnosed with gestational diabetes or steroid-induced diabetes during the current reporting period or prior 12-month program year who did NOT also receive a diagnosis of diabetes during the current reporting period or prior 12-month program year.


To qualify for any exclusion, the member must not have received any diagnosis of diabetes in a face-to-face encounter (see denominator for ICD-9 dx codes) during the current reporting period or prior 12 month program year. Members with a diagnosis of polycystic ovaries at any time during the member’s history through the end of the current reporting period.

ICD-9 diagnosis code(s): 256.4x

OR Members diagnosed with steroid-induced or gestational diabetes during the current reporting period or prior 12-month program year.

ICD-9 diagnosis code(s): 251.8x, 648.8x, 962.0x


Members in the denominator will be counted towards the numerator if, during the current reporting period, they received at least one screening exam for diabetic retinal disease by an eye-care professional or had at least one office visit with an ophthalmologist or optometrist.* *Eye exams provided by eye care professionals are a proxy for dilated eye




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examinations because there is no administrative way to determine that a dilated exam was performed.


At least one screening exam for diabetic retinal disease (including either retinal or dilated eye exam) performed by an eye care professional:

Retinal or dilated eye exam, or retinal repair Code Type Code CPT 67028, 67030, 67031, 67036, 67038-67040,

67101, 67105, 67107-67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210. 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260

Or HCPCS codes

S0620, S0621, S0625, S3000

Or CPT Cat II 2022F, 2024F, 2026F, 3072F Or ICD-9 Dx V72.0x Or ICD-9 Surg Proc

14.1x-14.5x, 14.9x, 95.02-95.04, 95.11, 95.12, 95.16

Rendering provider specialty must be:

Ophthalmologist or Optometrist or Ophthalmology, Pediatric or Ophthalmology, Retinal

OR At least one office visit with an ophthalmologist (HMSA spec code 018 or 208 or 250) or optometrist (HMSA spec code 090)

Office Visits (with an eye care professional) Code Type Code CPT 99203, 99204, 99205, 99213, 99214, 99215, or

99242-99245 Rendering provider specialty must be:

Ophthalmologist or Optometrist or Ophthalmology, Pediatric or Ophthalmology, Retinal


HbA1c Testing for Diabetics Twice Annually Version 1.00 for Program Guide


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Measure Glycosylated Hemoglobin (HbA1c) Testing for Diabetics Twice Annually (“Glyco”) Target > 75.00% Clinical Intent

To ensure that all diabetic members ages 18-75 receive at least 2 glycosylated hemoglobin (HbA1c) tests during the program year.


Continuously enrolled members ages 18-75 years as of the start of the reporting period who were identified as having diabetes during the current reporting period or the prior 12-month program year. Members are identified as having diabetes via prescription drug and diagnosis histories.


Members identified as having diabetes by satisfying at least one of the following criteria: Members who were dispensed at least one insulin and/or oral hypoglycemics/antihyperglycemic drug on an ambulatory basis during the current reporting period or the prior 12-month program year. Appropriate denominator drugs are identified via a drug list updated on an annual basis by NCQA for use in the HEDIS measure “Comprehensive Diabetes Care.” 2009 HEDIS: Prescriptions to Identify Members with Diabetes

Description Prescription Alpha-glucosidase inhibitors

acarbose miglitol

Amylin analogs pramlinitide Antidiabetic combinations

glimepiride-pioglitazone glimepiride-rosiglitazone glipizide-metformin glyburide-metformin

metformin-pioglitazone

metformin-rosiglitazone

metformin-sitagliptin Insulin insulin aspart

insulin aspart-insulin aspart protamine

insulin detemir insulin glargine insulin glulisine insulin inhalation insulin isophane beef-

pork insulin isophane human insulin isophane pork

insulin lispro insulin lispro-insulin

lispro protamine insulin regular beef-

pork insulin regular human insulin regular pork insulin zinc beef-pork insulin zinc extended

human insulin zinc human




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insulin isophane-insulin regular

insulin zinc pork

Meglitinides nateglinide repaglinide Miscellaneous antidiabetic agents

exenatide pramlintide sitagliptin

Sulfonylureas acetohexamide chlorpropamide glimepiride

glipizide glyburide

tolazamide tolbutamide

Thiazolidinediones pioglitazone rosiglitazone

Note: Per HEDIS 2009, glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis coding only.

