Practice
Reference Guide
2016 HEDIS® Measures
Updated: February 2016
Contents
Adolescent Well-Care Visits
Adult BMI
Annual Dental Visits
Annual Monitoring for Patients on Persistant Medications
Antidepressant Medication Management
Appropriate testing for Children with Pharyngitis
Appropriate treatment for Children with Upper Respiratory Infection
Asthma Medication Ratio
Avoidance of Antibiotic treatment in Adults with Acute Bronchitis
Breast Cancer Screening
Care of the Older Adult
Cervical Cancer Screening
Childhood Immunization Status
Chlamydia Screening in Women
Colorectal Cancer Screening
Comprehensive Diabetes Care
Controlling High Blood Pressure
Disease Modifying Anti-Rheumatic Drug Therapy (DMARD)
Flu Vaccinations in Adults
Follow-up for Children Prescribed ADHD Medication
Human Papillomavirus Vaccine for Female Adolescents
Immunization for Adolescents
Maternity: Timeliness of Prenatal Care, Frequency of Ongoing Prenatal Care and
Postpartum Care
Medical Assisance with Smoking and Tobacco Use Cessation
Medication Management for People with Asthma
Osteoporosis Management in Women who had a Fracture
Persistance of Beta-Blocker Treatment after a Heart Attack
Pharmacotherapy Management of COPD Exacerbation
Plan All Cause Readmissions
Pneumococcal Vaccination Status for Older Adults
Potentially Harmful Drug-Disease Interactions in the Elderly
Use of High-Risk Medications in the Elderly
Use of Imaging Studies for Low Back Pain
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and
Adolescents
Well-Child Visits in the First 15 Months of Life
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
Profiled Measures for 2016 GPE®
Practice Resource Page
Adolescent Well Care
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Adolescent Well Care
measure along with guidance and resources.
What is the Measure?
This measure looks at the percentage of enrolled patients 12–21 years of age who had
at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during
the measurement year.
What Codes Should Providers Use?
Component
ICD-10-CM Codes
CPT®
Category I
HCPCS
Adolescent Well Care Visit
Z00.00, Z00.01,
Z00.5, Z00.8,
Z00.121, Z00.129,
Z02.0 -Z02.9,
Z02.71, Z02.79,
Z02.83, Z02.89,
99384, 99385,
99394, 99395
G0438, G0439
How Can Providers Improve HEDIS® Scores?
 Conduct or schedule well-care visits when patients present themselves for
illnesses, or other events like sports physicals, accidental injuries, and colds.
 If documenting in the medical record, the notation must include health and
developmental history (mental & physical), physical exam, health
education/anticipatory guidance.
 Incorporate standing orders that apply specifically to adolescents, such as HPV,
Tdap, meningococcal vaccinations.
 Integrate screening reminders into EHRs.
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Adult BMI
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Adult BMI Assessment
measure along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicare and Medicaid patient’s ages 18-74 years
of age who had an outpatient visit and whose BMI was documented during the
measurement year or in the year prior.
Exclusions: Patients who have a diagnosis of pregnancy during the measurement year
or in the year prior.
What Codes Should Providers Use?
BMI less than 5th percentile for age
ICD-10-CM
Codes
Z68.51
BMI 5th percentile to less than 85th percentile for age
Z68.52
BMI 85th percentile to less than 95th percentile for age
Z68.53
BMI greater than or equal to 95th percentile for age
Z68.54
BMI Percentiles for 18-21 Year Olds
What Codes
Should Provide
Adult BMI for
21-74 Year Olds
BMI 19 or less
ICD-10-CM
Codes
Z68.10
Adult BMI for
21-74 Year Olds
BMI 30.0-30.9
ICD-10-CM Adult BMI for
Codes
21-74 Year Olds
Z68.30
BMI 40.0-44.9
ICD-10-CM
Codes
Z68.41
BMI 20.0-20.9
Z68.20
BMI 31.0-31.9
Z68.31
BMI 45.0-49.9
Z68.42
BMI 21.0-21.9
Z68.21
BMI 32.0-32.9
Z68.32
BMI 50.0-59.9
Z69.43
BMI 22.0-22.9
Z68.22
BMI 33.0-33.9
Z68.33
BMI 60.0-69.9
Z68.44
BMI 23.0-23.9
Z68.23
BMI 34.0-34.9
Z68.34
BMI 70 or >
Z68.45
BMI 24.0-24.9
Z68.24
BMI 35.0-35.9
Z68.35
BMI 25.0-25.9
Z68.25
BMI 36.0-36.9
Z68.36
BMI 26.0-26.9
Z68.26
BMI 37.0-37.9
Z68.37
BMI 27.0-27.9
Z68.27
BMI 38.0-38.9
Z68.38
BMI 28.0-28.9
Z68.28
BMI 39.0-39.9
Z68.39
How Can Providers Improve HEDIS® Scores?
 Document and code for BMI at every office visit.
 Weight and Height should be documented at every visit.
 Use BMI percentiles for patients under age 21!
 If using encounter forms for billing, confirm forms have the ICD-10 Z68.10Z68.54 codes for the BMI measure.
 If billing directly from EHR and/or practice management software, confirm the
appropriate BMI coding is configured in the system(s) and that all physicians and
physician extenders know how to access this coding.
 BMI measures are captured by ICD-10 / Z coding. Confirm your billing
mechanism maximizes the number of codes submitted and bill multiple claims if
necessary.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Annual Dental Visit
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Annual Dental Visit along with guidance
and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested in
learning more about how to quality for the 2016 GPE®, please contact Provider Relations
representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the number of Medicaid patients ages 2-20 as of December 31 of the
measurement year who have had at least one dental visit within the year.
What Codes Should Providers Use?
Definition
Annual Dental Visit Codes
HCPCS
D1110, D1120, D0145, D1206
How Can Providers Improve HEDIS® Scores?
 Educate parents/legal guardians on the importance of routine dental care and in finding
a Dental Home for their children for their children. Have a list of area dentists available
for referral and assist in making dental appointments for emergent issues.

