Embed Size (px)
Citation preview
Aetna HEDIS Tip Sheet 2017 Page 1
PCP HEDIS Documentation Tips: Older Adults
HEDIS Measure Definitions What You Can Do Coding/Tips
BCS - Breast Cancer Screening
Women 50-74 years of age with one or more mammograms within the last 2 years.
Educate women regarding the benefit of early detection of breast cancer through routine mammograms
Encourage mammography to all women who are within measure age group.
Submit the appropriate mastectomy code to exclude women from this measure if it is part of their history
Breast Cancer Screening Codes CPT Codes: 77055-77057HCPCS G0202, G0204, G0206 UB Rev Codes 0401, 0403
Mastectomy CodesICD-10CM Code: Z90.13, or Z90.12 and Z90.11 ICD-10PCS Code: 0HTV0ZZ, or 0HTU0ZZ and 0HTT0ZZCPT Codes: 19180. 19200, 19220, 19240, 19303-19307 with a Bilateral Modifier CPT Codes: 50, 09950 or LT and RT
MRP - Medication Reconciliation Post Discharge
The percentage of discharges during the year for member 18 and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days)
Document in the medical record must in-clude evidence of medication reconciliation of current and discharge meds and the date it was performed by a prescribing practition-er, clinical pharmacist or RN.
Regular medication review is a best practice. Have members bring all of their medications with them to appointments.
CPT Codes: 99495, 99496 CPT II Codes: 1111F
COA—Care for Older Adults
The percentage of adults 66 years and older who had each of the following during the measurement year:
Advance Care Planning
Medication Review
Functional Status Assessment
Pain Assessment
Advance Care Planning - document discus-sion and/or presence of advance directive or living will in the chart
Medication Review - Medication list in chart with a dated notation of meditation review annually by a prescribing provider or clinical pharmacist
Functional Status Assessment - Complete functional assessment must include one of the following: - Notation that Activities of Daily Living (ADL)
were assessed *or at least five of the follow-ing were assessed: bathing, dressing, eating, transferring, using toilet, walking+ - Notation that Instrumental Activities of
Daily Living (IADL) were assessed *or at least four of the following were assessed: shop-ping for groceries, driving or using public transportation, using the telephone, meal preparation, housework, home repair, laun-dry, taking medication, handling finances]- Result of assessment using a standardized
functional status assessment tool - Notation that at least three of the follow-
ing four components were assessed: cogni-tive status; ambulation status; hearing, vision and speech (sensory ability) ; other function-al independence (exercise, ability to perform job)
Pain Assessment - Notations for pain assess-ment must include one of the following: - Documentation that the member was as-
sessed for pain (positive or negative finding) - Result of assessment using a standardized
assessment tool A pain management/treatment plan alone does not count. Either does screening for chest pain or positive chest pain alone.
Advance Care Planning CPT: 99497 CPT II: 1157F, 1158F HCPCS: S0257
Medication Review CPT: 90863, 99605, 99606, 99494, 99496 CPT II: 1160F
Medication List CPT ll: 1159F HCPCS: G8427
Functional Status Assessment CPT II: 1170F
Pain Assessment CPT II: 1125F, 1126F
Aetna HEDIS Tip Sheet 2017 Page 2
HEDIS Measure Definitions What You Can Do Coding/Tips
CBP - Controlling High Blood Pressure
Members 18-85 years of age with a diagnosis of hypertension (HTN) and whose BP is adequately controlled.
Age 18-59 and age 60-85 with diabe-tes <140/90
Age 60-85 without diabetes <150/90).
If BP elevated (140/90 or greater) at initial vital sign assessment, alleviate potential factors that might cause temporary eleva-tion and retake BP during exam. Make sure you use the correct size cuff
If using a machine, record the actual num-ber, do NOT round up.
Schedule follow up visits to monitor effec-tiveness of BP medication.