OR Members who had at least two face-to-face encounters with a diagnosis of diabetes in an outpatient setting or non-acute inpatient setting on different dates of service during the current reporting period or prior 12-month program year. (Diagnosis may be in primary or additional dx positions).

Diagnosis of diabetes Code Type Code ICD-9 dx 250.XX, 357.2X, 362.0X, 366.41, or 648.0X

OR Members who, during the current reporting period or prior 12-month program year, had at least one face-to-face encounter in an acute inpatient or emergency room setting with any diagnosis of diabetes on the same claim. See above for diabetes diagnosis codes.


Members must be ages 18-75 years old as of the start of the reporting period For the 2009-10 program year, this is a DOB range from 7/1/1991 (18.00 yrs) to 7/2/1933 (75.99 yrs), inclusive. Members included in Patient Intervention Reports (PIRs) patient lists must be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled within the same HPH health center during the current reporting period, as specified below:




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Members in the denominator with a diagnosis of polycystic ovaries at any time in the member’s history prior to the end of the current reporting period who did NOT receive a diagnosis of diabetes during the current reporting period or prior 12-month program year. OR Members diagnosed with gestational diabetes or steroid-induced diabetes during the current reporting period or prior 12-month program year who did NOT also receive a diagnosis of diabetes during the current reporting period or prior 12-month program year.


To qualify for any exclusion, the member must not have received any diagnosis of diabetes in a face-to-face encounter (see denominator for ICD-9 dx codes) during the current reporting period or prior 12 month program year. Members with a diagnosis of polycystic ovaries at any time during the member’s history through the end of the current reporting period.

ICD-9 diagnosis code(s): 256.4x

OR Members diagnosed with steroid-induced or gestational diabetes during the current reporting period or prior 12-month program year.

ICD-9 diagnosis code(s): 251.8x, 648.8x, 962.0x


Members in the denominator will be counted towards the numerator if they received at least two (2) glycosylated hemoglobin (HbA1c) tests during the current reporting period.


Members who received at least 2 HbA1c tests during the current reporting period.




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HbA1c Tests Code Type Code CPT 83036 or 83037 OR CPT Cat II 3044F, 3045F, 3046F, 3047F*

*Code has been deleted but is appropriate for historical analysis

HPH Quality and Performance Evaluation Program 2009-2010 Drug Measure Specification

Mail Order Prescription Purchasing by HMSA Patients Version 1.00 for Program Guide

Page 1 of 5


Measure Mail-Order Prescription Purchasing by HMSA Patients (“Mail Order”) Target >15.00% Measure Rationale

This measure identifies the percentage of all mail order opportunity prescriptions that were filled via mail order provider “Medco by Mail.” “Mail order opportunity prescriptions” are for drugs which have been identified by HMSA pharmacy management personnel as appropriate for mail order dispensing. These drugs have previously been purchased by HMSA members via mail order and include those drugs that have the greatest opportunity for cost-savings based on script volume and cost per unit. The list of mail order opportunity drugs is based on Specific Therapeutic Class (STC) codes. This list is reviewed and updated annually by an HMSA Pharmacy Management pharmacist. See Appendix for the current list.


The denominator is calculated as the total normalized script count for all mail order opportunity drugs which were filled by HPH members during the current reporting period. This includes drugs that were dispensed via mail order provider Medco by Mail, or via non-mail order providers (e.g. Longs Drugs, Wal-Mart, etc). Prescriptions written by dentists and dental-type specialties including endodontists, periodontists, and oral surgeons will be excluded from measurement. All prescription counts are normalized based on the days supply provided. Script – Days’ Supply Normalization:

if days’ supply is > 0 and ≤ 30 days, script count = 1 If days’ supply is between 31 and 60 days, script count = 2

If days’ supply is between 61 and 90 days, script count = 3 If days’ supply is between 91 and 120 days, script count = 4 If days’ supply is between 121 and 150 days, script count = 5 Only drug claims with HMSA as the primary payer will be incorporated into measurement.


