PROVIDER GUIDE HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET - Florida Health Care Plans
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET
PROVIDER GUIDEHEDIS®/ STAR PROVIDER GUIDE – HEDIS MY 21 (Measurement Year 2021)
HEDIS® (Healthcare Effectiveness Data and Information Set) is a performance measurement tool developed by the National Committee for Quality
Assurance (NCQA) to assess the quality of healthcare and improve patient health and outcomes, and is an important factor in our accreditation.
Select HEDIS® measures are also part of the Star Rating System managed by the federal Centers for Medicare & Medicaid Services (CMS), which
evaluates health care plans based on a 5-Star rating system.
Adherence to these guidelines:
• Ensures health plans are offering quality preventive care and services.
• Provides a comparison to other plans.
• Identifies opportunities for quality improvement.
• Measures the plan’s progress from year to year.
HEDIS® data collection is permitted under HIPAA and is performed three ways:
• Administrative: Pertaining to diagnosis codes (in our claims database) and medication fills, based on the NCQA Vol. 2 Technical
Specifications & Value Sets (updated annually).
• Hybrid: A combination of Administrative, and medical chart review.
• Survey: Member and provider surveys.
Included within for your convenience are select HEDIS®/Star measures and their description and requirements. Star measures are designated with
a star symbol ( ).
This guide does not include every quality measure, but rather ones that are NCQA sensitive.
If you would like the complete list of diagnosis codes or medication lists for any measure, or have questions, please call (386) 676-7100 Ext. 7258,
or email QualityManagement@fhcp.com.
We hope you find this guide useful in your daily practice.
Sincerely,
FHCP Quality Management
Page 1 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansTABLE OF CONTENTS (Ctrl-Click for Link)
ADULT MENTAL / BEHAVIORAL HEALTH
: Risk of Continued Opioid Use – P. 13 ADD: Follow-Up Care for Children Prescribed ADHD Medication – P. 5
FRM: Fall Risk Management – P. 17 AMM: Antidepressant Medication Management – P. 6
FVA: Flu Vaccinations for Adults Ages 18 to 64 – P. 19 APM: Metabolic Monitoring for Children & Adolescents on Antipsychotics – P. 7
FVO: Flu Vaccinations for Adults Ages 65 and Older – P. 19 APP: Use of First-Line Psychosocial Care for Children & Adolescents on
Antipsychotics – P. 8
HDO: Use of Opioids at High Dosage – P. 19
FMC: Follow-Up After ED Visit for People With Multiple High-Risk Chronic
LBP: Use of Imaging Studies for Low Back Pain – P. 21 Conditions – P. 16
MSC: Medical Assistance W/Smoking & Tobacco Use Cessation – P. 21
FUA: Follow-Up After ED Visit for Alcohol & Other Drug Abuse or
PCR: Plan All-Cause Readmissions – P. 23 Dependence – P. 17
PNU: Pneumococcal Vaccination Status for Older Adults – P. 24 FUH: Follow-Up After Hospitalization for Mental Illness – P. 18
TRC: Transitions of Care – P. 27 FUM: Follow-Up After ED Visit for Mental Illness – P. 18
UOP: Use of Opioids From Multiple Providers – P. 28 IET: Initiation & Engagement of Alcohol & Other Drug Abuse or Dependence
Treatment – P. 20
ADULT / ELDERLY RESPIRATORY
DAE: Use of High-Risk Medications in Older Adults – P. 15 AAB: Avoidance of Antibiotic Treatment For Acute Bronchitis /
Bronchiolitis – P. 4
DDE: Potentially Harmful Drug-Disease Interactions-Older Adults – P. 16
AMR: Asthma Medication Ratio – P. 7
OMW: Osteoporosis Management in Women Who Had a Fracture – P. 22
CWP: Appropriate Testing for Pharyngitis (Strep Test) – P. 14
PSA: Non-Recommended PSA-Based Screening in Older Men – P. 25
PCE: Pharmacotherapy Management of COPD Exacerbation – P. 23
URI: Appropriate Treatment for Upper Respiratory Infection – P. 28
Page 2 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansTABLE OF CONTENTS cont’d
CANCER SCREENING WOMEN
BCS: Breast Cancer Screening – P. 8 CHL: Chlamydia Screening In Women – P. 11
CCS: Cervical Cancer Screening – P. 10 PPC: Prenatal & Postpartum Care – P. 24
COL: Colorectal Cancer Screening – P. 13
CARDIOVASCULAR DIABETES
CBP: Controlling High Blood Pressure – P. 9 CDC: Comprehensive Diabetes Care – P. 11
SPC: Statin Therapy for Patients with Cardiovascular Disease – P. 25 SPD: Statin Therapy for Patients with Diabetes – P. 26
CHILD / ADOLESCENT IMMUNIZATIONS WEIGHT & NUTRITION
CIS: Childhood Immunization Status – P. 12 WCC: Weight Assessment & Counseling for Nutrition & Physical Activity for
Children/Adolescents – P. 29
IMA: Immunizations for Adolescents – P. 20
Appendix 1: Antidepressant Medications – P. 30
Appendix 2: Antipsychotic Medications – P. 31
Appendix 3: ACE Inhibitor & ARB Medications – P. 32
Appendix 4: Opioid Medications / MME Conversion Factor – P. 33 - 38
Appendix 5: High and Moderate Intensity Statin Medications – P. 39
Appendix 6: Opioid Medications – P. 40 - 41
Appendix 7: High-Risk Medications – P. 42 - 45
Page 3 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
AAB
Avoidance of Antibiotic Treatment For Do not use the following acute bronchitis / Alternate Codes: The following codes are
Acute Bronchitis / Bronchiolitis bronchiolitis diagnoses with an antibiotic: acceptable with an antibiotic per the measure (not
a complete list):
• J20.3 Acute bronchitis due to coxsackievirus
Members 3 months and older, who were • H66.90: Otitis media, unspec.
• J20.4 Acute bronchitis due to parainfluenza
diagnosed with acute bronchitis or bronchiolitis, • J01.90: Acute sinusitis, unspec.
virus
should not be dispensed an antibiotic prescription. • J02.9: Acute pharyngitis (perform strep test)
• J20.5 Acute bronchitis due to respiratory
syncytial virus • J03.90: Acute tonsillitis (perform strep test)
Please explain to your patients that viruses
• J20.6 Acute bronchitis due to rhinovirus
are not treated with antibiotics. Promote
• J20.7 Acute bronchitis due to echovirus
symptom control instead. Also ok to give an antibiotic with acute
• J20.8 Acute bronchitis due to other specified
bronchitis or bronchiolitis diagnosis if these co-
Antibiotics filled on day of visit or within 3 days organisms
morbid conditions are coded at the visit or up
from visit, count in the measure as non- • J20.9 Acute bronchitis, unspecified
to a year prior (not a complete list):
compliant. • J21.0 Acute bronchiolitis due to respiratory
syncytial virus • Cancer
• J21.1 Acute bronchiolitis due to human • COPD
If you prescribe an antibiotic, please consider using
metapneumovirus • Cystic fibrosis
an alternate code other than Acute Bronchitis if
• J21.8 Acute bronchiolitis due to other • HIV
appropriate, such as the suggested examples listed
specified organisms • Pulmonary edema
in Column 3.