ICD-10 CM Code: I10
Exclusions: End Stage Renal Disease (ESRD) or a kidney transplant on or prior to December 31st of the measurement year or a diagnosis of pregnancy during the measurement year, would be excluded from this measure.
CDC—Comprehensive Diabetes Care
Members 18-75 years of age with diabetes should have each of the follow-ing at least annually: HbA1C testing, medi-cal attention for nephropathy, a retinal eye exam and blood pressure monitoring at each visit.
Order screenings annually or more often as needed and educate member on im-portance.
Include all current medications on the med-ication list. Be sure to indicate if a member is on an ACE/ARB medication
Document Stage 4 chronic kidney disease or End State Renal Disease (ESRD) with appro-priate codes: Stage 4 chronic kidney disease CD-10 CM: N18.4 ESRD ICD-10 CM: N18.5, N18.6, Z91.15, Z99.2 ICD-10 PCS: 3E1M39Z, 5A1D00Z, 5A1D60Z
Refer member to Optometrist for Dilated Retinal Eye Exam annually.
Diabetes ICD-10 CM Codes: E10.10-E13.9, O24.011-O24.33, O24.811-O24.83 Diabetes without complications ICD-10 CM: E10.9, E11.9, E13.9
HbA1c CPT Codes: 83036, 83037 HbA1c LOINC: 17856-6, 4548-4, 4549-2 CPTII Result Codes HbA1c level 7.0-9.0: 3045F
HbA1c level less than 7.0: 3044F HbA1c level greater than 9.0: 3046F
Urine Protein Tests CPT Codes: 81000-81003, 81005 , 82042-82044, 84156 CPT II Codes: 3060F-3062F
Blood Pressure CPT Codes: Systolic BP: < 140 3074F, 3075F ; >/= to 140 3077F Diastolic BP: 80-89 3079F; < 80 3078F; >/= 90 3080F
AAP - Adults’ Access to Preventive/Ambulatory Health Services
Members 20 years and older who had an ambulatory or preventive care visit during the year.
Each adult member should have a routine outpatient visit annually.
Utilize your Gaps in Care report to outreach members that have not had care.
CPT: 99201-99205, 99211-99215, 99241-99245. UB Rev Codes: 051X, 0520-0529, 0982, 0983 Preventive Medicine CPT: 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, G0463, T1015 General medical examination ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Home Services CPT: 99341-99345, 99347-99350 Nursing Facility Care CPT: 99304-99310, 99315, 99316, 99318 Domiciliary, rest home or custodial care services CPT: 99324-99328, 99334-99337
PSA—Non-Recommended PSA-Based Screening in Older men
Men 70 years and older who were screened unnecessarily for prostate can-cer using prostate-specific antigen (PSA)-based screening.
A lower rate indicates better performance
Total population PSA testing is not currently advised for men 70 years and older.
The exclusions to this measure are men with a prostate cancer diagnosis at any time, dysplasia of the prostate during the measurement year and year prior, anyone that had a PSA test during the year prior to the measurement year with an elevated result (>4.0 ng/mL), or anyone dispensed a prescription for 5-alpha reductase inhibitor during the measurement year.
Prostate Cancer
ICD 10: C61, D07.5, D40.0, Z15.03, Z85.46
Prostate DysplasiaICD 10: N42.3
ART - Disease-Modifying Anti-rheumatic Drug Therapy for Rheumatoid Arthritis
Members 18 years of age or older who were diagnosed with rheumatoid arthritis and were prescribed a disease-modifying anti-rheumatic drug (DMARD).
Prescribe DMARDs to members with rheu-
matoid arthritis.
Exclusions: A diagnosis of HIV anytime dur-ing the member’s history through the end of them measurement year or a diagnosis of pregnancy in the measurement year
ICD-10 CM Codes: M05.00-M06.9
DMARD HCPCS: J0129, J0135, J0717, J1438, J1600, J1602,
J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310
Aetna HEDIS Tip Sheet 2017 Page 3
HEDIS Measure Definitions What You Can Do Coding/Tips
OMW - Osteoporosis Management in
Women Who Had a Fracture
Women 67-85 years of age who suffered a fracture and had either a bone mineraldensity test or were prescribed a drug to treat osteoporosis in the 6 months after a fracture.