Filled prescriptions for HPH members during the current reporting period, for drugs which are included in the current list of mail order opportunity



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drugs. See Appendix for current list of Specific Therapeutic Classes. Prescriptions written by providers in the following reimbursement specialties will NOT be included in measurement:

o Oral Surgery (019) o Pharmacy (105) o Dentist (120) o Pedodontist (121) o Periodontist (122) o Prosthodontist (123) o Endodontist (124) o Orthodontist (125) o Specialty Pharmacy (127) o Non-Submitting Provider (200)


Members of an HPH health center at any time during the current reporting period. No continuous enrollment criteria are applied.


Drugs on the mail order opportunity drug list which are filled via mail order vendors Caremark or Rx America.


Exclude prescriptions filled via mail order vendors Caremark or Rx America.


Number of normalized (based on days supply) scripts for mail order opportunity drugs filled via mail order prescription provider “Medco by Mail” during the current reporting period.


Mail order opportunity prescriptions filled by Medco by Mail (January 1, 2009 and later) or Precision Rx or Precision Rx Specialty Solutions (prior to January 1, 2009) mail order vendors.

Prescription counts will be normalized based on days supply.

Reporting note:



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Reporting for this measure is member-driven. Prescriptions written by out-of-Health Center providers are included in measurement. Thus any prescription activity for a health center member will be traced back to the member’s health center (and PCP).

Appendix: List of Mail Order Opportunity Drugs, by Specific Therapeutic Class

SP TC THERAPEUTIC CLASS DESCRIPTION A1A DIGITALIS GLYCOSIDES A2A ANTI-ARRHYTHMICS A4A HYPOTENSIVES-VASODILATORS (ALPHA BLOCKERS) A4B HYPOTENSIVES-SYMPATHOLYTIC A4D HYPOTENSIVES-ACE INHIBITORS A4F HYPOTENSIVES-ANGIOTENSIN RECEPTOR ANTAGONISTS A4H ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR A4I HYPOTENSIVES-ANGIOTENSIN RECEPTOR ANTAGONISTS A4J ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC A4K ACE INHIBITOR/CALCIUM CHANNEL BLOCKERS A4T RENIN INHIBITOR, DIRECT A4U RENIN INHIBITOR/THIAZIDE DIURETIC COMBO A4Y HYPOTENSIVES-MISCELLANEOUS A7B CORONARY VASODILATORS A9A CALCIUM CHANNEL BLOCKING AGENTS C1A ELECTROLYTE DEPLETERS C4F ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB. C4G INSULINS C4H ANTIHYPERGLYCEMIC, AMYLINOMIMETICS C4I ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) C4J ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS C4K ORAL HYPOGLYCEMIC AGENTS; SULFONYLUREA TYPE C4L ORAL HYPOGLYCEMIC AGENTS; NON-SULFONYLUREA TYPE C4M ORAL HYPOGLYCEMIC AGENTS; NON-SULFONYLUREA TYPE C4N ORAL HYPOGLYCEMIC AGENTS; INSULIN-RESISTANT C4R HYPOGLY, INSULIN-RESPONSE & INSULIN RELEASE COMB. C4S HYPOGLY, INSULIN-REL STIM. & BIGUANIDE (N-S) COMB. C4T HYPOGLY, INSUL-RESP. ENHANCER & BIGUANIDE COMB. C6M FOLIC ACID PREPARATIONS C7A PURINE INHIBITORS D6F DRUG TX-CHRONIC INFLAM. CO... D7L BILE SALT INHIBITORS D8A PANCREATIC ENZYMES G1A ESTROGENIC AGENTS G1B ESTROGEN/ANDROGEN COMBINATION PREPARATIONS G1D ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB G2A PROGESTATIONAL AGENTS G8A CONTRACEPTIVES, ORAL G8F CONTRACEPTIVES,TRANSDERMAL