• J21.9 Acute bronchiolitis, unspecified • Respiratory failure
• TB
Note: This measure now includes both children
and adults. Includes Outpatient, Urgent Care, and ED visits.
Page 4 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
ADD
• ADHD Medications • Use an e-visit or virtual check-in for one of the
Follow-Up Care for Children Prescribed
visits after the first 30 days. *Only one online
ADHD Medication ▪ CNS stimulants:
o Dextroamphetamine assessment is allowed during the C&M phase.
Ages 6 to 12 with *newly prescribed attention- o Dexmethylphenidate
o Lisdexamfetamine • Schedule the first follow-up visit within 21-days
deficit/hyperactivity disorder (ADHD) medication
o Methylphenidate of the initial prescription while the patient is still
should have: o Methamphetamine in the office. This will allow time to reschedule
• At least 3 follow-up care visits within a 10- missed appointments within the 30-day
month period. ▪ Alpha-2 receptor agonists: initiation phase compliance timeframe.
• One of the visits should be within 30-days of o Clonidine
when the first ADHD medication was o Guanfacine
• Encourage compliance with follow-up
dispensed.
*Newly prescribed- no ADHD Rx for 120 days prior ▪ Miscellaneous ADHD Medication: appointments to evaluate medication
o Atomoxetine effectiveness and adverse events.
•
• Two rates are Tracked: • Telephone Visits • Consider prescribing the first ADHD medication
CPT 98966-68, 99441-99443
Initiation Phase *Acceptable for both phases of the measure for a 21- or 30-day supply to promote timely
1 follow-up visit during the 30-day initiation phase follow-up.
with a practitioner with prescribing authority. • Online Assessments/E-visit/Virtual Check-in:
*Telehealth and telephone visits added CPT 98969–98972, 99421–99423, 99444, 99458; • Schedule at least two additional appointments
HCPCS: G2010, G2012, G2061–G2063 while the patient is in the office for the first
*Can be used for 1 of the 2 C&M Phase visits follow-up visit. The first in 3 months and the
Continuation & Maintenance (C&M) Phase
Remained on the medication for at least 210 days; second in 6 months following the 30-day initial
and In addition to the visit in the Initiation Phase, • Exclusions visit. Again, this will allow time to reschedule
had at least 2 follow-up visits within 270 days/9 ▪ Patients in hospice. missed appointments within the 31-300-day
months after the Initiation Phase ended. ▪ Filled an ADHD prescription 120 days prior to C&M Phase compliance timeframe.
*One E-visit or virtual check-in encounter allowed the index prescription start date (IPSD).
▪ Have a diagnosis of narcolepsy. • Refer to Behavioral Health for further
• Intake period ▪ Had an acute inpatient encounter for mental, treatment as indicated.
12-month window- starting March 1st of the behavioral, or neurodevelopmental disorder:
prior measurement year to February 28th o 30 days after IPSD (initiation phase only)
of the current year o 300 days after the IPSD (C&M phase only)
• Compliance
Determined by pharmacy and billing claims
Page 5 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
AMM
Antidepressant Medication Consider using the Patient Health Questionnaire
Management (PHQ-9) to assess depressive symptoms, measure • Educate patients on medication compliance for
severity, develop a provisional diagnosis, and monitor optimum effectiveness.
treatment outcome.
Ages 18 and older who had a diagnosis of Major • Explain medication regimen, benefits, and
Depression and who were treated with an Scoring and Interpretation: expected duration of treatment.
antidepressant medication, are monitored for how
long they remained on the medication. PHQ-9 Provisional Proposed • Discuss potential side effects.
Score Diagnosis Treatment
Two rates are tracked for remaining on the Support; educate
antidepressant medication: • Make follow-up calls to check on patients and
to call if worsens; remind them of upcoming visits.
5-9 Minimal Symptoms* repeat PHQ-9 at
Effective Acute Phase Treatment: follow-up in 1
• At least 84 days (12 weeks) month • Reiterate the importance of attending follow-up
Support; watchful visits.
Effective Continuation Phase Treatment: Minor depression
waiting;
• At least 180 days (6 months) 10-14
Dysthymia*
Antidepressant • Refer patients to behavioral health as indicated.
Major Depression,
and/or
Mild
psychotherapy • Contact Case Management/Coordination of Care
• Intake Period
12-month window starting May 1st of Major Depression,
Antidepressant when barriers to medication compliance are
15-19 and/or identified: unable to afford medication/follow-up
the prior measurement year - April 30th Moderate
psychotherapy
of the current measurement year appt. co-pay, lack of transportation, education,
Antidepressant community resource, or home care needs.
with
• Compliance Major Depression,
20-27 psychotherapy;
Determined by pharmacy claims Severe • Emphasize the importance of continuing
collaborative
management. treatment even after they begin to feel better.
• Antidepressant Medications List:
See Appendix 1
Rule out other depressive disorders: • If no significant signs or symptoms of MDD
are present for 2 months, with or without
• Major Depression ICD-10 codes: • 34.1 Dysthymia* Symptoms present ≥ 2 years medication, please consider replacing the
32.0-32.4, 32.9, 33.0-33.3, 33.41, 33.9 active MDD diagnosis with:
• 43.21 Adjustment disorder w/ depressed mood F33.42 Major depressive disorder,
Symptoms following an adverse life event recurrent, in FULL remission.
• 6.31 Mood disorder due to physiological condition DSM-5 (psychiatry.org)
Symptoms resulting from systemic diseases https://www.pcpcc.org
http://www.agencymeddirectors.wa.gov
Page 6 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
AMR
Asthma Controllers: Members are excluded from the measure if
Asthma Medication Ratio they have:
Antiasthmatic combinations:
For ages 5 to 64 with persistent asthma, the • COPD
dyphylline- guaifenesin
ratio of controller medications to total asthma • Chronic respiratory conditions due
medications is 0.50 or greater during the Antibody inhibitors: omalizumab
to chemicals, gases, fumes, vapors
measurement year. Anti-interleukin-4: dupilumab • Cystic fibrosis
Anti-interleukin-5: benralizumab, mepolizumab, • Acute respiratory failure
Adjust dosage so patient is well-controlled on reslizumab
Asthma Controller Medications (see Column 2)
Inhaled steroid combinations: budesonide-
without frequent use of Asthma Reliever Also exclude members in
formoterol, fluticasone-salmeterol,
Medications (rescue inhalers).
fluticasone- vilanterol, formoterol-
mometasone hospice.