Here are two resources on pediatric dental health:
o
On-site training offered by AAP – PA Chapter’s Healthy Teeth Healthy Children
Collaboration. Visit www.healthyteethhealthychildren.org for more information
o
Online training offered by Smiles for Life. Visit www.smilesforlifeoralhealth.org to
access the training. Course 6 – Caries Risk Assessment, Fluoride Varnish, and
Counseling provides information on applying fluoride varnish – a reimbursable
service.
 For offices with staff trained to apply fluoride varnish, remember that patients under age
5 are eligible for the service once per quarter.
 Institute a reminder system in your EHR to alert staff when patients are due for oral
health screenings and fluoride application.
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Annual Monitoring for Patients
on Persistent Medications
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Annual Monitoring for
Patients on Persistent Medications measure along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid and Medicare Assured patients ages 18
and older as of December 31 of the measurement year 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 monitoring event for the therapeutic
agent in the measurement year.
Medications include:
 Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers
(ARB).
 Digoxin
 Diuretics (Antihypertensive combinations, Loop, Potassium-sparing, and thiazide)
Therapeutic monitoring events include one of the following:
 A lab panel test
 A serum potassium test and a serum creatinine test
Note: The tests do not need to occur on the same service date, only within the
measurement year.
Exclusions: those who had an acute inpatient encounter or a non-acute inpatient
encounter during the measurement year.
What Codes Should Providers Use?
Measure or Component
ACE/ARB Therapy (6 mo+)
Digoxin Therapy (6 mo+)
Diuretic Therapy (6 mo+)
HCPCS
G8473-G8475
How Can Providers Improve HEDIS® Scores?
 Patients may switch therapy with any medication during the measurement year
and have the days’ supply for those medications count toward the total 180
treatment days
 Pre-schedule lab tests when prescribing medications
 Document dates of prescription administration accurately and clearly
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Antidepressant Medication Management
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Antidepressant
Medication Management measure along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid and Medicare patients ages 18 years
and older as of April 30 of the measurement year who were prescribed an
antidepressant medication, had a diagnosis of major depression and remained on an
antidepressant medication treatment for at least 84 days in the acute phase of treatment
and for at least 180 days for the continuation phase of treatment.
Exclusions: Patients who did not have a diagnosis of major depression in an inpatient,
outpatient, ED, intensive outpatient, or partial hospitalization setting 60 days before or
after the initial start date of the medication.
Antidepressant Medications
Description
Miscellaneous
antidepressants
Bupropion
Vilazodone
Prescription
Monoamine oxidase
inhibitors
Isocarboxazid
Phenelzine
Selegiline
Tranylcypromine
Phenylpiperazine
antidepressants
Psychotherapeutic
combinations
Nefazodone
Trazodone
SNRI antidepressants
Desvenlafaxine
Duloxetine
Levomilnacipran
Venlafaxine
SSRI antidepressants
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Tetracyclic
antidepressants
Tricyclic antidepressants
Maprotiline
Mirtazapine
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin (>6 mg)
Imipramine
Amitriptyline-chlordiazepoxide
Amitriptyline-perphenazine
Vortioxetine
Fluoxetineolanzapine
Paroxetine
Sertraline
Nortriptyline
Protriptyline
Trimipramine
Note: NCQA posts a comprehensive list of medications and NDC codes to
www.ncqa.org.
How Can Providers Improve HEDIS® Scores?
 Patients who have started taking an antidepressant medication should be
carefully monitored to assess their response to pharmacotherapy as well as the
emergence of side effects, clinical condition and safety. Factors to consider when
determining the frequency of patient monitoring include the severity of illness, the
patient's cooperation with treatment, the availability of social supports and the
presence of comorbid general medical problems. In practice, the frequency of
monitoring during the acute phase of pharmacotherapy can vary from once a
week in routine cases to multiple times per week in more complex cases.
 Reasons behind patient non-adherence to antidepressants include confusion
over dosing, concerns/complaints about side effects as well as lack of sufficient
patient education and follow up
 Patients who were compliant with antidepressant medication for 6 months were
twice as likely to comply with their medical treatment (i.e. diabetes, CAD)
compared with non-adherent patients.
 Educate patients on how to take antidepressant medications. Key messages
include:
o How antidepressants works, their benefits and how long they should be
used
o Length of time patient should expect to be on the antidepressant before
they start to feel better
o Importance of continuing to take the medication even if they begin feeling
better
o Common side effects, how long the side effects may last and how to
manage them
o What to do if they have questions or concerns
 Gateway Health Medicare Assured patients can be referred to the Behavioral
Health Department at Gateway Health. A Behavioral Health Case Manager can
telephonically outreach to the patient to assist them in managing their behavioral
healthcare needs.
Gateway Health Medicare Assured Behavioral Health Case Managers can be reached
Monday- Friday 8am-5pm at:
Pennsylvania
1-866-755-7299
Ohio
1-855-445-4242
Kentucky
1-855-846-9237
North Carolina
1-855-878-4160
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan® will
continue to pay for all applicable services performed and submitted for its membership.
Appropriate Testing for Children with Pharyngitis
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Appropriate Testing for Children with
Pharyngitis measure along with guidance and resources.
What is the Measure?
This measure looks at the percentage of children 2–18 years of age who were diagnosed with
pharyngitis, dispensed an antibiotic and received a Group A streptococcus (strep) test for the
episode during the measurement year. A higher rate represents better performance (i.e.,
appropriate testing).
What Codes Should Providers Use?
Component
Group A streptococcus test
CPT® Category I
87070, 87071, 87081, 87430,
87650-87652, 87880
How Can Providers Improve HEDIS® Scores?
Providers can help improve CWP HEDIS® scores by prescribing antibiotics for group A
streptococcus (strep) pharyngitis only. According to the Agency for Healthcare Research and
Quality AHRQ (AHRQ): Pediatric clinical practice guidelines recommend that only children
diagnosed with group A streptococcus (strep) pharyngitis, based on appropriate lab tests, be
treated with antibiotics. A strep test (rapid assay or throat culture) is the definitive test of group A
strep pharyngitis.
Providers can also:
 Educate patients on which conditions antibiotics will work for, i.e., viral vs. bacterial
infections
 Resource for current guidelines: http://www.cdc.gov/getsmart/community/
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Appropriate Treatment for
Children with Upper Respiratory Infection
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Appropriate Treatment for Children with
Upper Respiratory Infection measure along with guidance and resources.
What is the Measure?
All children age 3 months as of six months prior to the measurement year to 18 years as of six
months into the measurement year who had an outpatient, observation or emergency
department visit during the Intake Period, with only a diagnosis of URI. This measure is reported
as an inverted rate. A higher rate indicates appropriate treatment of children with URI (the
population whom antibiotics were NOT prescribed)
How Can Providers Improve HEDIS® Scores?
Providers can help improve URI HEDIS scores by NOT prescribing antibiotics Upper
Respiratory Infection, or the common cold. Providers can also:
 Educate patients on which conditions antibiotics will work for, i.e., viral vs. bacterial
infections
 Resource for current guidelines: http://www.cdc.gov/getsmart/community/
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Asthma Medication Ratio
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Asthma Medication
Ratio measure along with guidance and resources.
What is the Measure?
This measure looks at the number of members ages 5-85 as of December 31 of the
measurement year, who were identified as having persistent asthma and had a ratio of
controller medications to total asthma medication of 0.50 or greater during the
measurement year.
Note: For Medicaid, report only members 5–64 years of age. For Medicare, report only members 18–85
years of age.
Exclusions: Any patient who had diagnosis of emphysema, COPD, Obstructive Chronic
Bronchitis, Chronic Respiratory Conditions due to Fumes/Vapors, Cystic Fibrosis, Acute
Respiratory Failure.
Asthma Controller and Reliever Medications
Description
Antiasthmatic combinations
Antibody inhibitors
Inhaled steroid combinations
Inhaled corticosteroids
Leukotriene modifiers
Mast cell stabilizers
Methylxanthines
Description
Short-acting, inhaled beta-2
agonists
ASTHMA CONTROLLER MEDICATIONS
Prescriptions
Dyphylline-guaifenesin
Guaifenesin-theophylline
Omalizumab
Budesonide-formoterol
Fluticasone-salmeterol
Beclomethasone
Flunisolide
Budesonide
Fluticasone CFC free
Ciclesonide
Mometasone
Montelukast
Zafirlukast
Cromolyn
Aminophylline
Dyphylline
ASTHMA RELIEVER MEDICATIONS
Albuterol
Prescriptions
Levalbuterol
Mometasone-formoterol
Zileuton
Theophylline
Pirbuterol
Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org.
How Can Providers Improve HEDIS® Scores?
 Assess compliance by performing a comprehensive medication reconciliation
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Avoidance of Antibiotic
Treatment in Adults with Acute Bronchitis
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Avoidance of Antibiotic
Treatment with Bronchitis along with guidance and resources.
What is the Measure?
This measure looks at the number of members ages 18 – 64 years of age as of
December 31 of the measurement year who were diagnosed with acute bronchitis and
not dispensed an antibiotic prescription.
Exclusions: Members with a claim with diagnosis for HIV, Malignant Neoplasms,
Emphysema, COPD, Cystic Fibrosis and co-morbid conditions.
How Can Providers Improve HEDIS® Scores?
Providers can help improve HEDIS® scores by NOT prescribing antibiotics for acute bronchitis
Providers can also:
 Educate patients on which conditions antibiotics will work for, i.e., viral vs. bacterial
infections
 Resource for current guideline: http://www.cdc.gov/getsmart/community/
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Breast Cancer Screening
Gateway Health Plan® wants to help you improve your quality scores on
HEDIS® measures. This resource guideline details the key aspects of the Breast Cancer
Screening along with guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested in
learning more about how to quality for the 2016 GPE®, please contact Provider Relations
representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the percentage of female Medicaid and Medicare patients ages 50-74 by
December 31 of the measurement year, who had a mammogram anytime between October 1
two years prior to the measurement year and December 31 of the measurement year.
Exclusions: Women with two unilateral mastectomies or a bilateral mastectomy at any time in
the patient’s history prior to the end of the measurement year.