Schedule women age 67-85 years old for a bone mineral density test (BMD) within six months after a fracture if they have not had a BMD test in the prior 24 months.
Prescribe medications to treat osteoporo-sis when indicated.
Bone Density:CPT Codes :76977, 77078, 77080-77082, 77085-77086ICD-10 PCS Codes: BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00Z-ZI, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1HCPCS G0130
Osteoporosis Medications J0630, J0897, J3110, J1740, J3487-J3489, Q2051
SPR -Use of Spirometry Testing in the
Assessment and Diagnosis of COPD
Members age 40years or older with a new diagnose of COPD or newly active COPD, who received appropriate spirometry to confirm the diagnosis.
Educate members that are newly diag-nosed with COPD or newly active COPD about the importance of spirometry testing
Submit timely claims for spirometry testing performed in your office.
COPD ICD-10 Codes: J44.0, J44.1, J44.9, Chronic Bronchitis ICD-10CM: J41 .0, J41.1, J41.8, J42 Emphysema ICD-10 CM Codes: J43- J43.0, J43.8, J43.9
Spirometry CPT Codes:
94010, 94014-94016, 94060, 94070, 94375, 94620
PCE - Pharmacotherapy Management of COPD Exacerbation
Members age 40 and older who had an acute IP stay or ED visit with a diagnosis of COPD exacerbation and were dispensed appropriate medications. Two rates are reported: 1. Dispensed a systemic corticosteroid
(or evidence of an active prescription within 14 days of the event
2. Dispensed a bronchodilator (or evi-dence of an active prescription) within 30 days of the event.
Schedule follow-up appointments with these members within a few days of their hospital discharge or ED visit
Medication reconciliation is key
Member education to include filling the prescriptions, appropriate use and side effects
Order medications that are on the member’s health plan formulary
Systemic Corticosteroids - Glucocorticosteroids - Betamethasone, Dexamethasone, Hydrocortisone, Methylprednisolone, Prednisolone, Prednisone, Triamcinolone Bronchodilators- Anticholinergic Agents - Albuterol-ipratropium, Ipratropium, Aclidinium-bromide, Tiotropium, Umeclidium Beta 2-agonists - Albuterol, Levalbuterol, Arformoterol, Mometasone-formoterol, Budesonide-formoterol, Met-aproterenol, Fluticasone-salmeterol, Olodaterol-hydrochloride, Olodaterol-tiotropium, Fluticasone-vilanterol, Pirbuterol, Formoterol, Salmeterol, In-dacaterol, Umeclidinium-vilanterol Methylxanthines - Aminophylline, Dyphylline, Dyphylline-guaifenesin, Theophylline, Guaifenesis-theophylline
MMA– Medication Management for Peo-ple With Asthma
Members age 5-85, identified as having persistent asthma and dispensed appropri-ate medications that they remained on during the treatment period (end of calen-dar year) Two rates reported: 1. Remained on asthma controller medi-
cation for at least 50% of the treat-ment period.