(Rescue inhalers include short-acting, inhaled Inhaled corticosteroids: beclomethasone,
beta- 2 agonists albuterol and levalbuterol). budesonide, ciclesonide, flunisolide,
fluticasone, mometasone
Leukotriene modifiers: montelukast, zafirlukast,
zileuton
Methylxanthines: theophylline
APM
Three rates are reported: The percentage of
Metabolic Monitoring for Children children and adolescents on antipsychotics
See Appendix 2 for the following
and Adolescents on Antipsychotics medications which pertain to this measure:
who:
Ages 1–17 who had two or more 1. Received blood glucose testing. • Antipsychotic medications
antipsychotic prescriptions should have • Antipsychotic combination medications
2. Received cholesterol testing.
metabolic testing. • Prochlorperazine medications
3. Received blood glucose and
cholesterol testing.
Page 7 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
APP
Exclude members for whom first-line antipsychotic
Use of First-Line Psychosocial Care for See Appendix 2 for the following medications
medications may be clinically appropriate, such as
which pertain to this measure:
Children and Adolescents on those diagnosed with:
Antipsychotics • Antipsychotic medications
• schizophrenia
• Antipsychotic combination medications.
Ages 1–17 that had a new prescription for an • schizoaffective disorder
antipsychotic medication should have • bipolar disorder
documentation of psychosocial care as first-line • other psychotic disorder
treatment. • autism, or
• other developmental disorder.
The above from at least 1 acute inpatient
encounter, or at least 2 visits in an outpatient,
intensive outpatient, or partial hospitalization
setting in the measurement year.
BCS All types of mammograms (screening, diagnostic, Members in hospice are excluded.
Breast Cancer Screening film, digital, or digital breast tomosynthesis)
qualify for compliance.
Women ages 50 to 74 should have a mammogram Mammogram Codes:
at least every two years. MRIs, ultrasounds, or biopsies do not count for the CPT Codes: 77055-77057, 77061-77063, 77065-
measure. 77067.
A note with the screening year is compliant
provided it is within the two-year time frame. Women who have had a bilateral mastectomy, or
two unilateral mastectomies are excluded.
Documented evidence should be present.
Please document in chart and/or notify Quality
Management if bilateral mastectomy occurred
outside of FHCP, including where done.
Page 8 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
CBP Blood pressure should be routinely assessed as If a member demonstrates a high blood pressure, a
Controlling High Blood Pressure part of a physical exam at each outpatient visit. second blood pressure should always be taken at
the same visit and documented in the chart.
Ages 18 to 85 with a diagnosis of hypertension The measure uses:
(HTN) should have adequately controlled blood Please remember that BP must be BELOW
pressure (BP) during the measurement year. • The most recently documented BP at an 140/90 to be considered compliant.
outpatient visit; telephone visit; e-visit or
Control is based upon: virtual check-in; nonacute inpatient encounter; Schedule a follow-up visit (can be a nurse visit).
or remote monitoring event.
• Ages 18 to 85 have BP controlled at LESS THAN
• The BP reading to be used for the measure must Essential (primary) Hypertension ICD 10 Code: I10
140/90.
occur on or after the second diagnosis of HTN.
Compliance is 139/89 or below. Diastolic 80-89 Code CPT-CAT-II Code (compliant):
• BP readings taken or reported by the member 3079F
are now acceptable, as long as result is
If BP is elevated, retake BP and document in the documented by the provider in the note. This Diastolic Less Than 80 CPT-CAT-II Code
chart. Treat as necessary. Chart all includes telehealth and telephone visits. (compliant): 3078F
measurements, and efforts to obtain BP control.
Systolic Less than 140 CPT-CAT-II Code
Control within the measurement year of 139/89 or The measure does NOT use:
(compliant):
below should be documented in the EHR if • BP readings from an acute inpatient stay or ED 3074F (less than 130 mm Hg)
attained. visit. 3075F (130-139 mm Hg)
• BP readings taken same day as a diagnostic test
or therapeutic procedure requiring a change of
diet or medication on or one day before (other Excluded members (optional): End-Stage Renal
than fasting blood tests), such as colonoscopy, Disease, kidney transplant, dialysis,
dialysis, infusions, chemotherapy, or a nephrectomy, hospice, or pregnancy during the
nebulizer treatment with albuterol. measurement year.
Page 9 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
CCS
Cervical Cancer Screening Documentation in the medical record must include both Cervical Cytology Lab Test CPT codes: 88141-
of the following: 88143, 88147-88148, 88150, 88152-88154, 88164-
Ages 21 to 64 should be screened for cervical 88167, 88174-88175
cancer using any one of the following: • A note indicating the date the procedure was
performed. High Risk HPV Lab Test CPT codes: 87620-87622,
• Age 21–64 have cervical cytology (Pap
• The result or finding. 87624-87625
smear) performed every 3 years.
• Age 30–64 years of age have cervical high-
Exclusion: Member does not need this screening if they Absence of Cervix Diagnosis: Q51.5, Z90.710,
risk human papillomavirus (hrHPV) testing
had a hysterectomy with no residual cervix, cervical Z90.712
performed every 5 years.
agenesis, or acquired absence of cervix.
• Age 30–64 years of age have cervical
Documenting a hysterectomy alone does not exclude
cytology/high-risk human papillomavirus
member; the removal of cervix must also be
(hrHPV) co-testing performed every 5
documented.
years.
Page 10 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
CDC
Comprehensive Diabetes Care (HbA1c control 9.0% ) event
• A visit with a nephrologist If you believe member is in the CDC measure population
3. HbA1c control ( < 8.0% )
• Evidence of stage 4 chronic kidney disease inappropriately, please notify Quality Management.
4. Eye Exam (retinal) - one of the • Evidence of ESRD Hospital claims with a diabetes diagnosis are
following: • Evidence of kidney transplant. occasionally received (if glucose is elevated), and these
a. Retinal or dilated eye exam by claims can be corrected if the member does not have
optometrist or ophthalmologist in diabetes.
See Appendix 3 for ACE Inhibitor & ARB
the measurement year. Medications.
b. A negative retinal or dilated eye Any member with gestational diabetes or steroid-
exam (negative for retinopathy) in induced diabetes is not counted in the measure.
the year prior to the measurement
year.