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G9B CONTRACEPTIVES, INTRAVAGINAL H1A ALZHEIMER'S THERAPY, NMDA H2S SEROTONIN SPECIFIC REUPTAKE INHIBITOR (SSRIS) H2U TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB H2W TRICYCLIC ANTIDEPRESSANTS, PERPHENAZINES H2X TRICYCLIC ANTIDEPRESSANTS, BENZODIAZAPINES H4B ANTI-CONVULSANTS H4C ANTI-CONVULSANTS H6A ANTI-PARKINSONISM DRUGS, OTHER H6B ANTI-PARKINSONISM DRUGS, ANTI-CHOLINERGIC H6I AMYOTROPHIC LATERAL SCLEROSIS H7B ALPHA-2 RECEPTOR ANTAGONISTS H7C SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITOR H7D NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITOR H7J MAOIS J1B CHOLINESTERASE INHIBITORS J5G BETA-ADRENERGICS AND GLUCO... J7A ADRENERGIC INHIBITORS J7B ALPHA-ADRENERGIC BLOCKING AGENTS J7C BETA-ADRENERGIC BLOCKING AGENTS J7D BETA-ADRENERGIC BLOCKING AGENTS M4A BLOOD SUGAR DIAGNOSTICS M4D ANTIHYPERLIPIDEMIC - HMG CHOLESTEROL REDUCERS M4E LIPOTROPICS (HMG'S) M4F LIPOTROPICS (HMG'S) M4I ANTIHYPERLIP(HMGCOA) & CALCIUM CHANNEL BLOCKER CMB M4L ANTIHYPERLIPIDEMIC-HMG COA REDUCTASE INHIB.&NIACIN M4M ANTIHYPERLIPID.HMG COA REDUCERS M9L ORAL ANTI-COAGULANTS, COUMARIN TYPE M9P PLATELET AGGREGATION INHIBITORS M9S HEMORRHEOLOGIC AGENTS P3A THYROID HORMONES P4L BONE OSSIFICATION SUPPRESSION AGENTS P4N BONE RESORPTION INHIBITORS P4O BONE RESORPTION INHIBITORS Q6G MIOTICS/OTHER INTRAOC. PRE... Q9B BENIGN PROSTATIC HYPERTROP... R1A URINARY TRACT ANTISPASMODIC AGENTS R1F THIAZIDE DIURETICS AND RELATED AGENTS R1H POTASSIUM SPARING DIURETICS R1I URINARY TRACT ANTISPASMODIC AGENTS R1L POTASSIUM SPARING DIURETIC R1M LOOP DIURETICS R1R URICOSURIC AGENTS V1A ALKYLATING AGENTS V1B ANTI-METABOLITES V1F MISCELLANEOUS ANTI-NEOPLASTICS



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V1H ANTINEOPLASTICS, MISCELLANEOUS V1J ANTIANDROGENIC AGENTS V1Q ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITOR V1T SELECTIVE ESTROGEN RECEPTOR W5C ANTI-VIRALS, H.I.V., PROTEASE INHIBITORS W5F HEPATITIS B TREATMENT AGENTS W5I ANTI-VIRALS, H.I.V., NUCLEOTIDE ANALOG, RTI W5J ANTI-VIRALS, H.I.V., NUCLEOSIDE ALG RTI W5K ANTI-VIRALS, H.I.V., NON-NUCLEOSIDE RTI W5L ANTI-VIRALS, H.I.V., NUCLEOSIDE ALG RTI COMB W5M ANTI-VIRALS, H.I.V., PROTEASE INHIB COMB W5O ANTI-VIRALS, H.I.V., NUCLEOSIDE-NUCLEOTIDE ANALOG W5P ANTI-VIRALS, H.I.V., NON-PEPTIDIC PROTEASE INHIB W5Q ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI W5U ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Z2E IMMUNOSUPPRESIVES


Postpartum Care Version 1.00 for Program Guide


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Measure Postpartum Care (“Postpartum”) Target Report-only measure; no scoring target Clinical Intent To ensure that women with live birth deliveries receive postpartum care

on or between 21 and 56 days after delivery.


