ABCBS PCMH
2016 Specifications
ARKANSAS BLUE CROSS and BLUE SHIELD
An Independent Licensee of the Blue Cross and Blue Shield Association
Table of Contents
I. Terminology
II. Transformation Activities
2016 List of Activities
3 month
6 month
12 month
13 month
III. Quality Metrics
2016 List of Quality Metrics and Targets
Facts
Exceptions
Specifications
IV. Summary of changes from 2015
V. Resources
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4
5-9
10
11
12
13-14
15
16
17-33
34
35
2
Terminology
Attest/ Attestation: Verifies that the information provided is truthful and can be supported
Numerator: The number of patients affected by the measure; the top number in a
fraction; the number of incidences (example on page 9)
Denominator: The total number of patients in the population being analyzed; shows how
many total parts/patients you have; the bottom number in a fraction (example on
page 9)
Domain: The grouping of measures by initiatives or organizations
Exclusion: Information that should be separated from the measure (not included)
High Priority Members: Members that are considered high risk by the clinic or Blue
Cross Blue Shield; Patients that require attention soon
Inclusion: Information to specifically include in the measure
Measurement Number: The specific identifying information for a measure in a program. A
measure that’s used in multiple programs may have several measure numbers.
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2016 Activities
Date
extended
to
04/30/16
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3 Month Activities
Activity A: Identify the top 10% of High Priority Arkansas Blue Cross and Blue Shield members using:
1. Arkansas Blue Cross and Blue Shield and its family of companies patient panel data that ranks
members by risk at beginning of performance period
OR
2. The clinic’s patient-centered assessment to determine which members on this list are high priority
Submit this list to the PCMH Provider Portal
Note: At this time, you may use a combination of both options listed above; however, make note that the
BCBS risk score tool includes many details about the patient and may contain medical history that the
clinic may not be aware of.
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3 Month Activities
Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood
Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents
(BMI).
Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should reflect
the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use.
Measure
Numerator
Denominator
Controlling High Blood
Pressure
The number of patients in the
denominator whose most recent BP
is adequately controlled (<140/90)
during the measurement year.
Total number of patients age 18-85 who
had at least one outpatient encounter
with a diagnosis of hypertension (HTN)
during the first six months of the
measurement year.
Coding
ICD-10
I10- hypertension, R03.0 -elevated blood
pressure w/o dx of HTN
Measure Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and
whose blood pressure was adequately controlled (<140/90) during the measurement period.
Domain: Clinical Process/Effectiveness
Measure Number: CMS 165v4, NQF 0018, PQRS 236/GPRO HTN-2
Exclusions: (1) All patients with evidence of end-stage renal disease (ESRD) or chronic kidney disease, stage
5, on or prior to the end of the measurement year. Documentation in the medical record must include a
related note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets the
criteria for evidence of ESRD.
(2) All patients with a diagnosis of pregnancy during the measurement year.
(3) All patients who had an admission to a nonacute inpatient setting during the measurement year.
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3 Month Activities
Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood
Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents
(BMI)
Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should
reflect the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use
Measure
Numerator
Denominator
Diabetes: Hemoglobin A1c Poor
Control
Patients whose most recent
HbA1c level is greater than 9.0% or
is missing a result, or for whom an
HbA1c test was not done during
the measurement year.
Patients 18-75 years of age by the
end of the measurement year
who had a diagnosis of diabetes
(type 1 or type 2) during the
measurement year or the year
prior to the measurement year.
Codes
CPT
83036-A1c
ICD10:
E11.65 type 2 with hyperglycemia
E10.65 type 1 with hyperglycemia
Measure Description: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c>
9% (poor control) during the measurement period.
Domain: Clinical Process/Effectiveness
Measure Number: CMS 122v4, NQF 0059, PQRS 001 GPRO DM-2
Exclusions: (1) Patients with a diagnosis of polycystic ovaries, in any setting, any time in their history through
December 31 of the measurement year.
(2) Patients with a diagnosis of gestational or steroid-induced diabetes, in any setting, during the
measurement year or the year prior to the measurement year.
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3 Month Activities
Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood
Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents
(BMI)
Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should
reflect the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use.
Measure
Numerator
Denominator
Weight Assessment and
Counseling for Children and
Adolescents
The percentage of patients in the
denominator who had evidence of
Body mass index (BMI) percentile
documentation during the
measurement year
*NQF 0024 also includes counseling for
nutrition and physical activity
Patients 3-17 years of age with at
least one outpatient visit with a
primary care physician (PCP) or OBGYN during the measurement year
Codes
HCPCS- BMI=G8418
CPT: 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215,
-99381-99385, 99391-99395
Measure Description: Percentage of patients 3-17 years of age who had an outpatient visit with a PCP or
OB/GYN and who had evidence of BMI percentile documentation during the measurement year.
*We are only capturing the BMI documentation at this time, not data on nutrition and physical activity counseling. The target age
range is 3-17 years; however, 2-17 years is also acceptable based on EHR reporting capabilities.
Domain: Population Health/ Effectiveness of Care
Measure Number: CMS 155v4, NQF 0024, PQRS 239
Exclusion(s): (1) Patients who have a diagnosis of pregnancy during the measurement year.
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Example: For Assistance on Activity B
Measure: Diabetes: Hemoglobin A1c Poor Control
• Clinic population: 5,000 patients
• Your report in your EHR shows that you have 300 patients that were seen
during the measurement period (last year)with a diagnosis of Diabetes.