5. Medical attention for nephropathy
(Medicare only)
6. BP control (Measure Comments More Tips
CIS – Combo 10
Document in medical record if member has DTaP Procedure Codes: 90698, 90700, 90723
Childhood Immunization Status evidence of the disease for which immunization is IPV Procedure Codes: 90698, 90713, 90723
By their 2nd birthday, children should receive all of intended, or contraindication due to anaphylactic HiB Procedure Codes: 90644, 90647, 90648, 90698,
the following: reaction. 90748
HepB Procedure Codes: 90723, 90740, 90744,
• Four: Diphtheria, tetanus, and acellular
90747, 90748
pertussis (DTaP) For MMR, HepB, VZV and HepA, count any of the
Pneumococcal Procedure Codes: 90670
• Three: Polio (IPV) following:
• One: Measles, mumps, and rubella (MMR) • Evidence of the antigen or combination vaccine, MMR Procedure Codes: 90707, 90710
• Three: Haemophilus influenza type B (HiB) or Measles Procedure Code: 90705
• Three: Hepatitis B (HepB) • Documented history of the illness, or Measles/Rubella Procedure Code: 90708
• One: Chicken pox (VZV) • A seropositive test result for each antigen.
Mumps Procedure Code: 90704
• Four: Pneumococcal conjugate (PCV)
• One: Hepatitis A (HepA) Rubella Procedure Code: 90706
• Two or Three: Rotavirus (RV) For DTaP, IPV, HiB, Pneumococcal conjugate, VZV Procedure Code: 90710, 90716
• Two: Influenza (flu) rotavirus and influenza, count only:
Rotavirus 2 dose Procedure Code: 90681
• Evidence of the antigen or combination vaccine.
Rotavirus 3 dose Procedure Code: 90680
Immunizations must be completed before member
turns age 2. HepA Procedure Code: 90633
For rotavirus:
Influenza Procedure Code: 90655, 90657, 90661,
• Recommended to complete by 32 weeks
Please educate office staff to schedule 90673, 90685, 90686, 90687, 90688, 90689
appointments PRIOR to 2nd birthday. • Do not mix brands (Merck RotaTeq, and GSK Influenza Virus LAIV Procedure Code: 90660,
ROTARIX)
90672
For MMR, VZV and HepA, vaccinations must be
between 1st and 2nd birthday. If prior to 1st For combination vaccinations that require more
birthday, will not count for the measure. than one antigen (i.e., DTaP and MMR), the
organization must find evidence of all the
antigens.
Page 12 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
COL
Documentation in the medical record must include Do not count digital rectal exams (DRE). Do not
Colorectal Cancer Screening a note indicating the date of the colorectal cancer count FOBT tests performed in an office setting or
Ages 50 to 75 should have appropriate screening screening within the time frame. performed on a sample collected via DRE.
for colorectal cancer.
Members who have had colorectal cancer or a
Any of the following meet criteria: total colectomy are excluded from this measure.
• Fecal occult blood test (FOBT) during the • Exclusionary evidence in the medical record
measurement year. must include a note indicating colorectal
cancer or total colectomy any time during
• Flexible sigmoidoscopy within the last 5 years. the member’s history, through December
• Colonoscopy within the last 10 years. 31st of the measurement year.
• CT colonography within the last 5 years.
• FIT-DNA (Cologuard) during the last 3 years.
COU
Risk of Continued Opioid Use The measure counts the earliest prescription Members in hospice are excluded from the eligible
dispensing date for an opioid medication from population.
Members 18 and older who have a new episode of November 1st of the year prior, and ending on
opioid use that puts them at risk for continued October 31st of the current year. Also excluded are those with at least one of the
opioid use are tracked. following from 1 year prior to the earliest
The following opioid medications are excluded: dispensing event for an opioid medication, through
Two rates are reported: • Injectables 61 days after:
1. The percentage of members with at least 15 • Opioid-containing cough and cold products • Cancer
days of prescription opioids in a 30-day period. • Single-agent and combination buprenorphine • Sickle cell disease
products used in medication-assisted
2. The percentage of members with at least 31
treatment of opioid use disorder.
days of prescription opioids in a 62-day period.
• Ionsys® (fentanyl transdermal patch). Please see Appendix 6, Opioid Medications.
A lower rate indicates better performance. • Methadone for the treatment of opioid use
disorder.
Page 13 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
CWP
Appropriate Testing for Pharyngitis A higher rate is better performance (i.e., Pharyngitis ICD-10 Codes:
appropriate strep test when an antibiotic is given • J02.0 Streptococcal pharyngitis
Ages 3 and older diagnosed with pharyngitis and for pharyngitis).
dispensed an antibiotic, should receive a Group A
• J02.8 Acute pharyngitis due to other specified
streptococcus (strep) test for the episode.
organisms
Group A Strep Tests:
• J02.9 Acute pharyngitis, unspecified
Note: This measure now includes both children CPT Codes:
and adults. 87070, 87071, 87081, 87430, 87650, 87651, • J03.00 Acute streptococcal tonsillitis, unspec.
87652, 87880
• J03.01 Acute recurrent streptococcal tonsillitis
• J03.80 Acute tonsillitis due to other specified
For a diagnosis of pharyngitis (see Column 3),
please be sure the Group A strep test is coded for organisms
the same visit. • J03.81 Acute recurrent tonsillitis due to other
specified organisms
• J03.90 Acute tonsillitis, unspecified
• J03.91 Acute recurrent tonsillitis, unspecified
Page 14 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
DAE
Use of High-Risk Medications in Older Caution should be used in dispensing high-risk
Please see Appendix 7 for High-Risk Medications
Adults medications to the elderly. for Rate 1, and for Rate 2.
The percentage of Medicare members 67 years of A lower rate represents better performance.
age and older who had at least two dispensing
Rate 1: High Risk Medications to Avoid:
events for the same high-risk medication during
the measurement year. The measure reflects potentially inappropriate • High-Risk Medications
medication use in older adults, both for:
Three rates are reported: • High-Risk Medications With Days’ Supply
Criteria
• Medications where any use is inappropriate
1. Rate 1: Member had at least two dispensing
(Rate 1); and • High-Risk Medications With Average Daily Dose
events for high-risk medications to avoid from Criteria
the same drug class.
• Medications where use under all but specific
2. Rate 2: Member had at least two dispensing indications is potentially inappropriate
events for high-risk medications to avoid from (Rate 2). Rate 2: High-Risk Medications to Avoid Except for
Appropriate Diagnosis:
the same drug class, except for appropriate
diagnoses. • High-Risk Medications Based on Prescription &
Members in hospice are excluded from this Diagnosis Data
3. Total rate: The sum of the two numerators measure.
divided by the denominator (deduplicating for
members in both numerators).