Continuously enrolled women who delivered a live birth between May 6, 2009, and May 5, 2010 (for the quarterly reports, women must have given birth between May 6, 2009 and up to 56 days prior to the end of the current reporting period). The denominator evaluation period is calculated to capture services for a full 56 days after every delivery in the evaluation period. Thus the start and end dates for the denominator identification period are both shifted to be 56 days earlier than the standard reporting period dates. Earliest delivery allowed in Final Report: May 6, 2009 Plus minimum numerator window: 21 days Earliest numerator DOS allowed: May 27, 2009 Latest delivery allowed in Final Report: May 5, 2010 Plus maximum numerator window: 56 days Latest numerator DOS allowed: June 30, 2010

Handling of Multiple Births: Women who had two separate deliveries

(different dates of service) between 5/6/09 and 5/5/10 should be counted twice. Women who had multiple live births (twins, triplets, etc) during one pregnancy should be counted once in the measure.


Women with live birth deliveries between May 6, 2009 and up to 56 days prior to the end of the current reporting period are identified via the following methods: Women with a known live birth delivery: Note: The codes listed below both identify a delivery and indicate that the outcome of the delivery was a live birth.

Codes to identify live birth delivery Code Type Code




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ICD-9 dx 650, V27.0, V27.2, V27.3, V27.5, V27.6

OR Women with a delivery, coded without indication of live birth status

Codes to identify deliveries Code Type Code CPT 59400, 59409, 59410, 59510, 59514, 59515,

59610, 59612, 59614, 59618, 59620, 59622 Or ICD-9 dx 640.x1, 641.x1, 642.x1, 642.x2, 643.x1, 644.21,

645.11, 645.21, 646.x1, 646.12, 646.22, 646.42, 646.52, 646.62, 646.82, 647.x1, 647.x2, 648.x1, 648.x2, 649.x1, 649.x2, 651.x1, 652.x1, 653.x1, 654.x1, 654.02, 654.12, 654.32, 654.42, 654.52, 654.62, 654.72, 654.82, 654.92, 655.x1, 656.01, 656.11, 656.21, 656.31, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.x1, 659.x1, 660.x1, 661.x1, 662.x1, 663.x1, 664.x1, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.x2, 667.x2, 668.x1, 668.x2, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92, 670.02, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.x1, 673.x2, 674.01, 674.51, 674.x2, 675.x1, 675.x2, 676.x1, 676.x2

Or ICD-9 Surg Proc

72.0x-73.99, 74.0-74.2, 74.4, 74.99

AND NOT

Deliveries not resulting in a live birth

Codes to identify deliveries not resulting in live births Code Type Code ICD-9 dx 630.xx-637.xx, 639.xx, 656.4x, 768.0, 768.1,

V27.1, V27.4, V27.7


This measure is for continuously enrolled female members.

Members included in the Patient Intervention Reports (PIRs) and final




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reporting must be continuously enrolled in the same HPH health center from 43 days prior to delivery through 56 days after delivery. No gaps of any length are allowed during this period.

Members must also be enrolled with the same Health Center as of the end of the reporting period.


None specified.


N/A


Women in the denominator who have a postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery. Earliest numerator event (Final Report): May 6, 2009 + 21 days =

May 27, 2009 Latest numerator event (Final Report): May 5, 2010 + 56 days =

June 30, 2010


Women will be counted in the numerator if they have at least one postpartum care visit on or between 21 and 56 days after delivery.

Postpartum care visit or pelvic exam Code Type Code CPT 57170, 58300, 59400*, 59410*, 59430, 59510*,

59515*, 59610*, 59614*, 59618*, 59622*, 88141-88145, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175

HCPCS codes

G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

Or UB Rev 0923 or 923 Or ICD-9 Dx V24.1, V24.2, V25.1, V72.3x, V76.2 Or ICD-9 Surg Proc

89.26, 91.46

Or CPT Cat-II 0503F




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*Generally, these codes are used on the date of delivery, not on the date of the postpartum visit, so this code may be used only if the claim form indicates when postpartum care was rendered.


Treatment of Coronary Artery Disease: Statins Version 1.00 for Program Guide

Codes Source: 2009 HEDIS/2010 PQSR V1.01 09-10 Q&P Spec

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Measure Treatment of CAD: Statins (“cadlip”) Target > 84.00% Clinical Intent To ensure that all members identified as having coronary artery disease

(CAD) receive statins.