What Codes Should Providers Use?
Definition
ICD-10-CM
Codes
HCPCS
77055, 77056, or
77057
Mammography
Breast Xerography
Mammography NEC
Screening Mammography,
bilateral
Diagnostic Mammography,
bilateral
Diagnostic Mammography,
unilateral
Note: add bilateral mastectomy
code
CPT® Category I
G0202
Z12.31, Z12.39
G0204
G0206
How Can Providers Improve HEDIS® Scores?
 Document and code exclusions
 Implement EHR alerts to create a system of reminders for routine preventive health
services
 Assist patients in making an appointment for a mammogram
 Resource for current guidelines:
http://www.uspreventiveservicestaskforce.org/BrowseRec/Index
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan® will
continue to pay for all applicable services performed and submitted for its membership.
Care of Older Adults
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Care of Older Adults
measure along with guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested
in learning more about how to quality for the 2016 GPE®, please contact Provider
Relations representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the number of Medicare Assured patient’s ages 66 years and
older as of December 31 of the measurement year who had the following elements
during the year:
 Comprehensive Functional Status Assessment
 Pain Assessment
 Medication Review – presence of a medication list in the medical record and at
least one medication review conducted by a prescribing practitioner or clinical
pharmacist
 Advanced care planning – notation in medical record of discussion, previously
executed or presence of an advanced care plan. While not part of the GPE®
incentive program, Advanced Directive/ Care Planning is part of the COA
measure. Evidence of Advanced Care Planning can be represented using code:
S0257
What Codes Should Providers Use?
Care of Older Adult Component
CPT® Category II
Functional Status Assessment
1170F
Pain Assessment
1125F, 1126F, 0521F
Medication Review
1159F (list) 1160F
(review)
G8427 (list)
Advanced Care Planning
1157F, 1158F
S0257
HCPCS
** Please note the Annual Wellness Visit codes (G0438, G0439) do not replace the above
codes.
How Can Providers Improve HEDIS® Scores?
Below are a few common HEDIS® billing fail points along with tips on how to accurately
complete your submission.
 Providers may conduct these assessments at any billable office visit throughout
the year. These assessments are not limited to Annual Wellness Visits.
 If using encounter forms for billing, make sure forms have CPT II codes for Care
of Older Adults (COA) measures.
 If billing directly from EHR and/or practice management software, please make
sure the appropriate COA coding is configured in the system(s) and that all
physicians and physician extenders know how to access this coding.
 If billing is done externally, communication with billing companies is the key to
ensure their systems are billing the CPT II codes appropriately.
 If billing electronically, billers and billing companies should pay special attention
to claims with HEDIS® coding, verifying the submissions are being accepted.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Cervical Cancer Screening
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Cervical Cancer Screening along with
guidance and resources.
What is the Measure?
This measure looks at the number of female Medicaid patients’ ages 21-64 years as of
December 31 of the measurement year who meet one of the following criteria:
 All women 24-64 years old - Cervical cytology in the measurement year or the two years
prior
 Women 30-64 years old – Cervical cytology and HPV test, 4 or less days apart, in the
measurement year or the four years prior where the woman was at least 30 years old or
older on the date of both tests.
Exclusions: a history of cervical agenesis, hysterectomy, or other acquired absence of cervix.
What Codes Should Providers Use?
Definition
ICD-10- CM
Cervical Cytology
Z12.4
HPV Testing
CPT® Category I
HCPCS
88141-88143, 88147, 88148,
88150, 88152-88154, 8816488167, 88174, 88175
G0123, G0124, G0141, G0143,
G0144, G0145, G0147, G0148,
P3000, P3001, Q0091
87620, 87621, 87622
How Can Providers Improve HEDIS® Scores?
 Implement EHR alert to create a system of reminders for routine preventive health
services that will help them remain up to date on testing.
 Assist patients in making an appointment for cervical cytology.
 Resource for current guidelines:
http://www.uspreventiveservicestaskforce.org/BrowseRec/Index
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Childhood Immunization Status
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Childhood
Immunization Status measure along with guidance and resources.
What is the Measure?
This measure looks at the percentage of children 2 years of age who had four
diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles,
mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B
(HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A
(HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second
birthday.
What Codes Should Providers Use?
Use applicable vaccination code or diagnosis indicating history of disease.
Immunization
ICD-10-CM
Codes
DTaP
Z23
IPV
Z23
MMR
Z23
Measles & Rubella
Z23
Measles
Z23
Mumps
Z23
Rubella
Z23
Z23
Hib
Hepatitis B
Z23
VZV
Z23
Pneumococcal Conjugate
Z23
Hepatitis A
Z23
Rotavirus (2 dose)
Z23
Rotavirus (3 dose)
Z23
Influenza
Z23
CPT® Category I
90698, 90700, 90721, 90723
90698, 90713, 90723
90707,90710
90708
90705
90704
90706
90645-90648, 90698, 90721,
90748
90723, 90740, 90744, 90747,
90748
90710, 90716
90669, 90670
90633
90681
90680
90655, 90657, 90661, 90662,
90673, 90685
HCPCS
G0010
G0009
G0008
How Can Providers Improve HEDIS® Scores?
 Document all seropositives and illness history of chicken pox, measles, mumps,
and rubella.
 Document the first HepB vaccine given at the hospital or at birth when applicable,
or–if unavailable–name of hospital where child was born.
 Document any parent refusal for immunizations, as well as anaphylactic
reactions.
 Provide parents/guardians with records of their child’s immunizations and ask
them to bring the record to each visit.
 Resource: http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Chlamydia Screening
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of Chlamydia Screening
measure along with guidance and resources.
What is the Measure?
Female patients 16-24 years of age as of the last day of the measurement year
identified as sexually active and who had at least one test for chlamydia by December
31 of the measurement year.
Exclusions: a pregnancy test during the measurement year that is followed within seven
days by a prescription for isotretinoin or an X-Ray.
What Codes Should Providers Use?
Definition
ICD-10-CM Codes
CPT® Category I
Chlamydia Test
Z11.3
87110, 87270, 87320,
87490-87492, 87810
How Can Providers Improve HEDIS® Scores?
 Implement EHR alert that serves as a reminder for chlamydia screening for all
sexually active women in the appropriate age group.
 Consider chlamydia screening easier for women by using a urine specimen for
testing rather than a vaginal swab.
 Educate sexually active women on the importance of being tested for STIs,
including chlamydia, even if they are not showing symptoms because they are
still transmissible and may cause future complications.
 Resource for current guidelines:
http://www.uspreventiveservicestaskforce.org/BrowseRec/Index
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Colorectal Cancer Screening
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Cervical Cancer
Screening along with guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested
in learning more about how to quality for the 2016 GPE®, please contact Provider
Relations representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the number of Medicare Assured patient’s ages 50-75 years as
of December 31 of the measurement year who had one of the following:
 Colonoscopy in the past 10 years
 Sigmoidoscopy in the past 5 years
 Completion of Fecal Occult Blood Testing (FOBT) within the past year
o FOBT kits conducted in an office setting or using a sample collected via
digital rectal exam do not meet HEDIS® specifications
Exclusions: history of colorectal cancer or a total colectomy.
What Codes Should Providers Use?
Definition
ICD-10-CM
Codes
Colonoscopy
Flexible
Sigmoidoscopy
FOBT
Z12.11
CPT® Category I
HCPCS
44388, 44389, 44390, 44391, 44392, 44393,
44394, 44397, 45355, 45378, 45379, 45380,
45381, 45382, 45383, 45384, 45385, 45386,
45387, 45391, 45392
G0105,
G0121
45330, 45331, 45332, 45333, 45334, 45335,
45337, 45338, 45339, 45340, 45341, 45342, 45345
G0104
82270, 82274
G0328
How Can Providers Improve HEDIS® Scores?
 Implement EHR alerts to create a system of reminders for routine preventive
health services.
 Educate patients on the risks vs. benefits of screening for preventing colorectal
cancer death, including the possibility of a false positive and what one means.
 Assist patients in making an appointment for a colonoscopy by recommending
specific practices for referral.
 Explain the colonoscopy procedure to comfort patients and to promote this test
as a thorough screening tool that is only required every ten years if no issues are
found.
 Provide patients with a guaiac FOBT or immunochemical FOBT kit that can be
done at home; FOBT tests performed in an office setting or from a sample
collected by a digital rectal exam are not appropriate for screening.
 Resource for current guidelines:
http://www.uspreventiveservicestaskforce.org/BrowseRec/Index
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Comprehensive Diabetes Care
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Comprehensive
Diabetes Care HEDIS® measure and the codes associated with the measure; as well
as guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested
in learning more about how to quality for the 2016 GPE®, please contact Provider
Relations representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at members 18 to 75 years of age as of December 31, 2015 who
received care for diabetes (type 1 and type 2) and had each of the following:
hemoglobin A1C testing, blood pressure reading, retinal eye examination, and
nephropathy screening.
Exclusions: gestational or steroid-induced diabetes, polycystic disease, pregnancy, and
end stage renal disease (ESRD).
What Codes Should Providers Use?
Measure or
Component
A1c test & A1c
level
ICD- 10 Codes
R73.09,
E10.36E10.44,
E11.41E11.44,
E11.49
CPT® Category I
83036,83037
CPT® Category II
3044F HbA1c <7
3045F HbA1c 7.0-9.0
3046F HbA1c >9
Retinal Eye
Examination
*A negative retinal or
dilated eye examination
in the prior year counts
towards this measure.
2022F,2024F, 2026F,3072F
Measure or
Component
ICD- 10 Codes
CPT® Category I
I10 (Essential
Hypertension)
CPT® Category II
3074F- systolic <130
3075F-systolic 130-139
3077F- systolic ≥ 140
Blood Pressure
Control
(<140/90mm Hg)
3078F –diastolic < 80
3079F – diastolic 80-89
3080F – diastolic ≥ 90
Nephropathy
screening
(Any nephrologists’ visit
identified by specialty
code may also be valid
for this numerator)
E08.41,
E08.610,
E 10.-610,
E 10.21, E11E11.6,E11.21,
E11.9,
E 11.21,
E11.40-E11.43,
E 13.21,
E13.40-E13.43
3060F,3061F, 3062F,3066F,
4010F
How Can Providers Improve HEDIS® Scores?
 Discuss current medications and explore any difficulties in obtaining or
administering their medications. Encourage members to keep a medication list.
 Educate members about noncompliance and the consequences (i.e. heart
attack and stroke). Follow-up abnormal values with repeat testing, appropriate
referrals, and treatment modalities
 Evaluate current software systems to identify any gaps in clinical conditions or
workflow processes.
 Consider ACE therapy to prevent nephropathy
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Controlling Blood Pressure