Page 15 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
DDE Avoid the following conditions and drugs:
A lower rate of these prescriptions for these
Potentially Harmful Drug–Disease • A history of falls (accidental fall or hip conditions represents better performance.
Interactions in Older Adults fracture) and a prescription for Evaluate if the member has one of these
antiepileptics, antipsychotics, conditions before dispensing these medications.
The percentage of Medicare members age 65 and benzodiazepines, nonbenzodiazepine
older with evidence of an underlying disease, hypnotics or antidepressants (SSRIs, tricyclic Members in hospice are excluded from the
condition or health concern, who were dispensed antidepressants and SNRIs). measure.
an ambulatory prescription for a potentially
• Dementia and a prescription for
harmful medication, concurrent with or after the For falls, exclude members with a diagnosis of
antipsychotics, benzodiazepines,
diagnosis. psychosis, schizophrenia, schizoaffective disorder,
nonbenzodiazepine hypnotics, tricyclic
antidepressants, or anticholinergic agents. bipolar disorder, major depression, or seizure
Counts members with at least one disease, disorder up to 2 years prior.
condition, or procedure within the last 2 years. • Chronic Kidney Disease and a prescription
for Cox-2 selective NSAIDs or non-aspirin For dementia, exclude members with a diagnosis
The start date is the earliest diagnosis, procedure, NSAIDs. of psychosis, schizophrenia, schizoaffective
or prescription between January 1 of the prior disorder, or bipolar disorder up to 2 years prior.
year, to December 1 of the current year. Total rate is the sum of the three numerators
divided by the sum of the three denominators.
FMC Eligible ED visits: Member had two or more
Follow-Up After ED Visit for People different chronic conditions prior to the ED visit, May use follow-up visits that occur on the
With Multiple High-Risk Chronic within the past 2 years. The following are date of the ED visit.
Conditions eligible chronic conditions:
Follow-up visits can include Telehealth or by
• COPD and Asthma. telephone.
The percentage of ED visits for members 18 and
• Alzheimer’s Disease and related disorders.
older with multiple high-risk chronic conditions,
• Chronic Kidney Disease.
who had a follow-up service within 7 days of the
ED visit. • Depression.
• Heart Failure.
Exclude ED visits that result in an inpatient stay, • Acute Myocardial Infarction.
and ED visits followed by admission to an acute or • Atrial Fibrillation.
nonacute inpatient care setting on the date of the • Stroke and Transient Ischemic Attack.
ED visit or within 7 days after the ED visit,
regardless of the principal diagnosis for admission.
Page 16 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
FRM
Fall Risk Management 1. Discussing Fall Risk: This measure is collected using survey
The percentage of Medicare members 65 years methodology, in the Medicare Health Outcomes
For Medicare members: Two components of this of age and older who were seen by a Survey (HOS).
measure assess different facets of fall risk practitioner in the past 12 months and who
management (see Column 2). discussed falls or problems with balance or
walking with their current practitioner. The survey measures each member’s physical and
mental health status at the beginning and the end
2. Managing Fall Risk: of a two-year period.
The percentage of Medicare members 65 years
of age and older who had a fall or had A two-year change score is calculated and each
problems with balance or walking in the past member’s physical and mental health status is
12 months, who were seen by a practitioner in categorized as:
the past 12 months and who received a • Better
recommendation for how to prevent falls or • Same
treat problems with balance or walking from
• Worse than expected
their current practitioner.
FUA Two rates are reported:
Follow-Up After ED Visit for Alcohol & If a member has more than one ED visit in a 31-day
1. The percentage of ED visits for which the period, include only the first eligible ED visit.
Other Drug Abuse or Dependence member received follow-up within 30 days of
Members 13 years of age and older who visited the ED visit. Exclude ED visits that result in an inpatient stay,
the ED with a principal diagnosis of alcohol or 2. The percentage of ED visits for which the and exclude ED visits followed by an admission to
other drug (AOD) abuse or dependence, should member received follow-up within 7 days of an acute or nonacute inpatient care setting on the
have a follow up visit for AOD. the ED visit. date of the ED visit or within the 30 days after the
ED visit, regardless of principal diagnosis for the
• The follow-up visit can be with any admission.
practitioner, with a principal diagnosis of AOD.
A telephone visit with a principal diagnosis of AOD
• Can include visits that occur on the date of the
abuse or dependence counts for the measure.
ED visit.
Page 17 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
FUH Two rates are reported: A follow-up visit with a mental health provider
Follow-Up After Hospitalization for 1. The member received follow-up within 30 does not include visits that occur on the date of
Mental Illness days after discharge with a mental health discharge.
provider.
Members 6 years of age and older who were In addition to outpatient, telehealth and telephone
hospitalized for treatment of selected mental 2. The member received follow-up within 7
visits with a mental health provider also count.
illness or intentional self-harm diagnoses, should days after discharge with a mental
have a follow-up visit with a mental health health provider.
This measure is based on discharges, not
provider. members. If more than 1 discharge, count all
Discharges followed by readmission or direct discharges between January 1 and December 1.
transfer to a nonacute inpatient care setting within
This measure counts an acute inpatient discharge the 30-day follow-up period are excluded
with a principal diagnosis of mental illness or regardless of principal diagnosis for the
intentional self-harm on the discharge claim. readmission (as may prevent outpatient follow-up
visit from taking place).
FUM Two rates are reported: If a member has more than one ED visit in a 31-
Follow-Up After ED Visit for Mental day period, include only the first eligible ED visit.
1. The percentage of ED visits for which the
Illness member received follow-up within 30 days of
Members 6 years of age and older who had an ED the ED visit. Exclude ED visits that result in an inpatient stay,
visit with a principal diagnosis of mental illness or 2. The percentage of ED visits for which the and exclude ED visits followed by admission to an
intentional self-harm, should have a follow-up visit member received follow-up within 7 days of acute or nonacute inpatient care setting on the
for mental illness. the ED visit. date of the ED visit or within the 30 days after the
ED visit, regardless of principal diagnosis for the
• The follow-up visit can be with any admission.
practitioner, with a principal diagnosis of a
mental health disorder or intentional self-
harm.
• Include visits that occur on the date of the
ED visit.
• May include Telehealth and telephone
visits.
Page 18 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
FVA
Please educate your patients on the importance of This measure is collected using survey
Flu Vaccinations for Adults Ages 18-64 an annual flu shot. methodology, in the Consumer Assessment of
Members age 18-64 should receive an annual flu Healthcare Providers and Systems (CAHPS).
vaccination.