2. Remained on asthma controller medi-cation for at least 75% of the treat-ment period.
Schedule regular follow-up for people with persistent asthma
Patient education about benefits of medi-cation compliance
Order medications that are on the Member’s health plan formulary
Asthma Controller Medications Antiasthmatic Combinations - Dyphylline-guaifenesin, Guaifenesin-theophylline Antibody Inhibitor - Omalizumab Inhaled Steroid Combinations - Budesonide-formoterol, Mometasone-formoterol, Fluticasone-salmeterol Inhaled Corticosteroids - Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone CFC free, Mometasone Leukotriene Modifiers - Montelukast, Zafirlukast, Zileuton Mast Cell Stabilizers - Cromolyn Methylxanthines - Aminophylline, Dyphylline, Theophyl-line
Exclusion ICD-10 CM Codes Acute Respiratory Failure: J96.00-J96.02, J96.20-J96.22 Chronic Respiratory Conditions due to Fumes/Vapors: J68.4 COPD: J44.0, J44.1, J44.9 Cystic Fibrosis: E84.0, E84.11, E84.19, E84.8, E84.9 Emphysema: J43.0-J43.2, J43.8-J43.9 Other Emphysema: J98.2, J98.3
ABA - Adult BMI Assessment
Members 18-74 years of age who had their body mass index (BMI) and weightdocumented at least every other year.
Perform and document Ht/Wt/BMI calcu-lation at each visit or at least annually.
Patients younger than 20 years old need to have a BMI percentile documented
*Pregnant members are excluded fromthis measure*
ICD-10 CM Codes: BMI—Z68.1, Z68.20-Z68.29, Z68.30-Z68.39, Z68.41- Z68.45 BMI Percentile—Z68.51-Z68.54
Aetna HEDIS Tip Sheet 2017 Page 4
HEDIS Measure Definitions What You Can Do Coding/Tips
AMM - Antidepressant Medication Management
Patients 18 years of age and older who were newly treated with antidepressant medication, had a diagnosis of major de-pression and who remained on antidepres-sant medication treatment. Two rates are reported:
Effective Acute Phase: Percentage of pa-tients who remained on an antidepressant medication for at least 84 days (12 weeks)
Effective Continuation Phase: Percentage of patients who remained on an antide-pressant medication for at least 180 days (6 months)
Educate patients that medication may take several weeks to become effective, they should call with any medication concerns/reactions
Stress that they should not stop medication abruptly or without consulting you first for assistance
Schedule follow up appointments prior to patient leaving your office
Outreach patients that cancel appointments and have not rescheduled
Stress the importance of medication compli-ance. Share tips to help them remember to take their medication.
ICD-10 CM Codes for Major Depression:
F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
CCS - Cervical Cancer Screening
Women 21-64 years of age with one or more Pap tests within the last 3 years or for women 30-64 years of age, a cervical cytol-ogy and human papillomavirus (HPV) co-testing with in the last 5 years.
Women who have had a total hysterectomy with no residual cervix are excluded. This must be documented in the history or prob-lem list.
Notation of Pap test located in progress notes MUST include the lab results in order to meet NCQA® requirements. Reflex testing: perform-ing HPV test after determining cytology result, does not count.
Cervical cytology and human papillomavirus test must be completed four or less days apart in order to qualify for every 5 year testing.
Cervical Cytology CPT Codes: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175
HCPCS: G0123, G0124, G0141, G0143-G0145, G0147,
G0148, P3000, P3001, Q0091 UB Rev Codes : 0923 LOINC Codes: 10524-7, 18500-9, 19762-4,19764-0, 19765-7,19766-5, 19774-9,33717-0, 47527-7, 47528-5 HPVCPT Codes: 87620-87622, 87624-87625 HCPCS: G0476LOINC Codes: 21440-3, 30167-1, 38372-9, 49896-4, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75406-9, 75694-0, 77379-6, 77399-4, 77400-0
COL - Colorectal Cancer Screening
Adults 50-75 years of age with anappropriate screening for colorectal cancer.
Educate members on importance of screening to enable early detection of colon cancer.
Any of the following meet compliance of done in the correct time period:
Colonoscopy: 2007-2016
Flexible sigmoidoscopy: 2012-2016
CT colonography: 2007-2016
FIT-DNA test : 2014-2016
Fecal occult blood test (3 samples): 2016
A guaiac test in the office during a rectal exam does not count.
Members with colorectal cancer or a history of a total colectomy are excluded. Document accordingly.