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Controlling Blood Pressure measure and
the codes associated with the measure as well as, guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested in
learning more about how to quality for the 2016 GPE®, please contact Provider Relations
representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
The measure looks at the number of member’s ages 18 to 85 as of December 31, 2015 who
had a diagnosis of hypertension and whose blood pressure (BP) was controlled (less than
140/90 mm Hg) during the measurement year.
Exclusions: end stage renal disease (ESRD), dialysis, kidney transplant, and pregnancy.
What Codes Should Providers Use?
Measure or
Component
Hypertension/Blood
Pressure
ICD-10
Codes
I10 (Essential
Hypertension)
CPT®
Category II
CPT®
Category I
HCPCS
99201, 99202,
99203, 99204,
G0402, G0438,
99205, 99211,
G0439
99212, 99213,
99214, 99215
3074F
3075F,
3077F
3078F ,
Diastolic blood
3079F,
pressure
3080F
Note: If there are multiple readings on the same date of service, use the lowest systolic and
diastolic pressure readings.
Systolic blood
pressure-
How Can Providers Improve HEDIS® Scores?
 Evaluate current software systems to identify any potential gaps in clinical conditions or
workflow processes
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Disease-Modifying
Anti-Rheumatic Drug Therapy for
Rheumatoid Arthritis (DMARD/ART)
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the 2016 GPE® profiled
measure Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
(DMARD) along with guidance and resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested
in learning more about how to quality for the 2016 GPE®, please contact Provider
Relations representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the number of Medicare or Medicaid patients age 18 years or
older as of December 31 of the measurement year who were diagnosed with
rheumatoid arthritis and where dispensed at least one ambulatory prescription for a
disease-modifying anti-rheumatic drug (DMARD).
Exclusions: Diagnosis of HIV (042, V08) at any time during patients’ history or
pregnancy (630-679, V22, V23, V28) at any time during the measurement year.
DMARDs
Description
Prescription
5-Aminosalicylates
Sulfasalazine
Alkylating agents
Cyclophosphamide
Aminoquinolines
Hydroxychloroquine
Anti-rheumatics
Auranofin
Gold sodium
thiomalate
Leflunomide
Methotrexate
Penicillamine
Immunomodulators
Abatacept
Adalimumab
Anakinra
Certolizumab
Certolizumab
pegol
Etanercept
Golimumab
Infliximab
Rituximab
Tocilizumab
Immunosuppressive
agents
Janus kinase (JAK)
inhibitor
Tetracyclines
Azathioprine
Cyclosporine
Mycophenolate
Tofacitinib
Minocycline
How Can Providers Improve HEDIS® Scores?
Providers can help improve HEDIS® scores by implementing the following practices.
 Members must have a record of 2 visits with any diagnosis of rheumatoid arthritis
(714.0-714.2, 714.81). The visits must be on 2 different dates of service and the
service dates must fall between January 1 and November 30 of the
measurement year. Visits can be either outpatient or inpatient discharge.
 Carefully review all codes before submitting claims and use the correct diagnosis
codes for RA once a definite diagnosis is confirmed.
 Prescribe DMARDS to your patients diagnosed with RA.
 Properly document exclusions in the medical record.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Flu Vaccinations in Adults
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Flu Vaccinations in
Adults along with guidance and resources.
What is the Measure?
This measure addresses the Medicaid members 18-64 and the Medicare members 65
and older who received an influenza vaccination. Gateway collects this information via
survey methodology not via claims.
The question posed to the member is:
 For ages 18-64 “Have you had either a flu shot or flu spray in the nose since July
1, 2015?”
 For ages 65 and older “Have you had a flu shot since July 1, 2015?”
How Can Providers Improve HEDIS® Scores?
 Accurately document vaccination status
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Follow-Up Care for Children Prescribed
ADHD Medication
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Follow-Up Care for
Children Prescribed ADHD Medication (ADD) measure along with guidance and
resources.
What is the Measure?
This measure looks at the percentage of children newly prescribed attentiondeficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care
visits within a 10-month period, one of which was within 30 days of when the first ADHD
medication was dispensed.
Two rates are reported:
 Initiation
Phase: The percentage of patients 6–12 years of age as of the
prescription start date with an ambulatory prescription dispensed for ADHD
medication, who had one follow-up visit with practitioner with prescribing
authority during the 30-day Initiation Phase.
 Continuation
and Maintenance (C&M) Phase: The percentage of patients 6–12
years of age as of the prescription start date with an ambulatory prescription
dispensed for ADHD medication, who remained on the medication for at least
210 days and who, in addition to the visit in the Initiation Phase, had at least
two follow-up visits with a practitioner within 270 days (9 months) after the
Initiation Phase ended.
ADHD Medications
Description
Prescription
Amphetaminedextroamphetamine, Dexmethylphenidate,
Dextroamphetamine,
CNS Stimulants
Lisdexamfetamine,
Methamphetamine,
Methylphenidate
Alpha-2 receptor
agonists
Miscellaneous
ADHD medications
Clonidine, Guanfacine
Atomoxetine
How Can Providers Improve HEDIS® Scores?
 Educate parent/guardian that their child must be seen within 30 days of starting
to make sure the medication is working and to assess any adverse side-effects.
 Discuss the importance of follow-up appointments with the parent/guardian and
explain that their child must have at least two follow-up appointments with a
medical provider or a behavioral health provider in the 9 months after the initial
30 days.
What Codes Should Providers Use?
Component
HCPCS
Stand Alone ADD Visit
(applies to initiation and
continuation phases)
G0155, G0176, G0177,
G0409G0411, G0463, H0002,
H0004, H0031, H0034-H0037,
H0039, H0040, H2000, H2001,
H2010-H2020, M0064, S0201,
S9480, S9484, S9485
Component
POS
CPT® Category I
90804-90815, 96150-96154,
98960-98962, 99078, 9920199205, 99211-99215, 9921799220, 99241-99245, 9934199345, 99347-99350, 9938199384, 99391-99394, 9940199404, 99411, 99412, 99510
CPT® Category I
School
03
Indian Health Service FreeStanding
05
Tribal 638 Free Standing
07
Prison/Correctional Facility
09
Office
11
Home
12
ADD Visit with Point of
Service (POS) Code
Assisted Living Facility
13
Group Home
14
 These CPT codes
Mobile Unit
15
Urgent Care Facility
20
Outpatient Hospital
22
Custodial Care Facility
33
Independent Clinic
49
Federally Qualified Health Center
50
Public Health Clinic
71
Rural Health Clinic
72
Psychiatric-Partial Hospitalization
52
Community Mental Health Center
53
must be submitted with
a POS code.
90791, 90792, 90801,
90802, 90816-90819,
90821-90824, 90826,
90829, 90832-90834,
90836-90840, 90845,
90847, 90849, 90853,
90857, 90862, 90875
For POS 52 and 53, you
can also use - 9922199223, 99231-99233,
99238, 99239, 9925199255
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Human Papillomavirus Vaccine (HPV) for
Female Adolescents
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Human Papilloma
Virus Vaccine for Female Adolescents measure along with guidance and resources.
What is the Measure?
This measure looks at the percentage of female adolescents 13 years of age during the
measurement period, who had three doses of the human papillomavirus (HPV) vaccine
by their 13th birthday.
Exclusions: Female patients with evidence of anaphylactic reaction to the vaccine or its
components any time on or before the patients 13th birthday.
What Codes Should Providers Use?
Component
ICD-10-CM
CPT® Category I
HPV Vaccine
Z23
90649, 90650 90651
Anaphylactic reaction (for exclusions)
T80.5
How Can Providers Improve HEDIS® Scores?
 The CDC recommends promoting the HPV vaccine as a routine vaccine for
adolescents. Incorporate the HPV vaccine as part of the standard vaccine set for
ages 11 and 12.
 Accurate documentation of all three HPV immunizations in the series.
 Document parental refusals and patient contraindications/allergies (see
anaphylactic coding noted above).
 If patient’s received vaccinations elsewhere, document where the patient
received these immunizations, i.e., health department. If possible, include a copy
of the patient’s immunizations record from the health department.
 HPV vaccines administered prior to a patient’s 9th birthday or after the 13th
birthday cannot be counted.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Immunizations for Adolescents
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Immunizations for Adolescents measure
along with guidance and resources.
What is the Measure?
This measure looks at the percentage of adolescents 13 years of age during the measurement
year, who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and
acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th
birthday.
Exclusions: evidence of anaphylactic reaction to the vaccine or its components any time on or
before the patients 13th birthday.
What Codes Should Providers Use?
Component
CPT® Category I
ICD-10-CM
Meningococcal Vaccine
Tdap
Td
Tetanus
Anaphylactic reaction (for exclusions)
90733, 90734
Z23
90715
Z23
90714, 90718
Z23
90703
Z23
T80.5
How Can Providers Improve HEDIS® Scores?
 Children/Adolescents must receive one dose of the meningococcal vaccine on or
between their 11th and 13th birthdays.
 Children/Adolescents must receive one dose of the Tdap/TD vaccine on or between their
10th and 13th birthdays.
 Document parental refusals and patient contraindications/allergies (see anaphylactic
coding noted above).
 If patient’s received vaccinations elsewhere, document where the patient received these
immunizations, i.e., health department. If possible, include a copy of the health
department record.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
MATERNITY
Gateway Health Plan® wants to help you maximize your bonus dollars and improve
HEDIS® rates. This resource guideline details the key aspects of Prenatal and
Postpartum Care along with specific bonus criteria.
What is the Measure?
Information in this sheet applies to Medicaid female patients who are continuously
enrolled and deliver a live birth. The 3 areas of focus are:
 Timeliness of Prenatal Care: intake visit in the first trimester or within 42 days of
enrollment with Gateway
 Frequency of Ongoing Prenatal Care: may vary due to risk factors - > 81% of
expected visits
 Postpartum Care: visit within 21-56 days after the delivery date.
Suggested Maternity Codes
This is not an all-inclusive list. Refer to the Provider Manual and coding tip sheet for
further details. *ICD-10 codes now allow specific detail regarding prenatal and postpartum
care. (see back)
Description
Prenatal Codes
CPT Code Category I
ICD 10 Codes
99201-99205, 99211-99215
*Z34.01-Z34.03
Postpartum Codes
*Z39.1, Z39.2
Include dates of service on HCFA 1500 form and identify with valid E & M codes with U9 pricing
modifier in the first position on the claim form. Include pregnancy diagnosis codes as applicable.
How Can Providers Improve HEDIS® Scores
 Provide an appointment in the first trimester whenever possible.
 Return the ONAF form to Gateway in a timely fashion so our Maternity Team can
make appointment reminder calls and arrange transportation
 Encourage regular visits during pregnancy.
 Provide members with directions on how to access after hour care if available
 Reinforce the importance of a postpartum visit 21-56 after delivery

