HEDIS measures - Amerigroup...Health care providers should check with accrediting organizations to...

HEDIS measures

Behavioral health

WAPEC-1884-19 April 2019

• Medication management (15 minutes):o Antidepressant Medication Management (AMM) o Adherence to Antipsychotic Medications for Individuals with

Schizophrenia (SAA)• Follow-up care (20 minutes):

o Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

o Follow-Up Care for Children Prescribed ADHD Medication (ADD)o Follow-Up After Hospitalization for Mental Illness (FUH)o Follow-Up After Emergency Department Visit for Mental Illness

(FUM)o Follow-Up After Emergency Department Visit for Alcohol and

Other Drug Dependence (FUA)

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Agenda

• Chronic condition management (15 minutes):oDiabetes Screening for People with Schizophrenia or Bipolar

Disorder Who Are Using Antipsychotic Medications (SSD)oDiabetes Monitoring for People with Diabetes and Schizophrenia

(SMD)oMetabolic Monitoring for Children and Adolescents on

Antipsychotics (APM)o Cardiovascular Monitoring for People with Cardiovascular Disease

and Schizophrenia (SMC)• Resources (10 minutes):

oQuestion and answer sessiono Resources for your patients o Resources for practitioners

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Agenda (cont.)

This training awards one continuing medical education unit approved by the American Association of Family Physicians (AAFP). Health care providers should check with accrediting organizations to ensure that AAFP-approved medical education is accepted.

Coding guidance provided does not, nor is it intended to, replace the official coding guidelines or professional coding expertise. Providers should always ensure that documentation supports all codes submitted for conditions and services. Please contact provider services for billing/claim specific questions.

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Continuing education credit

Medication monitoring

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Antidepressant Medication Management (AMM)Fo

cus

gro

up • Members

> 18 with a new diagnosis of majordepression

Serv

ice • Newly treated

with antidepressant medication

Freq

uen

cy • On treatment for at least 84 days

• Ongoing treatment for at least 180 days

• Diagnosis and treatment visits will be counted through one of the following:

o Outpatient visit

o Emergency department (ED) visit

o Intensive outpatient encounter

o Partial hospitalization

o New — telehealth visit

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AMM (cont.)

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Antidepressant medications

9

AMM

Understanding coding: ICD-10 classifies major depression according to:

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AMM (cont.)

ICD-10 codes for major depression disorder:

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Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)

Focu

s gr

ou

p • Ages 19-64 years of age as of December 31 of the measurement year

Serv

ice • Must be on an antipsychotic medication during the measurement year Fr

equ

ency • Patients who

were dispensed and remained on antipsychotic medication for at least 80 percent of their treatment period

• Pimozide and fluoxetine-olanzapine have been removed from the medications table.

• Telehealth has been added as a visit type.

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SAA (cont.)

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Antipsychotic medications

Description Prescription

Miscellaneous antipsychotic

agents

Aripiprazole Lurisadone

Asenapine Molindone

Brexpiprazole Olanzipine

Cariprazine Paliperidone

Clozapine Haloperidol

Quetiapine Ziprasidone

Iloperidone Quetiapine fumarate

Loxapine Risperidone

Phenothiazine antipsychotics Chlorpromazine Prochlorperazine

Fluphenazine Thioridazine

Perphenazine Trifluoperazine

Thioxanthenes Thiothixene

Long-acting injections Aripiprazole Olanzipine

Fluphenazine decanoate Paliperidone Palmitate

Haloperidol decanoate Risperidone

Psychotherapeutic combinations Perphenazine-amitryptiline

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SAA

Understanding codes for schizophrenia: F20 category in ICD-10 contains codes for schizophrenia by type.

F20.0: paranoid schizophrenia (includes

paraphrenic schizophrenia)

F20.1: disorganized schizophrenia (includes

hebephrenic schizophrenia and

hebephrenia)

F20.2: catatonic schizophrenia (includes schizophrenic catalepsy, catatonia and flexibilitas

cerea)

F20.3: undifferentiated schizophrenia (includes atypical schizophrenia)

F20.5: residual schizophrenia (includes

restzustand and schizophrenia residual

state)

F20.8: other schizophrenia (includes

F20.81 schizophreniform disorder and F20.89 other schizophrenia)

F20.9: schizophrenia unspecified

Refer to Amerigroup Washington, Inc. billing guides for allowable codes.

Understanding codes for schizoaffective disorders: F25 category in ICD-10 contains codes for schizoaffective disorders by type

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SAA (cont.)