Colonoscopy
CPT Codes: 44388-44394, 44397, 44401-44408, 45355, 45378-45393, 45398ICD-9 PCS Codes: 45.22, 45.23, 45.25, 45.42, 45.43HCPCS G0105, G0121
Flexible Sigmoidoscopy
CPT Codes: 45330-45335, 45337-45342, 45345-45347, 45349-45350ICD-9 PCS Code: 45.24 HCPCS: G0104
CT Colonography CPT Code: 74263
FIT-DNA test CPT Code: 81528 HCPCS: G0464 LOINC: 77353-1, 77354-9
Fecal Occult Blood Test (FOBT)
CPT Codes: 82270, 82274 HCPCS: G0328 LOINC: 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 2335-8, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2, 80372-6
PBH - Persistence of Beta-Blocker Treat-ment After a Heart Attack
Members 18 years of age and older who were hospitalized and discharged with a diagnosis of AMI and received persistent beta-blocker treatment for six months after discharge.
Stress the importance of medication compli-ance and why they need to take a beta blocker at follow-up visits.
Advise member not to stop medication with-out talking with provider first.
Consider ordering a 90 day supply if permitted by member’s benefit.
There are exclusions for intolerance or allergy to beta blockers as well as conditions listed in next column.
ICD-10 Codes to Identify Exclusions:
History of Asthma: J45.20-J45.998 COPD: J44.0, J44.1, J44.9 Chronic Respiratory Conditions due to Fumes/Vapors: J68.4
Hypotension: I95.0-I95.9 Heart Block > 1st degree: l44.1-I44.7, I45.10-I45.3, I45.6, I49.5 Sinus Bradycardia: R00.1
Aetna HEDIS Tip Sheet 2017 Page 5
HEDIS Measure Definitions What You Can Do Coding/Tips
SPC—Statin Therapy for Patients with Cardiovascular Disease
Males 21–75 years of age and females 40–75 years of age, who were identified as having clinical atherosclerotic cardiovascu-lar disease (ASCVD) and met the following criteria. The following rates are reported:
Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity statin medication during the measure-ment year.
Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period. (RX date through end of year).
Educate patients about the importance of statin therapy
Educate patients on side effects and im-portance of reporting any side effects to you so their medication can be adjusted/changed if necessary Advise patients not to stop taking without consulting you
Exclusions do apply for
members pregnant or undergoing IVF or Rx for clomiphene during the measure-ment year or year prior
Dx of ESRD or Cirrhosis during the measurement year or year prior
Myalgia, myositis, myopathy or rhabdo-myolysis during the measurement year.
High-intensity statin therapy Atorvastatin 40-80 mg Rosuvastatin 20-40mg Amlodipine-atorvastatin 40-80 mg Simvastatin 80mg Ezetimibe-atorvastatin 10-20mg Ezetimibe-simvastatin 80 mg Moderate-intensity statin therapy Atorvastatin 10-20 mg Lovastatin 40 mg Amlodipine-atorvastatin 10-20 mg Ezetimibe-atorvastatin 10-20 mg Sitagliptin-simvastatin 20-40 mg Pravastatin 40-80mg Rosuvastatin 5-10mg Ezemtimibe-simvastatin 20-40mg Niacin-simvastatin 20-40mg Niacin-lovastatin 40mg Fluvastatin XL 80mg Fluvastatin 40 mg BID Pitavastatin 2-4 mg
SPD—Statin Therapy for Patients With Diabetes
Patients 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovas-cular disease (ASCVD) who met the follow-ing criteria. Two rates are reported:
Received Statin Therapy. Dispensed at least one statin medication of any intensity during the year
Statin Adherence 80%. Remained on a statin medication of any intensity for at least 80% of the treatment period (Rx date through end of year.
Educate patients about the importance of statin therapy in patients with diabetes
Educate patients on side effects and im-portance of reporting any side effects to you so medication can be adjusted/changed
Advise patients not to stop taking without consulting you
In addition to the exclusions noted above in the SPC measure, members are excluded with cardiovascular disease.