Remind patients that they qualify for an incentive if they have a first trimester visit
and keep all appointments during their pregnancy
2 Provider Incentives are now Available! (paid in addition to fee for service)
Your practice can receive $200 for completing a prenatal visit in the first trimester.
1. Submit the following on the same claim: procedure codes 99429-HD and T1001-U9
within 180 days of intake visit. Include E & M code, modifier and pregnancy diagnosis
codes for office visit.
2. Fax a complete 2015 OBNAF form within 2 to 5 days of the intake visit.
3. Fax to 412-255-5639 or 1-888-225-2360.
Late, incomplete or outdated OBNAFS will jeopardize incentive payment
Additional bonus dollars are available for perinatal care so visit the Gateway to Provider
Excellence (GPE® ) section of the Gateway website for details.
Resources
The Maternity Team is available for questions at 800-642-3550 #2
To navigate to the Provider Manual:
www.gatewayhealthplan.com > Providers > Provider Manual > Medical Assistance
Provider Manual > OB/GYN Services
To navigate to the GPE® Program:
www.gatewayhealthplan.com > Providers > Gateway to Practitioner Excellence®
*ICD-10 Prenatal Code Examples
Z34.01 Encounter for supervision of normal pregnancy,
first trimester (less than 14 weeks 0 days)
Z34.02 Encounter for supervision of normal pregnancy,
second trimester (14 weeks 0 days through less than 28 weeks 0 days)
Z34.03 Encounter for supervision of normal pregnancy,
third trimester (28 weeks until delivery)
ICD-10 Postpartum Code Examples
Z39.1 Encounter for care and examination of lactating mother
Z39.2 Encounter for routine postpartum follow-up
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Medical Assistance with
Smoking and Tobacco Use
Cessation (MSC) Advising
Smokers to Quit
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Medical Assistance
with Smoking and Tobacco Use Cessation – Advising Smokers to Quit HEDIS® CAHPS
Survey Measure along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid and Medicare Assured member’s ages
18 years and older who smoke or use tobacco products.
The three areas of focus are:
 Advising smokers and tobacco users to quit
 Discussing cessation medications
 Discussing cessation strategies
How Can Providers Improve HEDIS® Scores?
 Assess and document patients smoking/tobacco status (including e-cigarettes
and vaping) in EHR
 Document advise, strategies (telephone helpline, counseling programs) and/or
including any cessation medications recommended ( gum, patch, nasal spray,
inhaler or prescription medication) in EHR as well as patient summary
 Resources:
http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/compr
ehensive.pdf
http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullreport.pdf
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan® will
continue to pay for all applicable services performed and submitted for its membership.
Medication Management for
People with Asthma
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Medication Management for People with
Asthma along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid patients ages 5-64 as of December 31 of the
measurement year who were identified as having persistent asthma and were dispensed
appropriate medications then remained on an asthma controller medication for at least 75% of
their treatment period.
Exclusions: Those who had any diagnosis from any of the following any time during the patient’s
history through December 31 of the measurement year: Emphysema, COPD, Obstructive
Chronic Bronchitis, Chronic Respiratory Conditions Due to Fumes/Vapors, Cystic Fibrosis,
Acute Respiratory Failure. Patients who had no asthma controller medication dispensed during
the measurement year are also excluded.
What Codes Should Providers Use?
Measure or Component
Medication specific codes will be collected via Pharmacy claims
How Can Providers Improve HEDIS® Scores?
 Persistent asthma is identified by at least one of the following:
o
At least one ED visit with a principal diagnosis of asthma.
o
At least one acute inpatient encounter with a principal diagnosis of asthma.
o
At least four outpatient visits or observation visits on different dates of service,
with any diagnosis of asthma and at least two asthma medication dispensing
events. Visit type need not be the same for the four visits.
o
At least four asthma medication dispensing events.
 Assess compliance with medication reconciliations at each visit. Educate on proper use.
 Document the dates in which prescriptions are first prescribed and then refilled.
 Dosing frequency impacts compliance; delayed-released technology that decreases
frequency of dosing has been shown to enhance compliance.
 Educate patients on how to administer their medication in an emergency asthmatic
situation
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Osteoporosis Management in Women Who
Had a Fracture
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Osteoporosis
Management in Women Who Had a Fracture measure along with guidance and
resources.
Note: This is a 2016 GPE® Program for those qualifying practices. If you are interested
in learning more about how to quality for the 2016 GPE®, please contact Provider
Relations representative or visit us at www.gatewayhealthplan.com.
What is the Measure?
This measure looks at the number of female Medicare patients ages 67-85 as of
December 31 of the measurement year who suffered a fracture and who had either a
bone mineral density (BMD) test or a prescription for a drug to treat osteoporosis in the
six months after the fracture.
Exclusions:
 Patients with a pathological fracture or fracture of a finger, toe, face, or skull
 Patients who had a BMD test in the 24 months preceding the fracture
 Patients who had a claim/encounter for osteoporosis therapy or a pharmacy
claim for an approved prescription to treat osteoporosis in the 12 months
preceding the fracture
What Codes Should Providers Use?
Osteoporosis Testing &
Treatment Codes
Bone Mineral Density Test
Osteoporosis Therapy
CPT®
Category I
76977, 77078,
77080, 77081,
77082
HCPCS
G0130
J0630, J0897, J1740, J3110, J3487,
J3488, J3489
How Can Providers Improve HEDIS® Scores?
 Ask all female patients aged 67-85 years whether they’ve had a fracture since
their last office.
 Adopt a standard order for bone mineral density testing for those patients who
meet the measure criteria.
 If treating with an oral medication, please keep in mind that only the following are
considered approved medications:
Description
Prescription
Bisphosphonates
 Alendronate
 Alendronate-cholecalciferol
 Calcium carbonate-risedronate
Other agents
 Calcitonin
 Denosumab
 Ibandronate
 Risedronate
 Zoledronic acid
 Raloxifene
 Teriparatide
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Persistence of Beta-Blocker
Treatment After a Heart Attack
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Persistence of BetaBlocker Treatment After a Heart Attack measure along with guidance and resources.
What is the Measure?
The percentage of members 18 years of age and older during the measurement year
who were hospitalized and discharged from July 1 of the year prior to the measurement
year to June 30 of the measurement year with a diagnosis of AMI and who received
persistent beta-blocker treatment for six months after discharge.
Exclusions: Members identified as having an intolerance or allergy to beta-blocker
therapy. Any member with a diagnosis of asthma, COPD, obstructive chronic bronchitis,
chronic respiratory conditions due to fumes or vapors, hypotension, heart block >1
degree or sinus bradycardia.
What Codes Should Providers Use?
Description
Noncardioselective betablockers
Cardioselective beta-blockers
Antihypertensive combinations
Carvedilol
Penbutolol
Labetalol
Pindolol
Nadolol
Propranolol
Acebutolol
Betaxolol
Atenolol
Bisoprolol
Atenolol-chlorthalidone
Bendroflumethiazide-nadolol
Bisoprolol-hydrochlorothiazide
Prescription
Timolol
Sotalol
Metoprolol
Nebivolol
Hydrochlorothiazide-metoprolol
Hydrochlorothiazide-propranolol
Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org
How Can Providers Improve HEDIS® Scores?
 Assess compliance by performing a comprehensive medication reconciliation
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan® will
continue to pay for all applicable services performed and submitted for its membership.
Pharmacotherapy Management of COPD
Exacerbation
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Pharmacotherapy
Management of COPD Exacerbation HEDIS® CAHPS Survey measure along with
guidance and resources.
What is the Measure?
This measure looks at the percentage of COPD exacerbations for members 40 years of
age and older who had an acute inpatient discharge or ED visit on or between January
1 – November 30 of the measurement year and who were dispensed appropriate
medications.