FVO
Please educate your patients on the importance of This measure is collected using survey
Flu Vaccinations for Adults Ages 65 and an annual flu shot. methodology, in the Consumer Assessment of
Older Healthcare Providers and Systems (CAHPS).
Members age 65 and older should receive an
annual flu vaccination.
HDO MME: Morphine milligram equivalent. The dose of Cont’d from previous column
oral morphine that is the analgesic equivalent of a
Use of Opioids at High Dosage given dose of another opioid analgesic.
Total Daily MME: The total sum of the MME Daily
Doses for all opioid dispensing events on one day.
The proportion of members 18 years and older Opioid Dosage Unit:
who received prescription opioids at a high dosage For each dispensing event, use the following Average MME: The average MME for all opioids
(average morphine milligram equivalent dose calculation to determine the Opioid Dosage Unit: dispensed during the treatment period.
[MME] ≥90) for ≥15 days during the measurement • # of Opioid Dosage Units per day = (opioid
year. quantity dispensed) / (opioid days supply) • This measure does not include the following
A lower rate indicates better performance. opioid medications:
MME Daily Dose: For each dispensing event, use
– Injectables.
the following calculation to determine MME Daily
Dose: Convert each medication into the MME – Opioid cough and cold products.
Eligible population: Members 18 and older who – Ionsys® (fentanyl transdermal patch).
using the appropriate MME conversion factor and
had two or more opioid dispensing events on
strength associated with the opioid product of the ▪ This is for inpatient use only and is available
different dates of service during the year, AND who
dispensing event. only through a restricted program under a
had ≥15 total days covered by opioids.
MME Daily Dose = (# of opioid dosage units per Risk Evaluation and Mitigation Strategy
day) X (strength (e.g., mg, mcg)) X (MME (REMS).
The tracked rate is the number of these members
in the eligible population whose average MME was
conversion factor). – Methadone for the treatment of opioid use
≥90 during the treatment period. Example 1: 10 mg oxycodone tablets X (120 disorder.
tablets / 30 days) X 1.5 = 60 MME/day.
See Appendix 4: Example 2: 25 mcg/hr fentanyl patch X (10 Excluded from the measure: Hospice, cancer, or
Opioid Medications / MME Conversion Factor patches / 30 days) X 7.2 = 60 MME/day. sickle cell disease during current year.
Page 19 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
IET • Consider using the AUDIT-C to screen patients for
For diagnosis of alcohol abuse or dependence, one symptoms of substance use disorders upon intake,
Initiation and Engagement of Alcohol or more medication treatments beginning on the annually, and as indicated.
and Other Drug Abuse or Dependence day after the initiation encounter through 34 days AUDIT-C-Plus-2-Screening-Questionnaire.pdf (nationalcouncildocs.net)
(AOD) Treatment after, meets criteria for Alcohol Abuse and AUDIT-C-Plus-2-Screening-Results.pdf (nationalcouncildocs.net)
Dependence Treatment:
Age 13 and older with a new episode of alcohol • When a new AOD diagnosis is detected immediately
or other drug (AOD) abuse or dependence should Alcohol Use Disorder Treatment Medications: schedule 3 follow up visits:
receive the following: 1 IOT visit in 7 days and 2 EOT visits within 24 days.
*New episode - no AOD billing claim in 60 days • Aldehyde dehydrogenase inhibitor: This will allow time to reschedule missed visits within
Disulfiram (oral) the 14-day / 34-day compliance windows.
Initiation of Treatment (IOT) • Antagonist: Naltrexone (oral and injectable)
via an inpatient AOD admission, outpatient visit, • Other: Acamprosate (oral; delayed-release • Educate patients on the effects of alcohol or other
intensive outpatient encounter or partial tablet) drug abuse and discuss treatment options and refer
hospitalization, telehealth or medication to Behavioral Health as indicated.
treatment within 14 days of the diagnosis. For diagnosis of opioid abuse or dependence, one
Engagement of Treatment (EOT) or more medication treatments beginning on the • Document AOD diagnosis and submit corresponding
Members who initiated treatment should be day after the initiation encounter through 34 days ICD-10 billing code on all claims.
engaged in ongoing AOD treatment within 34 after, meets criteria for Opioid Abuse and
days of the initiation visit. Dependence Treatment: • If a drug is prescribed, monitored, and used as
directed do not use a diagnosis/billing code that will
• Intake Period: January 1st – November 13th Opioid Use Disorder Treatment Medications: place patient in the measure. For example:
of the current measurement year Opioid treatment:
• Compliance: The initial AOD diagnosis code • Antagonist: Naltrexone (oral and injectable) Z79.891 Long term current use of opiate analgesic
must be included on all IOT and EOT billing • Partial Agonist: Buprenorphine (sublingual tablet, Vs. F11.10 Opioid abuse Or F11.20 dependence
claims injection, implant); or Buprenorphine/naloxone Cannabis treatment:
(sublingual tablet, buccal film, sublingual film) F12.90 Medical cannabis use
• Telephone Visits: Vs. F12.10 Cannabis abuse Or F12.20 dependence
CPT 98966–98968, 99441–99443 For members with more than one episode of AOD abuse
• Online Assessments/E-visit/Virtual check-in: or dependence, use the first episode. • When AOD is no longer active remove / replace with
CPT 98969–98972, 99421–99423, 99444, 99458 appropriate “in remission” diagnosis.
HCPCS G2010, G2012, G2061–G2063
IMA Educate staff to schedule PRIOR to 13th birthday. Meningococcal Procedure Code: 90734
Immunizations for Adolescents Must be completed by the 13th birthday.
Tdap Procedure Code: 90715
By age 13, member should have had:
• One dose of meningococcal vaccine Document and submit timely with correct code. HPV Procedure Codes: 90649, 90650, 90651
• One tetanus, diphtheria toxoids and
Offer HPV Vaccine to members age 9 to age 13.
acellular pertussis (Tdap) vaccine and
Two doses should be completed prior to age 13.
• Completed the human papillomavirus
(HPV) vaccine series.
The measure calculates a rate for each vaccine
and two combination rates.