Continuously enrolled members ages 18 to 75 years as of the start of the reporting period who were identified as having coronary artery disease during the current reporting period or prior 12-month program year. Members are required to be continuously enrolled with both medical and pharmacy benefits. Members are identified with CAD if they suffered from or underwent treatment for an acute myocardial infarction (PTCA or CABG) during the prior 12-month program year or had evidence of ischemic vascular disease on an encounter record during the current reporting period AND the prior 12-month program year.


Members with at least one episode of Acute Myocardial Infarction during the prior 12-month program year in an inpatient setting

Acute Myocardial Infarction Code Type Code ICD-9 dx 410.x1

OR Members who underwent a PTCA during the prior 12-month program year (in any setting).

PTCA Code Type Code CPT 33140, 92980-92982, 92995 or ICD-9 Surg Proc

00.66, 36.01*, 36.02*, 36.05*, 36.06, 36.07, 36.09

*Codes were retired in 2005 but are retained for historical reporting

OR Members who underwent a CABG during the prior 12-month program year, in an inpatient setting.




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CABG Code Type Code CPT 33510-33514, 33516-33519, 33521-33523,

33533-33536 Or HCPCS S2205-S2209 Or ICD-9 Surg Proc

36.1x, 36.2x

OR Members who had, in both the current reporting period and the prior 12 month program year, at least 1 outpatient visit or 1 inpatient visit with an Ischemic Vascular Disease (IVD) diagnosis.

Codes to identify Ischemic Vascular Disease (IVD) Code Type


ICD-9 dx 414.0x, 414.8x, 414.9x, 429.2, 414.2x

Other forms of IHD

or ICD-9 dx 411.xx, 413.x Stable Angina or ICD-9 dx 440.2x, 443.9x*, 440.4x Lower extremity arterial

disease/peripheral artery disease

Or ICD-9 dx 433.xx, 434.xx, 436.x*-

438.9x* Stroke

or ICD-9 dx 444.xx, 445.xx Athero-embolism or ICD-9 dx 440.1 Renal Artery Atherosclerosis

* Code was retired but is still appropriate for retrospective analysis


Members must be ages 18-75 years as of the start of the current reporting period. For the 2009-10 program year, this is a DOB range from 7/1/1991 (18.00 yrs) to 7/2/1933 (75.99 yrs), inclusive. Members included in Patient Intervention Reports (PIRs) patient lists must




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be active in their health center as of the end of the reporting period. Members included in quarterly rate calculations and final measurement must also be continuously enrolled within the same HPH health center during the current reporting period, as specified below:





Members are required to be continuously enrolled for pharmacy benefits for the same time periods as given above


Members with evidence of contraindications to statins including rhabdomyolosis at any time in the member’s history prior to the end of the current reporting period. Or, members with evidence of acute renal failure, active liver dysfunction (acute or chronic) or alcoholism during the current reporting period or the prior 12-month program year. Or, members who were pregnant during the current reporting period.


Members in the denominator with myositis or rhabdomyolosis at any time prior to the end of the current reporting period.

Myositis or rhabdomyolosis Code Type

Code

ICD-9 dx 710.3, 710.4, 728.19, 728.81, 728.88, 729.1x

OR Members diagnosed with acute renal disease during the current reporting period or the prior 12-month program year.

Acute renal disease Code Code




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Type ICD-9 dx 584.xx, 788.5x

OR Members diagnosed with liver dysfunction (acute or chronic), or alcoholism during the current reporting period or the prior 12-month program year.

Liver dysfunction or alcoholism Code Type

Code

ICD-9 dx 070.xx,121.1, 275.0, 275.1x, 456.2x, 570, 571.xx, 573.xx, 864.xx Or 265.2, 291.xx, 303.0x, 303.9x

OR Members with evidence of pregnancy during the current reporting period.

Pregnancy events Code Type

Codes

CPT 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, 59850-59852, 59855-59857, 59866, 59870, 59871, 59897-59899, 76801, 76802, 76805, 76810-76812, 76815-76819, 76825-76828, 76941, 76945, 76946, 82106, 82143, 82731, 88235, 88267, 88269

Or ICD-9 dx 630.xx-677.xx, V22.xx, V23.xx, V24.xx, V27.xx,

V28.xx, V72.42 Or ICD-9 Surg Proc

66.62, 69.0x, 72.xx-75.xx

Or DRG 370-391 Or MS-DRG 765-795

Numerator




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Numerator Definition

Denominator members with at least one prescription for a statin drug during the current reporting period.