• Schizoaffective psychosis not otherwise specified

F25.9: schizoaffective disorders, unspecified type

F25.8: other schizoaffective disorders

• Schizoaffective psychosis, depressive type

• Schizophreniform psychosis, depressive type

F25.1: schizoaffective disorder, depressive type

• Cyclic schizophrenia

• Schizoaffective disorder, manic type

• Schizoaffective disorder, mixed type

• Schizoaffective psychosis, bipolar type

• Schizoaffective psychosis, manic type

F25.0: schizoaffective disorder, bipolar type

Refer to Amerigroup billing guides for allowable codes.

• Gaining trust and adherence in treatment plan:oHelp patient understand the diagnosis from his or her point of

view: What impact does the illness have on the patient’s life?

oDiscuss treatment options and patient willingness to consider each.

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Medication management tips

• Gaining trust and compliance in treatment plan:oOutline medication actions:

Discuss how long to expect a change in symptoms. Discuss the success of integration of medication and

therapy. Describe side effects and how to manage. Explain potential for need to change medications.

o Listen to patient concerns to gauge potential for adherence.o Express hope for improvement.oCommunicate your commitment to partner with them.oAsk for verbal and signature agreement to the plan.

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Medication management tips (cont.)

• Document in chart for support team:oDiagnosis:

Symptoms of serious mental illness Patient’s support system and resources Referral to behavioral health provider when appropriate

oMedications: Dose and frequency Reported side effects or patient concerns

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• Document in chart for support team:o Schedule for lab work and follow-up appointments.oRequest access to behavioral health records if you are the PCP:

Share diagnostic assessment and medication treatment plan with the behavioral health clinician (if not internal or if there is limited access/info sharing to your documentation).

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• Educate your patients and their supports about the importance of:oAdhering to medications as prescribed.oNot stopping medications without consulting you.oContacting you immediately if they experience any

unwanted/adverse reactions so that their treatment can be re-evaluated.

o Scheduling and attending follow-up appointments to review the effectiveness of their medications.

oCalling your office if they cannot get their medications refilled.oAdherence assistance, such as divided pill boxes, setting

alarms, etc.

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• Medication adherence does not need to be the focus of your behavioral health treatment plan:oBe aware of the medication management plan and provide

supportive assistance: Access to pharmacy or appointments, reminder programs,

etc. Enrollment in mail delivery Rx services

• Route questions and concerns to the prescriber:oChanges in symptoms, side effects, drug/alcohol use, etc. must

be reported to the prescriber.• Review available records and collaborate with the prescriber.

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Tips for behavioral health line staff

Follow-up care

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Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

Focu

s gr

ou

p • Adolescent or adult members with a new episode of alcohol or other drug (AOD) dependence

Serv

ice • Treatment through

inpatient, outpatient, telehealth or partial hospitalization Fr

equ

ency • Initiation visit

within 14 days of the diagnosis

• Engagement (two or more) visits within 34 days of the initial visit

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ICD-10 codes for IET

Alcohol disorders:

• F10.1 — Alcohol abuse

• F10.2 — Alcohol dependence

• F10.9 — Alcohol use, unspecified

Drug disorders:• F11 — Opioid related disorders• F12 — Cannabis related disorders• F13 — Sedative, hypnotic or

anxiolytic related disorders• F14 — Cocaine related disorders• F15 — Other stimulant related

disorders• F16 — Hallucinogen related

disorders• F17 — Nicotine dependence• F18 — Inhalant related disorders• F19 — Other psychoactive

substance related disorders


• Stand-alone CPT codes: 98960-98962, 99078, 99201-99205, 99211-99215, 99217, 99218, 99219, 99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99408, 99409, 99411, 99412, 99510

• Stand-alone HCPCS codes: G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

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CPT and HCPCS codes for IET


Informational only, no reimbursement guarantee

• Group 1 visit: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876

• Group 2 visit: 99221-99223, 99231-99233, 99238, 99239, 99251-99255

• ED: 99281-99285

• Medication assisted treatment: H0020, H0033, J0571-J0575, J2315, S0109

• Detoxification: H0008-H0014

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CPT and HCPCS codes for IET (cont.)



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Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Focu

s gr

ou

p • Members ages 6-12 with a new diagnosis of ADHD within the measurement year

Serv

ice • Newly treated

with ADHD

Freq

uen

cy • First visit after medication prescribed within 30 days, then two additional visits, all within a 10-month period

Telehealth has been added as a visit type for one of the two additional visits to meet requirements of the measure.

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ADD (cont.)