Page 20 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
LBP Exclusions – Imaging acceptable within 28 days of Alternate codes: Consider if any of these apply in
Use of Imaging Studies for Low Back a primary low back pain diagnosis if member had: the primary position rather than low back pain,
Pain Cancer, or major organ transplant any time during and then imaging within 28 days would be
the member’s history through 28 days after the acceptable (not a complete list):
Ages 18-50 with a primary diagnosis of low back pain diagnosis.
uncomplicated low back pain should not have an • Discitis, unspecified, lumbar region (M46.46)
imaging study (plain x-ray, MRI, or CT scan) within Recent trauma (fractures, dislocations, • Discitis, unspecified, lumbosacral region
28 days of the diagnosis. lacerations, internal injuries, etc.). Trauma any (M46.47)
time during the 3 months prior to the low back • Discitis, unspecified, sacral and sacrococcygeal
pain diagnosis through 28 days after. region (M46.48)
There are exclusions where imaging may be • Other specified inflammatory spondylopathies,
Intravenous drug abuse, neurologic impairment,
clinically appropriate within the first 28 days. lumbar region (M46.86)
spinal infection, or HIV any time during the 12
• Unspecified thoracic, thoracolumbar and
months prior to the low back pain diagnosis
Exclusion diagnoses (such as a fracture) must be lumbosacral intervertebral disc disorder;
through 28 days after.
submitted in a claim to count. herniated intervertebral disc (M51.9)
Prolonged use of corticosteroids. 90 consecutive • Muscle spasm of back (M62.830)
days of corticosteroids any time during the 12 • Contusion of lower back (S30.0XXA)
months prior to the low back pain diagnosis. • Unspecified superficial injury of lower back
(S30.91XA)
MSC 1. Advising Smokers and Tobacco Users to Quit:
Medical Assistance With Smoking and The percentage of members who were This measure is collected using survey
current smokers or tobacco users, who methodology, in the Consumer Assessment of
Tobacco Use Cessation
received advice to quit during the year. Healthcare Providers and Systems (CAHPS).
Members 18 and older: 2. Discussing Cessation Medications:
The percentage of members who were
The three components of this measure assess
current smokers or tobacco users, and who
different facets of providing medical assistance
discussed or were recommended cessation
with smoking and tobacco use cessation.
medications during the year.
(See Column 2).
3. Discussing Cessation Strategies:
The percentage of members who were current
smokers or tobacco users and who discussed or
were provided cessation methods or strategies
during the year.
Page 21 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
OMW Either a BMD test or the drug therapy within 6 Osteoporosis drug therapies:
Osteoporosis Management in Women months after the fracture meets the criteria.
• Bisphosphonates: alendronate,
Who Had a Fracture Drug therapy would be indicated (rather than alendronate-cholecalciferol, ibandronate,
Ages 67 to 85 who suffered a fracture (other than another BMD test) if a previous test already shows risedronate, zoledronic acid.
osteoporosis.
finger, toe, face, or skull), should have either one • Other agents:
of the following within the 6 months after the abaloparatide, denosumab, raloxifene,
fracture: Members with either of the following are also romosozumab, teriparatide.
considered compliant:
• A bone mineral density (BMD) test, also
known as a DEXA scan, • BMD test within the 24 months prior to the
fracture; Reminder to Staff PCPs: Please put in the BMD
or test order after a fracture, and notify the patient
• Fill a prescription for a drug to treat or
how to call and schedule an appointment. (For
osteoporosis. • Osteoporosis drug therapy within the 12 example, FHCP Radiology in Daytona Beach does
months prior to the fracture. not call patients to schedule, from an EHR Task).
Page 22 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
PCE In addition to filling the medications timely after PCPs: At the 7-day follow-up visit after an INP or
Pharmacotherapy Management of discharge from INP or ED, the member will also ED hospital encounter for a COPD exacerbation,
COPD Exacerbation count as compliant if: please ask the member when they last filled these
• Member has previously filled prescriptions for medications.
Age 40 and older with an acute inpatient (INP)
discharge or emergency department (ED) visit for a both medications, with enough days’ supply
If not yet filled, please consider prescribing both a
COPD exacerbation should fill a prescription for to cover hospital admission and discharge.
systemic corticosteroid and a bronchodilator (if
both: there are no contraindications), and encourage
• Systemic corticosteroid within 14 days of patient to fill immediately.
The eligible population is based on INP and ED
discharge visits, so the member may appear more than
and The patient may tell the hospitalist they have a
once in the measure for the year. nebulizer at home; however, prescriptions for a
• Bronchodilator within 30 days of discharge. bronchodilator have not been filled recently.
PCR
Plan All-Cause Readmissions Discharge from the hospital is a critical transition Exclude hospital stays from the measure for the
point in a patient’s care. following reasons:
For ages 18 and older (or ages 18-64 for non-
Medicare), the number of acute inpatient and • Pregnancy
Hospital readmission is associated with longer
observation stays during the year, that were lengths of stay and higher mortality for patients. • A principal diagnosis of a condition originating
followed by an unplanned acute readmission for in the perinatal period
any diagnosis within 30 days and the predicted Hospital readmissions are commonly related to • Member died during hospital stay
probability of an acute readmission. CHF, Acute MI, COPD, and pneumonia. • A principal diagnosis of maintenance
chemotherapy
• An organ transplant
Members in hospice also excluded.
-
Page 23 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
PNU
Please educate your older patients on the This measure is collected using survey
Pneumococcal Vaccination Status for methodology, in the Consumer Assessment of
importance of a pneumococcal vaccination.
Older Adults Healthcare Providers and Systems (CAHPS).
The percentage of Medicare members 65 years of
age and older, who have ever received one or
more pneumococcal vaccinations.
PPC Prenatal: Prenatal Visit Codes: 99201-99205, 99211-99215,
Prenatal & Postpartum Care 99241-99245, 99483.
Educate staff to schedule first appointment with
For members with live births: (Must also include a pregnancy related diagnosis
the OB/GYN, other prenatal care practitioner, or
code).
• Timeliness of Prenatal Care: Members should PCP in the first trimester.
receive a prenatal care visit in the first • For visits to a PCP, a diagnosis of pregnancy Stand Alone Prenatal Visit Codes: 99500, 0500F,
trimester, on or before the enrollment start must be present. 0501F, 0502F
date or within 42 days of enrollment in the
health care plan. Prenatal Bundled Services Codes: 59400, 59425,
Postpartum: 59426, 59510, 59610, 59618
• Postpartum Care: Members should have a
postpartum visit on or between 7 and 84 days Must be visit to an OB/GYN or other prenatal care Postpartum Visit Codes: 57170, 58300, 59430,
after delivery. practitioner, or PCP. 99501, 0503F
Postpartum visit for a pelvic exam meets the Postpartum Bundled Services: 59400, 59410,
requirement. 59510, 59515, 59610, 59614, 59618, 59622
Telephone visits may be used for both prenatal
Do not include postpartum care provided in an
and postpartum care.
acute inpatient setting.
Do not count visits that occur on the date of
delivery.
Page 24 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
PSA The following are considered clinically appropriate
Non-Recommended PSA-Based PSA-based screening for prostate cancer for men indicators for PSA-based testing for age 70 and
Screening in Older Men age 70 and older should not be used unless a older:
clinically indicated diagnosis is present.