Members will be counted in the numerator if they filled at least one prescription for a statin during the current reporting period.

Statins by Specific Therapeutic Class Code Type Code Specific Therapeutic Class M4D, M4I, M4J, M4L, or M4M OR Generic Category Number 43720

HPH Quality and Performance (Q&P) Evaluation Program 2009-2010 Clinical Measure Specification

Appropriate Testing for Children with Pharyngitis Version 1.00 for Program Guide


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Measure Appropriate Testing for Children with Pharyngitis (“Phartest”) Target > 75.00% Clinical Intent

To ensure that members who were diagnosed with pharyngitis (or strep throat or tonsillitis) and dispensed an antibiotic receive appropriate testing for group A streptococcus within a clinically appropriate timeframe.


Continuously enrolled members ages 2-17 years old as of the start of the reporting period who were diagnosed with only pharyngitis in an outpatient or emergency room setting during the current reporting period and who filled a prescription for an antibiotic during the 0-3 days following the index date. The final denominator (reported to health centers and used in scoring) for this measure will contain just one episode per member, selected as the earliest/first episode per member during the current reporting period.


Members who were diagnosed with only pharyngitis (or strep throat or tonsillitis) in an outpatient or emergency room setting during the current reporting period.

Pharyngitis: Pharyngitis diagnosis Code Type Code Description ICD-9 dx 034.0x Strep sore throat Or ICD-9 dx 462.xx Acute pharyngitis Or ICD-9 dx 463.xx Acute tonsillitis

AND Denominator members must also have filled a prescription for an antibiotic 0-3 days after the index pharyngitis diagnosis date (inclusive of the index date).

Antibiotic Drug List (2009 HEDIS/NCQA) Description Prescription

Aminopenicillins amoxicillin ampicillin

Beta-lactamase inhibitors amoxicillin-clavulanate

First generation cephalosporins

cefadroxil cefazolin

cephalexin cephradine

Folate antagonist trimethoprim




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Lincomycin derivatives clindamycin

Macrolides azithromycin clarithromycin erythromycin erythromycin

ethylsuccinate

erythromycin lactobionate erythromycin estolate erythromycin stearate

Miscellaneous antibiotics erythromycin-sulfisoxazole

Natural penicillins penicillin G potassium

penicillin G sodium

penicillin V potassium

Penicillinase-resistant penicillins

dicloxacillin

Quinolones ciprofloxacin gatifloxacin levofloxacin lomefloxacin

moxifloxacin ofloxacin sparfloxacin

Second generation cephalosporins

cefaclor cefprozil

cefuroxime loracarbef

Sulfonamides sulfamethoxazole-trimethoprim

sulfisoxazole

Tetracyclines doxycycline minocycline

tetracycline

Third generation cephalosporins

cefdinir cefixime cefpodoxime

ceftibuten cefditoren ceftriaxone


Members must be ages 2 through 17 years old as of the start of the reporting period (July 1, 2009). For the 2009-10 program year, this is a DOB range from 7/1/2007 (2.00 yrs) to 7/2/1991 (17.99 yrs), inclusive. Members must be continuously enrolled 30 days prior through 3 days after the index denominator diagnosis date (inclusive of the index date). Members must also be continuously enrolled with pharmacy benefits 30 days prior through 3 days after the index date (inclusive of the index date). Members must also be active within their health center as of the end of the reporting period.

Denominator Exclusion Denominator Members who filled a prescription for an antibiotic in the 1-30 days prior to the




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Exclusion Definition

index pharyngitis diagnosis date will be excluded from the denominator (and numerator). Drug List: See “Antibiotic Drug List (2009 HEDIS/NCQA)” in denominator criteria.


Members will be numerator positive if they were given a strep test in the 7 day period starting 3 days prior to the index pharyngitis diagnosis date and ending 3 days after the index date (inclusive of index date).


Strep tests given in the 7 day period starting 3 days prior to the index denominator diagnosis date and ending 3 days after the index date (inclusive of index date).

Strep Test Code Type Code CPT 87070, 87071, 87081, 87430, 87650-87652,

87880

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