In addition to the high and moderate intensity statins listed above, the following low-intensity statins pertain to this measure:
Simvastatin 10 mg Lovastatin 20 mg Ezemtimibe-simvastatin 10 mg Niacin-lovastatin 20 mg Sitagliptin-simvastatin 10mg Fluvastatin 20-40 mg Pravastatin 10-20 mg Pitavastatin 1 mg
DDE—Potentially Harmful Drug-Disease Interactions in the Elderly
The percentage of Medicare members 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Three rates reported:
1. A history of falls and a prescription for anticonvulsants, SSRIs, antipsychotics, benzodiazepines, non-benzodiazepine hypnotics or tricyclic antidepressants.
2. Dementia and a prescription for anti-psychotics, benzodiazepines, non-benzodiazepine hypnotics, tricyclic antidepressants, H2 receptor antago-nists or anticholinergic agents.
3. Chronic kidney disease and prescrip-tion for Cox-2 selective NSAIDs or nonaspirin NSAIDs
Carefully review patient’s history before prescribing anticonvulsants, SSRIs, antipsy-chotics, benzodiazepines, non-benzodiazepine hypnotics or tricyclic antidepressants. Patients with an accidental fall or hip fracture in the
past 2 years are at an increased risk if taking these medications. There are exclusions for this measure: patients with a diagnosis of psychosis, schizophrenia, bipolar disorder, or seizure disorder during the 2 year period.
Carefully review patient’s history before pre-scribing any antipsychotics, benzodiazepines, non-benzodiazepine hypnotics, tricyclic anti-depressants, H2 receptor antagonists or anti-cholinergic agents. Patients with a diagnosis of dementia in the past two years have increased risk. There are exclusions for this measure: patients with a diagnosis of psychosis, schizophrenia or bipolar disorder during the 2 year period.
Review patient history for CKD, ESRD or kid-ney transplant before ordering any Cox-2 selective NSAIDs or nonaspirin NSAIDs
Falls and Hip Fracture: Any fall or Hip Fracture ICD10 or CPT code is pulled into the denominator Dementia: ICD 10: F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F04, F10.27, F10.97, F13.27, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.83
Refer to the list of medications attached
Chronic Kidney Disease Stage 4 ICD 10: N18.4 ESRD CPT: 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 HCPCS: G0257, S9339 ICD 10 CM: N18.5, N18.6, Z91.15, Z99.2 ICD10 PCS : 3E1M39Z, 5A1D00Z, 5A1D60Z Kidney Transplant CPT: 50300, 50320, 50340, 50360, 50365, 50370, 50380 HCPCS: S2065 ICD10CM: Z94.0 ICD10PCS: 0TY00Z0, OTY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2
Aetna HEDIS Tip Sheet 2017 Page 6
HEDIS Measure Definitions What You Can Do Coding/Tips
DAE—Use of High-Risk Medication in the Elderly
The percentage of Medicare members 66 years of age and older who had at least one dispensing event for a high-risk medication.
The percentage of Medicare members 66 years of age and older who had at least two dispensing events for the same high-risk medication.
For both rates, a lower rate represents better performance.
Always complete a thorough medication re-view and re-evaluate the use of high risk drugs at each visit.
Monitor adverse side effects and possibility of it being misinterpreted as a new diagnosis or symptom.
Whenever possible, avoid prescribing these medications for patients over age 66
Refer to attached list of medications considered high risk in the elderly.
MPM– Annual Monitoring for Patients on Persistent Medications
Members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitor-ing event for the therapeutic agent in the measurement year.
Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB).—at least one serum K+ and serum Cr during the year
Annual monitoring for members on digoxin.—at least one serum K+ , serum Cr and digoxin level during the year
Annual monitoring for members on diuretics—at least one serum K+ and serum Cr during the year
Total rate (the sum of the three nu-merators divided by the sum of the three denominators
Educate patients on the importance of lab work when taking certain medications
Check each visit to see if lab work has been completed, if not re-educate and reorder
CPT Codes Lab panels that include K+ and CR 80047, 80048, 80050, 80053, 80069
Serum K+ 80051, 84132
Serum Cr 82565, 82575
Digoxin Level 80162
Data collected through member surveys for members 65 years and older:
- Fall Risk Management - Management of Urinary Incontinence in Older Adults - Osteoporosis Testing in Older Women - Physical Activity in Older Adults
Other data collected though surveys : - Aspirin Use and Discussion - Flu Vaccination for Adults - Medical Assistance With Smoking and Tobacco Use Cessation - Pneumococcal Vaccination Status for Older Adults
Talk to your patients about these topics
Ask patients if they are having problems with balance or walking. If they are, make recom-mendations for how to prevent falls or treat balance/walking issues
Ask patients if they are having any urinary leakage and discuss treatment options if they are. Be sure to ask if it is interfering with their daily activities or sleep and address those issues.
Discuss bone mineral density testing with women over 65 and order a screen if they have never had one.
Ask patients about their level of exercise or physical activity and advise on starting, in-creasing or maintaining that level.
More Tips:
Ask patients if they are taking a daily aspirin and dis-cuss the risks and benefits of using it.
Encourage all patients to get a flu shot annually unless it is contraindicated.
Ask you patients if they smoke. If they do, advise them to quit, discuss cessation medications and other quitting strategies.
Encourage patients over 65 to get the pneumococcal vaccine unless contraindicated.
Aetna HEDIS Tip Sheet 2017 Page 7
DDE Measure Medications for Rates 1 and 2
Potentially Harmful Drugs - Rate 1
Description Prescription
Anticonvulsants
· Carbamazepine
· Clobazam
· Divalproex sodium
· Ethosuximide
· Ethotoin
· Ezogabine
· Felbamate
· Fosphenytoin
· Gabapentin
· Lacosamide
· Lamotrigine
· Levetiracetam
· Mephobarbital
· Methsuximide
· Oxcarbazepine
· Phenobarbital
· Phenytoin
· Pregabalin
· Primidone
· Rufinamide
· Tiagabine HCL
· Topiramate
· Valproate sodium
· Valproic acid
· Vigabatrin
· Zonisamide
SSRIs · Citalopram
· Escitalopram
· Fluoxetine
· Fluvoxamine
· Paroxetine
· Sertraline
Potentially Harmful Drugs - Rates 1 & 2
Description Prescription
Antipsychotics
· Aripiprazole
· Asenapine
· Brexpiprazole
· Cariprazine
· Chlorpromazine
· Clozapine
· Fluphenazine
· Haloperidol
· Iloperidone
· Loxapine
· Lurasidone
· Molindone
· Olanzapine
· Paliperidone
· Perphenazine
· Pimozide
· Quetiapine
· Risperidone
· Thioridazine
· Thiothixene
· Trifluoperazine
· Ziprasidone
Benzodiazepines
· Alprazolam
· Chlordiazepoxide products
· Clonazepam
· Clorazepate-dipotassium
· Diazepam
· Estazolam
· Flurazepam HCL
· Lorazepam
· Midazolam HCL
· Oxazepam
· Quazepam
· Temazepam
· Triazolam
Nonbenzodiazepine hyp-notics
· Eszopiclone · Zaleplon · Zolpidem
Tricyclic antidepressants
· Amitriptyline
· Amoxapine
· Clomipramine
· Desipramine