Ages 70 and older should not be screened • Prostate cancer any time during the
unnecessarily for prostate cancer, using prostate- member’s history.
specific antigen (PSA)-based screening. A lower rate indicates better performance. • Dysplasia of the prostate during the
measurement year, or year prior.
• A PSA test during the year prior to the
measurement year, where lab data indicate
an elevated result (>4.0 ng/mL).
• An abnormal PSA test result or finding during
the prior year.
• Dispensed prescription for 5-alpha reductase
inhibitor (5-ARI) during the measurement
year.
SPC The treatment period is the earliest prescription Members are not included in this measure if they
Statin Therapy for Patients with dispensing date for any high or moderate intensity have the following:
Cardiovascular Disease statin medication, through the last day of the year.
• End Stage Renal Disease (ESRD), cirrhosis,
Males ages 21 to 75, and females ages 40 to 75, pregnancy, in vitro fertilization, or a
Members in the measure include those with MI,
who were identified with clinical atherosclerotic prescription for clomiphene during the
CABG, PCI, other revascularization, or a diagnosis
cardiovascular disease (ASCVD), should meet the measurement year or year prior.
of ischemic vascular disease (IVD) with treatment
following criteria: during the year or year prior. • Myalgia, myositis, myopathy, or
• Received Statin Therapy: Dispensed at least rhabdomyolysis during the measurement
one high or moderate intensity statin year.
medication during the measurement year. See Appendix 5 for Statin Medications.
Members in hospice are excluded.
• Statin Adherence 80%: Remained on a high or
moderate intensity statin medication for at
least 80% of the treatment period.
Page 25 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
SPD
Statin Therapy for Patients with Members are excluded from this measure if they Members are also excluded from this measure if
Diabetes have: they have the following:
Ages 40 to 75 with diabetes, but without clinical • MI inpatient, CABG, PCI, other • End Stage Renal Disease (ESRD), cirrhosis,
atherosclerotic cardiovascular disease (ASCVD), revascularization, or a diagnosis of ischemic pregnancy, in vitro fertilization, or a
should meet the following criteria: vascular disease (IVD) with treatment during prescription for clomiphene during the
the year or year prior. measurement year or year prior.
• Received Statin Therapy: Dispensed at least
one statin medication of any intensity during • Myalgia, myositis, myopathy, or
the measurement year. See Appendix 5 for Statin Medications. rhabdomyolysis during the measurement
• Statin Adherence 80%: Remained on a statin year.
medication of any intensity for at least 80% of
the treatment period. Members in hospice are excluded.
Page 26 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
TRC
1. Notification of Inpatient Admission. Applies to discharges for acute and non-acute
Transitions of Care inpatient stays.
Documentation of receipt of notification of
The percentage of discharges for members 18 inpatient admission on the day of admission
years of age and older who had each of the through 2 days after the admission (3 total A telephone visit may count for the measure.
following during the measurement year (see days).
second column – four rates are reported). May not use documentation that the member or
2. Receipt of Discharge Information. the member’s family notified the PCP or ongoing
Documentation of receipt of discharge care provider of the admission or discharge.
The record where documentation is expected is
information on the day of discharge through
with the member’s Primary Care Physician (PCP).
2 days after the discharge (3 total days). At a There must be a time frame or date when the
minimum, must include the practitioner documentation was received.
However, if a practitioner other than the PCP
responsible for the member’s care during the
manages the member’s ongoing care, the health
inpatient stay, procedures or treatment Members in hospice excluded.
plan may use the medical record kept by that
provided, diagnoses at discharge, current
practitioner.
medication list, test results, and instructions
for patient care post-discharge.
3. Patient Engagement After Inpatient
Discharge. Documentation of patient
engagement (e.g., office visits, visits to the
home, Telehealth, telephone) provided
within 30 days after discharge. May not
occur on date of discharge.
4. Medication Reconciliation Post-Discharge.
Documentation of medication reconciliation
on the date of discharge through 30 days after
discharge. Conducted by a prescribing
practitioner, clinical pharmacist, or RN.
Patient does not have to be present.
Page 27 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansMeasure Comments More Tips
UOP 1. Rate 1: Multiple Prescribers. The proportion
Members in hospice are excluded.
Use of Opioids From Multiple Providers of members receiving prescriptions for
opioids from four or more different
The proportion of members 18 years and older, prescribers during the measurement year. • The following opioid medications are excluded
receiving prescription opioids for ≥15 days during from this measure:
2. Rate 2: Multiple Pharmacies. The proportion
the measurement year, who received opioids – Injectables.
from multiple providers. of members receiving prescriptions for opioids
from four or more different pharmacies during – Opioid cough and cold products.
Three rates are reported (see Column 2). the measurement year. – Single-agent and combination buprenorphine
products used as part of medication assisted
A lower rate indicates better performance for 3. Rate 3: Multiple Prescribers and Multiple treatment of opioid use disorder (i.e.,
all three rates. Pharmacies. The proportion of members buprenorphine sublingual tablets,
receiving prescriptions for opioids from four or buprenorphine subcutaneous implant and all
Eligible population: Members 18 & older who met more different prescribers and four or more buprenorphine/naloxone combination
both of the following criteria during the year: different pharmacies during the measurement products).
• At least two or more opioid dispensing events year.
– Ionsys® (fentanyl transdermal patch).
on different dates of service.
See Appendix 6 for Opioid Medications List. – Methadone for opioid use disorder.
• ≥15 total days covered by opioids.
URI
URI codes (do not give antibiotic): Alternate Codes: Acceptable with an antibiotic per
Appropriate Treatment for Upper the measure (not a complete list):
Respiratory Infection • J00: Acute nasopharyngitis (common cold)
• J06.0: Acute laryngopharyngitis H66.90: Otitis media, unspec.
Age 3 months and older with a diagnosis of upper J01.90: Acute sinusitis, unspec.
• J06.9: Acute upper respiratory infection,
respiratory infection (URI) should not be dispensed unspecified J02.9: Acute pharyngitis (perform strep test)
an antibiotic prescription. J03.90: Acute tonsillitis (perform strep test)
URI should be treated symptomatically, and not
Antibiotics filled on or within 3 days of the visit
with an antibiotic. Also ok to give antibiotic with URI if these co-
with a diagnosis of URI, count in the measure
morbid conditions are coded at the visit or up
as non-compliant.
to a year prior (not a complete list):
Note: This measure now includes both children -Cancer -COPD -Cystic fibrosis -HIV
and adults. -Pulmonary edema -Respiratory failure -TB
Page 28 - HEDIS® / STAR PROVIDER GUIDE (MY 21 – Revised January 2021) Florida Health Care PlansYou can also read