Helpful tips:• Request access to behavioral health records if you are the PCP.• Engage the patient’s guardian in the treatment plan.• Gain agreement and signature of patient/guardian on treatment

plan.• Schedule the 30-day follow-up and all follow-up visits before they

leave the office:o Engage staff to call patient to remind of visit.oUse email/text as appropriate.

• Provide resources for success, including:o A phone number to call if they experience any adverse reactions.o Local support groups.o Family therapy.oNote for school counselors.

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ADD

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ICD-10 codes for ADHD disorders

F90.0ADHD, predominantly inattentive

F90.1ADHD, predominantly hyperactive

F90.8ADHD, other type

F90.9ADHD, unspecified type

F90.2ADHD, combined type

https://www.cdc.gov/ncbddd/adhd/index.html

https://www.cdc.gov/ncbddd/adhd/index.html

• Stand-alone CPT codes: 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99384, 99391-99394, 99401-99404, 99411, 99412, 99510

• Stand-alone HCPCS codes: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015

• Group 1 visit: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876

• Group 2 visit: 99221-99223, 99231-99233, 99238, 99239, 99251-99255

• Telephone visit codes: 98966-98968, 99441-99443

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CPT and HCPCS codes for ADD



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Follow-Up After Hospitalization for Mental Illness (FUH)

Focu

s gr

ou

p • Members age6 years and older as of the date of discharge

Serv

ice • An acute

inpatient discharge with a diagnosis of mental illness on or between January 1 and December 1 of the measurement year

Freq

uen

cy • Member to follow up within seven days and within 30 days after discharge with a mental health provider.

• Telehealth has been added as a visit type for one of the two additional visits to meet requirements of the measure.

• Visits on the day of discharge are no longer counted for follow-up care.

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FUH (cont.)

• Stand-alone CPT codes: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510

• Group 1: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90869, 90870, 90875, 90876

• Group 2: 99221-99223, 99231-99233, 99238, 99239, 99251-99255

• Traditional care management services: 99495, 99496

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CPT and HCPCS codes for FUH



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Follow-Up After Emergency Department Visit for Mental Illness (FUM)

Focu

s gr

ou

p • Members age 6 years and older as of the date of discharge Se

rvic

e • An ED visit with a diagnosis of mental illness on or between January 1 and December 1 of the measurement year

Freq

uen

cy • Member to follow up within seven days and within 30 days after discharge with any provider.

• The update clarified that the member must be 6 years or older on the date of the visit.

• Telehealth has been added as a visit type for follow-up care.

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FUM (cont.)

• CPT codes: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412,99245, 99246, 99510

• HCPCS codes: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, S0201, S9480, S9484, S9485, T1015

• Group 1 visit: 0791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876

• Group 2 visit: 99221-99223, 99231-99233, 99238, 99239, 99251-99255

• Telehealth: 98966-98969, 99441-99444

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CPT and HCPCS Codes for FUM



Behavioral health codes: F20-F99

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ICD-10 codes for FUH and FUM

Schizophrenia Bipolar disorders Major depressionMany other

psychotic/mental disorders

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Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

Focu

s gr

ou

p • Members age 13 and older with a diagnosis of AOD dependence as of the date of discharge

Serv

ice • An emergency department visit with a diagnosis of AOD abuse or dependence between January 1 and December 1 of the measurement year

Freq

uen

cy • Member to follow up within seven days and within 30 days after discharge with any provider.

• Alcohol disorders:o F10.1 — Alcohol abuseo F10.2 — Alcohol dependenceo F10.9 — Alcohol use, unspecified

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ICD-10 codes for FUA



Other drugs:• F11 — Opioid related disorders• F12 — Cannabis related disorders• F13 — Sedative, hypnotic or anxiolytic related disorders• F14 — Cocaine related disorders• F15 — Other stimulant related disorders• F16 — Hallucinogen related disorders• F17 — Nicotine dependence• F18 — Inhalant related disorders• F19 — Other psychoactive substance related disorders

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ICD-10 codes for FUA (cont.)

• Stand-alone CPT codes: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99408, 99409, 99411, 99412, 99510

• Stand-alone HCPCS codes: G0155, G0176, G0177, G0396, G0397, G0409-G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2036, S0201, S9480, S9484, S9485, T1006, T1012, T1015

• Group 1 visit: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876

• Group 2 visit: 99221-99223, 99231-99233, 99238, 99239, 99251-99255• Telehealth: 98966-98969, 99441-99444

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CPT and HCPCS codes for FUA



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Follow-up care

X with MH

Chronic condition management andmetabolic monitoring

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• Diabetes screening for members with schizophrenia (F20) or bipolar disorder (F31) who use antipsychotic medications

• Diabetes monitoring for members with diabetes (E08-E13) and schizophrenia (F20)

• Monitoring of cardiovascular disease (I25) in members with schizophrenia (F20)

• Metabolic monitoring for child and adolescent members on antipsychotic medications

Note: ICD-10 diagnosis code categories appear in (parentheses).