Dispensed a systemic corticosteroid (or there was evidence of an active
prescription) within 14 days of the event
Dispensed a bronchodilator (or there was evidence of an active prescription)
within 30 days of the event.
Exclusions: When members are readmitted to an acute or non-acute inpatient setting for
any diagnosis within 14 days of discharge or ED as outlined above or had an ED visit
within 14 days of discharge or the original ED visit as outlined above.
Systemic Corticosteroids
Description
Glucocorticoids
Betamethasone
Dexamethasone
Prescription
Hydrocortisone
Prednisolone
Methylprednisolone
Prednisone
Triamcinolone
Bronchodilators
Description
Anticholinergic agents
Beta 2-agonists
Methylxanthines
Albuterol-ipratropium
Aclidinium-bromide
Albuterol
Arformoterol
Budesonide-formoterol
Fluticasone-salmeterol
Fluticasone-vilanterol
Aminophylline
Dyphylline-guaifenesin
Guaifenesin-theophylline
Prescription
Ipratropium
Tiotropium
Formoterol
Indacaterol
Levalbuterol
Mometasone-formoterol
Metaproterenol
Dyphylline
Theophylline
Umeclidinium
Olodaterol hydrochloride
Pirbuterol
Salmeterol
Umeclidinium-vilanterol
Note: NCQA posts comprehensive lists of medications and NDC codes to www.ncqa.org.
How Can Providers Improve HEDIS® Scores?
 Assess compliance by performing a comprehensive medication compliance
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities.
They are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been
made to assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the
provider of the services. The measure descriptions and codes in this document are derived from the 2016 HEDIS®
Volume 1 Technical Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements
Technical Specifications manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will
continue to pay for all applicable services performed and submitted for its membership.
Plan All-Cause Readmission
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Plan All-Cause
Readmission measure along with guidance and resources.
What is the Measure?
This measure looks at patients Medicare Assured patients 18 years of age and older,
the number of acute inpatient stays during the measurement year that were followed by
an unplanned acute readmission for any diagnosis within 30 days.
What Codes Should Providers Use?
No coding is looked at for this measure. The only way to remain compliant with this
measure is if the patient does not have a readmission within 30 days of a discharge
date.
Exclusions:
 Hospital stays where the Index Admission Date is the same as the Index
Discharge Date.
 Inpatient stays with discharges for death.
 Acute inpatient discharges with a principal diagnosis of pregnancy or condition
originating in the perinatal period.
 Acute inpatient discharges as an IHS if the admission date of the first planned
hospital stay is within 30 days and includes any of the following: principal
diagnosis of maintenance chemotherapy, rehabilitation, organ transplant or
potential planned procedure without a principal acute diagnosis.
How Can Providers Improve HEDIS® Scores?
Providers can help improve STARS/HEDIS scores in this measure by applying Best
Practice interventions into the office process which can include:
 Monitoring admission, discharge and emergency department visit reports
 Contacting patients to schedule follow-up appointments within 2-7 days of
hospital discharge
 Transmission of hospital records (d/c instructions) to practice by fax or EMR
 Conduct Medication Reconciliation
 Provide Home Care Referrals
 Onsite Care Coordinator/Care Coordination
 Health Plan Care Management Referral
o PA Medicare 1-800-685-5212
o PA Medicaid 1-800-642-3550
 Ensure that ALL diagnosis codes that are being monitored, evaluated, assessed
and treated are reported on claims. ( CPT,HCPCS,CPT II,ICD-10)
 Continuously monitor utilization activity and institute appropriate intervention.
 Evaluate patients’ compliance with treatment plan of care from specialty providers such
as Behavior Health, Endocrinology, Nephrology, Cardiology, Pulmonology etc.
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Pneumococcal Vaccination Status for
Older Adults
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Pneumococcal
Vaccination Status for Older Adults along with guidance and resources.
What is the Measure?
This measure addresses the Medicare members 65 and older who have ever received a
pneumococcal vaccination. Gateway collects this information via survey methodology
not via claims.
The question posed to the member is: “Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a person’s lifetime and is different from a flu
shot. It is also called the pneumococcal vaccine.”
How Can Providers Improve HEDIS® Scores?
 Accurately document vaccination status
This document was prepared as a tool to assist practices by providing a sample of potential coding
opportunities. They are examples only and not to be considered an all-inclusive listing. Although every
reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for correct
submission of claims is the provider of the services. The measure descriptions and codes in this document are
derived from the 2016 HEDIS® Volume 1 Technical Specifications/Value Set Directory, and the Quality
Assurance Reporting Requirements Technical Specifications manual. Please provide to your office personnel as
appropriate. Gateway Health Plan® will continue to pay for all applicable services performed and submitted for
its membership.
Potentially Harmful Drug-Disease
Interactions in the Elderly
Gateway Health Plan® wants to help you improve your quality scores on HEDIS®
measures. This resource guideline details the key aspects of the Potentially Harmful
Drug-Disease Interactions in the Elderly along with guidance and resources.
What is the Measure?
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.
Rate 1: Drug-Disease Interactions—History of Falls and Anticonvulsants,
Nonbenzodiazepine Hypnotics, SSRIs, Antiemetics, Antipsychotics,
Benzodiazepines or Tricyclic Antidepressants
Description
Anticonvulsants
Nonbenzodiazepine
hypnotics
SSRIs