· Doxepin (>6 mg)
· Imipramine
· Nortriptyline
· Protriptyline
· Trimipramine
Potentially Harnful Drugs - Rate 2
Description Presciption
H2 receptor antagonists · Cimetidine · Famotidine · Nizatidine · Ranitidine
Anticholinergic agents, antiemetics
· Prochlorperazine Promethazine
Anticholinergic agents, antihistamines
· Carbinoxamine
· Chlorpheniramine
· Hydroxyzine
· Brompheniramine
· Clemastine
· Triprolidine
· Cyproheptadine
· Dimenhydrinate
· Diphenhydramine
· Meclizine
· Dexbrompheniramine
· Dexchlorpheniramine
· Doxylamine
Anticholinergic agents, antispasmodics
· Atropine
· Homatropine
· Belladonna alka-loids
· Dicyclomine
· Hyoscyamine
· Propantheline
· Scopolamine
· Clidinium-chlordiazepoxide
Anticholinergic agents, antimuscarinics (oral)
· Darifenacin
· Fesoterodine
· Trospium
· Flavoxate
· Oxybutynin
· Tolterodine
· Solifenacin
Anticholinergic agents, anti-Parkinson agents
· Benztropine · Trihexyphenidyl
Anticholinergic agents, skeletal muscle relaxants
· Cyclobenzaprine · Orphenadrine
Anticholinergic agents, SSRIs or antiarrhythmic
· Paroxetine · Disopyramide
Page 8
DAE Measure Medications
High-Risk Medications Prescriptions
Anticholinergics, first-generation antihistamines
· Brompheniramine
· Carbinoxamine
· Chlorpheniramine
· Clemastine
· Cyproheptadine
· Dexbrompheniramine
· Dexchlorpheniramine
· Diphenhydramine (oral)
· Dimenhydrinate
· Doxylamine
· Hydroxyzine
· Meclizine
· Promethazine
· Triprolidine
Anticholinergics, anti-Parkinson agents · Benztropine (oral) · Trihexyphenidyl
Antispasmodics
· Atropine (exclude ophthalmic)
· Belladonna alkaloids
· Clidinium-chlordiazepoxide
· Dicyclomine
· Hyoscyamine
· Propantheline
· Scopolamine
Antithrombotics · Dipyridamole, oral short-acting (does not apply to the extended-release combination with aspirin)
· Ticlopidine
Cardiovascular, alpha agonists, central · Guanabenz
· Guanfacine
· Methyldopa
Cardiovascular, other · Disopyramide · Nifedipine, immediate release
Central nervous system, antidepressants
· Amitriptyline
· Clomipramine
· Amoxapine
· Desipramine
· Imipramine
· Trimipramine
· Nortriptyline
· Paroxetine
· Protriptyline
Central nervous system, barbiturates
· Amobarbital
· Butabarbital
· Butalbital
· Mephobarbital
· Pentobarbital
· Phenobarbital
· Secobarbital
Central nervous system, vasodilators · Ergot mesylates · Isoxsuprine
Central nervous system, other · Meprobamate
Endocrine system, estrogens with or without progestins; include only oral and topical patch products
· Conjugated estrogen
· Esterified estrogen
· Estradiol
· Estropipate
Endocrine system, sulfonylureas, long-duration · Chlorpropamide · Glyburide
Endocrine system, other · Desiccated thyroid · Megestrol
Pain medications, skeletal muscle relaxants
· Carisoprodol
· Chlorzoxazone
· Cyclobenzaprine
· Metaxalone
· Methocarbamol
· Orphenadrine
Pain medications, other · Indomethacin
· Ketorolac, includes parenteral
· Meperidine
· Pentazocine
High-Risk Medications With Days Supply Criteria Prescriptions Days Supply Criteria
Anti-Infectives, other
· Nitrofurantoin
· Nitrofurantoin macrocrystals
· Nitrofurantoin macrocrystals- monohydrate
> 90 days
Nonbenzodiazepine hypnotics
· Eszopiclone
· Zaleplon
· Zolpidem
> 90 days
High-Risk Medications With Average Daily Dose Criteria Prescriptions Average Daily Dose Criteria
Alpha agonists, central · Reserpine >0.1 mg/day
Cardiovascular, other · Digoxin >0.125 mg/day
Tertiary TCAs (as single agent or as part of combination prod-ucts)
· Doxepin >6 mg/day
Aetna HEDIS Tip Sheet 2017