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Chronic condition management and metabolic monitoring


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Diabetes Screening for People with Schizophrenia or Bipolar

Disorder Who Are Using Antipsychotic Medications (SSD)Fo

cus

gro

up • Members ages

18-64 years of age with schizophrenia or bipolar disorder during the measurement year

Serv

ice • Member was

dispensed an antipsychotic medication between January 1 and December 1 of the measurement year

Freq

uen

cy • Had a diabetes screening test — a blood glucose or A1C test during the measurement year

• Pimozide and fluoxetine-olanzapine have been removed from the list of antipsychotic medications.

• Schizoaffective disorder has been added as a diagnosis.

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SSD (cont.)

• Glucose tests: 80047, 80048, 80050, 80069, 82947, 82950, 82951• HbA1c: 83036, 83037• Category II: 3044F, 3045F, 3046F• Long-acting injections: J0401, J1631, J2358, J2456, J2680, J2794• Outpatient: 99201-99205, 99211-99215, 99241-99245,

99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99429, 99455, 99456

• HCPCS: G0402, G0438, G0439, G0463, T1015

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CPT and HCPCS codes for SSD



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Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)

Focu

s gr

ou

p • Members ages 18-64 years of age with schizophrenia and diabetes during the measurement year

Serv

ice • Member was seen

for diagnoses of both schizophrenia and diabetes between January 1 and December 1 of the measurement year

Freq

uen

cy • Had both an A1C test and an LDL-C test during the measurement year

• Schizoaffective disorder has been added as a diagnosis.

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SMD (cont.)

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Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)

Focu

s gr

ou

p • Members age18-64 years of age with schizophrenia and cardiovascular disease during the measurement year

Serv

ice • Member was

seen for both schizophrenia and cardiovascular disease between January 1 and December 1 of the measurement year

Freq

uen

cy • Had an LDL-C test during the measurement year

Schizoaffective disorder has been added as a diagnosis.

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SMC (cont.)

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Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

Focu

s gr

ou

p • Children and adolescents 1-17 years of age who had two or more antipsychotic prescriptions

Serv

ice • At least two

antipsychotic medication dispensing events of the same or different medications on different dates of service during the measurement year

Freq

uen

cy • Metabolic testing to include one blood glucose or HbA1C + one LDL-C or cholesterol test during the measurement year

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Metabolic monitoring

• Cholesterol tests other than LDL: 82465, 83718, 84478• Glucose tests: 80047, 80048, 80050, 80053, 80069, 82947, 82950,

82951• HbA1c: 83036, 83037, 3044F, 3045F, 3046F• LDL-C tests: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F,

3050F

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CPT and HCPCS for APM

Information only, no reimbursement guarantee


For additional questions, contact:Quality Training Specialist:

Maria [email protected]

Hedis Manager:Tim Davern

[email protected]

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Q&A session

• Homelessness: ICD-10 — Z590, Dial 211, http://wliha.org/resources/find-affordable-housing

• Washington State Tobacco Quitline:o1-800-QUIT-NOW (1-800-784-8669): oAvailable in other languages and for vets:https://2morrowhealth.net/WADOH#waquitline

• Washington Recovery Help Line — 1-866-789-1511, https://www.warecoveryhelpline.org

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Resources for your patients

http://wliha.org/resources/find-affordable-housing

https://2morrowhealth.net/WADOH#waquitline

https://www.warecoveryhelpline.org/

• American Academy of Child and Adolescent Psychiatry:https://www.aacap.org

• American Academy of Family Physicians: https://www.aafp.org/patient-care.html

• American Academy of Pediatrics: https://brightfutures.aap.org• NCQA Updates Quality Measures for HEDIS:

https://www.ncqa.org/news/ncqa-updates-quality-measures-for-hedis-2019

• Consumer Assessment of Healthcare Providers & Systems (CAHPS): https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS

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Provider resources

https://www.aacap.org/

https://www.aafp.org/patient-care.html

https://brightfutures.aap.org/

https://www.ncqa.org/news/ncqa-updates-quality-measures-for-hedis-2019

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS

Thank you!

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