Carbamazepine
Clobazam
Divalproex sodium
Ethosuximide
Ethotoin
Ezogabine
Felbamate
Eszopiclone
 Citalopram
 Escitalopram








Fosphenytoin
Gabapentin
Lacosamide
Lamotrigine
Levetiracetam
Mephobarbital
Methsuximide
Zaleplon
 Fluoxetine
 Fluvoxamine
Prescription
 Oxcarbazepine
 Phenobarbital
 Phenytoin
 Pregabalin
 Primidone
 Rufinamide
 Tiagabine HCL
 Zolpidem





Topiramate
Valproate sodium
Valproic acid
Vigabatrin
Zonisamide
 Paroxetine
 Sertraline
Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org.
Description
Prescription
Antiemetics
 Prochlorperazine
 Promethazine
Antipsychotics
 Aripiprazole
 Iloperidone
 Perphenazine
 Trifluoperazine
 Asenapine
 Loxapine
 Pimozide
 Ziprasidone
 Chlorpromazine
 Lurasidone
 Quetiapine
 Clozapine
 Molindone
 Risperidone
 Fluphenazine
 Olanzapine
 Thioridazine
 Haloperidol
 Paliperidone
 Thiothixene
Benzodiazepines
 Alprazolam
 Diazepam
 Oxazepam
 Chlordiazepoxide
 Estazolam
 Quazepam
products
 Flurazepam HCL
 Temazepam
 Clonazepam
 Lorazepam
 Triazolam
 Clorazepate Midazolam HCL
Dipotassium
Tricyclic antidepressants  Amitriptyline
 Desipramine
 Nortriptyline
 Amoxapine
 Doxepin (>6 mg)
 Protriptyline
 Clomipramine
 Imipramine
 Trimipramine
Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org.
Rate 2: Drug-Disease Interactions—Dementia and Antiemetics, Antipsychotics,
Benzodiazepines, Tricyclic Antidepressants, H2 Receptor Antagonists,
Nonbenzodiazepine Hypnotics or Anticholinergic Agents
Description
H2 receptor antagonists
Nonbenzodiazepine hypnotics
Anticholinergic agents,
antihistamines
Anticholinergic agents,
antispasmodics
Anticholinergic agents,
antimuscarinics (oral)
Anticholinergic agents, antiParkinson agents
Anticholinergic agents, skeletal
muscle relaxants





Cimetidine
Zolpidem
Carbinoxamine
Chlorpheniramine
Hydroxyzine
products
 Atropine products
 Homatropine
 Belladonna
alkaloids
 Darifenacin
 Fesoterodine
 Solifenacin
 Benztropine
 Tizanidine
Prescription
 Nizatidine
 Famotidine







Loratadine
Brompheniramine
Clemastine
Cyproheptadine
Dicyclomine
Hyoscyamine products
Propantheline
 Trospium
 Flavoxate
 Ranitidine
 Dimenhydrinate
 Diphenhydramine
 Meclizine
 Scopolamine
 Oxybutynin
 Tolterodine
 Trihexyphenidyl
 Carisoprodol
 Cyclobenzaprine
 Orphenadrine
Note: NCQA post a comprehensive list of medications and NDC codes to www.ncqa.org.
Rate 3: Drug-Disease Interactions—Chronic Kidney Disease and Cox-2 Selective NSAIDs or
Nonaspirin NSAIDs
Descripti
on
 Celecoxib
Cox-2 Selective
NSAIDs
Nonaspirin NSAIDs
 Diclofenac potassium
 Diclofenac sodium
 Etodolac
 Fenoprofen
 Flurbiprofen
Prescription





Ibuprofen
Indomethacin
Ketoprofen
Ketorolac
Meclofenamate





Mefenamic acid
Meloxicam
Nabumetone
Naproxen
Naproxen sodium




Oxaprozin
Piroxicam
Sulindac
Tolmetin
Note: NCQA posts a comprehensive list of medications and NDC codes to www.ncqa.org.
How Can Providers Improve HEDIS® Scores?
 Assess compliance for performing comprehensive medication reconciliation
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They
are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to
assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the
services. The measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications
manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all
applicable services performed and submitted for its membership.
Use of High Risk Medications
in the Elderly
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Use of High Risk Medications in the
Elderly profiled measure along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicare patients 65 years and older as of the last day of
the measurement year who received two or more prescription fills for a high-risk medication
during the measurement year.
Description
Anticholinergics (excludes TCAs), first-generation
antihistamines
Anticholinergics (excludes TCAs), anti-Parkinson agents
Antithrombotics
Cardiovascular, alpha agonists, central
Cardiovascular, other
Central nervous system, tertiary TCAs
Central nervous system, barbiturates
Central nervous system, vasodilators
Central nervous system, other
Endocrine system, estrogens with or without progestins;
include only oral and topical patch products
Endocrine system, sulfonylureas, long-duration
Endocrine system, other
Gastrointestinal system, other
Pain medications, skeletal muscle relaxants
Pain medications, other






























Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Benztropine (oral)
Dipyridamole, oral shortacting (does not apply to
the extended-release
combination with aspirin)
Guanabenz
Guanfacine
Disopyramide
Amitriptyline
Clomipramine
Amobarbital
Butabarbital
Butalbital
Mephobarbital
Ergot mesylates
Thioridazine
Chloral Hydrate
Conjugated estrogen
Esterified estrogen
Chlorpropamide
Desiccated thyroid
Trimethobenzamide
Carisoprodol
Chlorzoxazone
Cyclobenzaprine
Indomethacin
Ketorolac, includes
parenteral
Prescription
 Dexchlorpheniramine
 Diphenhydramine (oral)
 Doxylamine
 Hydroxyzine
 Promethazine
 Triprolidine
 Trihexyphenidyl
 Ticlopidine
 Methyldopa






Nifedipine, immediate release
Imipramine
Trimipramine
Pentobarbital
Phenobarbital
Secobarbital
 Isoxsuprine
 Meprobamate




Estradiol
Estropipate
Glyburide
Megestrol





Metaxalone
Methocarbamol
Orphenadrine
Meperidine
Pentazocine
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 2,
2015. Combination drugs will be added to Table DAE-A with the release of the NDC list.
How Can Providers Improve HEDIS® Scores?
 Assess compliance by performing a comprehensive medication reconciliation
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They are
examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to assure the
accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the services. The
measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications manual.
Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all applicable services
performed and submitted for its membership.
Use of Imaging Studies for Low Back Pain
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Use of Imaging Studies for Low Back
Pain along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid patient’s ages 18- 50 years old by December
31 of the measurement year, with an outpatient or ED visit with the primary diagnosis of low
back pain. The measure is reported as an inverted rate. A higher score indicates appropriate
treatment of low back pain.
Exclusions:
 Patients with a diagnosis of LBP during the six months prior to IESD.
 Diagnosis of cancer any time during the patients history through 28 days after the IESD
 Trauma, IV drug use or neurologic impairment anytime during the 12 months prior to the
IESD through 28 days after the IESD.
How Can Providers Improve HEDIS® Scores?
 Educate patients on ways to prevent episodes of low back pain by stretching
appropriately and using safe habits when exercising or lifting heavy objects.
 Educate patients that not all low back pain requires an imaging study. Majority of low
back pain diagnoses resolve within six weeks.
 Teach patients about ways to alleviate symptoms at home and when they should seek
additional treatments or consultations.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They are
examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to assure the
accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the services. The
measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications manual.
Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all applicable services
performed and submitted for its membership.
Weight Assessment and Counseling for
Nutrition and Physical Activity for Children
and Adolescents
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures. This
resource guideline details the key aspects of the Weight Assessment and Counseling for Nutrition and
Physical Activity measure along with guidance and resources.
What is the Measure?
This measure looks at the percentage of patients 3–17 years of age who had an outpatient visit with a
PCP or OB/GYN and who had evidence of the following during the measurement year:
 BMI percentile documentation
 Counseling for nutrition
 Counseling for physical activity
Exclusions: Those patients with a diagnosis of pregnancy during the measurement year.
What Codes Should Providers Use?
Component
BMI Percentile
ICD-10-CM
BMI < 5%
Z68.51
BMI 5% -<85 %
Z68.52
BMI 85%-<95%
Z68.53
BMI ≥ 95%
Z68.54
Component
Nutrition Counseling
Physical Activity Counseling
ICD-10-CM
Z71.3
CPT® Category I
97802-97804
Z71.89
HCPCS
S9470
S9451
How Can Providers Improve HEDIS® Scores?
 Document BMI and gender on each visit. BMI percentile plotted on a growth chart in the medical
record is acceptable
 Documentation of any/all counseling should include service date and note of counseling
received including but not limited to education, guidance or referrals.

Confirm billing systems support current Z codes.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They are
examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to assure the
accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the services. The
measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications manual.
Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all applicable services
performed and submitted for its membership.
Well-Child Visits in the First 15 Months of Life
(six or more visits)
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures. This
resource guideline details the key aspects of the Well-Child Visits in the First 15 Months (six or more
visits) of Life along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid patients who turned 15 months old between January 1
and December 31 of the measurement year who had six or more well-child visits with any PCP during
the first 15 months of life.
What Codes Should Providers Use?
Measure or Component
New Patient
Established Patient
Newborn Visit
ICD-10-CM Codes
Z00.110, Z00.111,
Z00.121,Z00.129,
Z00.8, Z02.81,
Z02.82,
Z02.89,Z02.9
CPT® Category I
(age <1): 99381; (age 1-4): 99382
(age <1): 99391; (age 1-4): 99383
99461
How Can Providers Improve HEDIS® Scores?
 Conduct or schedule well-care visits when patients present for illnesses, or other events
like sports physicals, accidental injuries, and colds. – add modifier for separate and
distinct services.
 Pre-schedule the next well-visit before the patient leaves the office.
 Document the date when the well-child visit occurred and evidence of all of the
following:
o A health history.
o A physical developmental history.
o A mental developmental history.
o A physical exam.
 Provide health education/anticipatory guidance.
 Services rendered during an inpatient or ED visit do not count as a well-child visit.
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They are
examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to assure the
accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the services. The
measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications manual.
Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all applicable services
performed and submitted for its membership.
Well-Child Visits in the Third,
Fourth, Fifth and Sixth Years of Life
Gateway Health Plan® wants to help you improve your quality scores on HEDIS® measures.
This resource guideline details the key aspects of the Well-Child Visits in the Third, Fourth,
Fifth and Sixth Years of Life along with guidance and resources.
What is the Measure?
This measure looks at the number of Medicaid patients ages 3-6 between January 1 and
December 31 of the measurement year who had one or more well-child visits with any PCP
during the measurement year.
What Codes Should Providers Use?
Measure or Component
Well-Child Visits in the Third,
Fourth, Fifth and Sixth Years of
Life
ICD-10-CM
Codes
CPT® Category I
New patient:
99382 (age 1-4),
Z00.8,
Z00.121,Z00.129, 99383 (age 5-11)
Z02.0, Z02.5,
Z02.71, Z02.81,
Established
Z02.82, Z02.89,
patient: 99392
Z02.9
(age 1-4), 99393
(age 5-11)
HCPCS
G0438,
G0439
How Can Providers Improve HEDIS® Scores?
 Conduct or schedule well-care visits when patients present themselves for illnesses, or
other events like sports physicals, accidental injuries, and colds. – Must add modifier for
separate and distinct services.
 Document the date when the well-child visit occurred and evidence of all of the
following:
o A health history.
o A physical developmental history.
o A mental developmental history.
o A physical exam.
 Provide health education/anticipatory guidance.
 Services rendered during an inpatient or ED visit do not count as a well-child visit.
 Integrate screening reminders into EHRs
This document was prepared as a tool to assist practices by providing a sample of potential coding opportunities. They
are examples only and not to be considered an all-inclusive listing. Although every reasonable effort has been made to
assure the accuracy of the information, the ultimate responsibility for correct submission of claims is the provider of the
services. The measure descriptions and codes in this document are derived from the 2016 HEDIS® Volume 1 Technical
Specifications/Value Set Directory, and the Quality Assurance Reporting Requirements Technical Specifications
manual. Please provide to your office personnel as appropriate. Gateway Health Plan ® will continue to pay for all
applicable services performed and submitted for its membership.
Profiled Measures for 2016
What is a Profiled Measure?
Gateway Health will be introducing Profile measures in the 2016 GPE ® program. Profile
measures are not scored, but are informational only. Profile measures will be tracked and
reported to providers to encourage closer monitoring of high-utilization services. PCPs can
influence during the course of preventative treatment. Although these are not scored at this
time, there is an increased likelihood for their appearance in future GPE ® programs.
 Use of High Risk Medications in the Elderly
Members 65 years of age and older who received prescriptions for certain drugs with
high risk of side effects, when there may be safer drug choices.
 Medication Adherence Measures
Percent of plan members who fill their prescriptions often enough to cover 80% or more
of the time they are supposed to be taking the medication.
o
o
o
o
Oral hypoglycemic:
Anti-hypertensives
Statins
Adherence to antipsychotic medications in individuals with Schizophrenia
Practice Resource Page
Medical Assistance (Medicaid)
1-800-392-1145
8:30 am – 4:30 pm M-F
Medicare Assured
1-800-685-5205
8:30 am – 4:30 pm M-F
Gateway at a Glance
https://www.gatewayhealthplan.com/node/254
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
To navigate to the Provider Manual:
www.gatewayhealthplan.com > Providers > Provider Manual > Medical Assistance Provider
Manual > OB/GYN Services
To navigate to the GPE® Program:
www.gatewayhealthplan.com > Providers > Gateway to Practitioner Excellence®