• Your A1c report shows 22 of the 300 patients had an A1c >9 or didn’t have
an A1c drawn/recorded
Numerator=22
Denominator=300
Divide 22/300 and x 100 to get a % (the portal will do the math for you)
7.3% of your patients with Diabetes were uncontrolled
*Note: Don’t forget to add the exclusions into your reports. For example, did any of the 300 patients with
Diabetes have Gestational Diabetes? If the answer is yes, you subtract them from the 300. Most EHRs will
allow you to add exclusions when you run the report.
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6 Month Activities
Activities C-G:
Answer the questions that accompany each activity on the portal.
Activity Topics
Tips
C: Assess operations of practice
and opportunities to improve
1. Some questions require a single
answer, while others allow for
multiple answers.
D: Develop strategy to implement
care coordination and practice
transformation
2. If you select “other” for any
question, you must give a detailed
explanation.
E: Identify and address medical
neighborhood barriers to
coordinated care (including BH
professionals and facilities)
3. Each activity requires an
attestation before submitting and
completing.
F: Provide 24/7 access to care
G: Document approach to
expanding access to same-day
appointments
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12 Month Activities
Activities H-M:
Answer the questions that accompany each activity on the portal.
Activity Topics
Tips
H. Identify Childhood/Adult
Vaccination Practice Strategy
I. Establish processes that result in
contact with patients who have
not received preventative care
J. Describe patients' ability to
receive timely care, appointments,
and information from specialists
(including BH specialists)
K. Incorporate e-prescribing into
practice workflows
L. Integrate EHR into practice
workflows
M. Complete care plans for HighPriority patients
1. Some questions require a single
answer, while others allow for
multiple answers.
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2. If you select “other” for any
question, you must give a detailed
explanation.
3. Each activity requires an
attestation before submitting and
completing.
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13 Month Activities
This activity is the same as the 3 month Activity B EXCEPT the 13 month CQM reports should
reflect your 2016 patient data as opposed to the 2015 data reported for the 3 month
Activity.
Activity N: Report Clinical Quality Measure Data for calendar year 2016 for: Controlling High
Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for
Children and Adolescents (BMI).
• These measures should reflect the whole patient empanelment and NOT just BCBS
members.
• On the portal, you will be directed to Activity N. There you will be able to view your
2015 data and input your 2016 data.
• For more details, refer to pages 6-9
Example:
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2016 Quality Metrics
Targets
1. Percentage of patients who turned 15 months old during the performance period who
received at least four wellness visits in the first 15 months
At least
70%
2. Percentage of patients 3-6 years of age who had one or more well-child visits during the
measurement year
At least
67%
3. Percentage of patients 12-21 years of age who had one or more well- care visits during the
measurement year
At least
45%
4. Percentage of patients 6-12 years of age with an ambulatory prescription dispensed for ADHD
medication that was prescribed by their PCMH, who had a follow-up visit within 30 days by any
practitioner with prescribing authority
At least
36%
5. Percentage of patients prescribed appropriate asthma medications
At least
85%
6. Percentage of CHF patients age 18 and over on beta blockers
At least
49%
7. Percentage of children who received appropriate treatment for an Upper Respiratory
Infection (URI)
8. Percentage of diabetes patients who complete annual HbA1C, between 18-75 years of age
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No more
than 65%
At least
78%
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2016 Quality Metrics
Targets
9. Percentage of patients with Diabetes and CAD that are currently taking a statin
At least
70%
10. Percentage of a clinic’s high priority patients seen by a member of the PCP’s care
management team at least twice in the past 12 months
At least
76%
11. Percentage of patients who had an acute inpatient hospital stay who were seen by a
health-care provider within 10 days of discharge
At least
40%
12. Percentage of patients age 18 years and older who were prescribed chronic Alprazolam
(Xanax) during the measurement period
No more
than 12%
13. Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose
blood pressure was adequately controlled (<140/90mmHg) during the measurement period
(All payer source)
At least
55%
14. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) whose most
recent HbA1C level during the measurement period was greater than 9.0% (poor control), was
missing the most recent result, or was not done during the measurement period
(All payer source)
No more
than 35%
15. Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care
Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of height,
weight, and body mass index (BMI) percentile documentation during the measurement period
(All payer source)
At least
45%
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Quality Metrics Facts
WHAT:
There are a total of 15 Quality Metrics for 2016. These metrics were developed to
assist practices with improving patient care. They are based on quality metrics that
are currently used in many initiatives.
WHERE:
Clinics will not be responsible for collecting the data needed for Quality Metrics 112. This data will be retrieved through the claims process and will be presented to
the clinics quarterly. We do recommend that you build similar reports/registries in
your EHR to assist with practice transformation, but this is not required.
WHEN:
The targets for the metrics are 12 month goals, allowing clinics to work on improving
their quality of care throughout the year.
WHY:
These metrics can provide insight to the clinic regarding possible areas of strengths
and weaknesses; therefore, initiating planning and implementation of population
management techniques, programs, and policies.
HOW:
Due to the quantity of measures currently being used to improve quality in the
primary care setting across the U.S., BCBS selected measures that are similar or
currently used throughout the state of Arkansas. The measures may vary in detail, so
the numerator and denominator used by Arkansas Blue Cross Blue Shield is listed for
each metric.
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Quality Metrics- Exceptions
Clinics will NOT be responsible for meeting the target for BCBS on the following
Quality Metric until notified. BCBS will provide data when available.
•
Metric 12 (Xanax prescriptions)
Metrics that vary from the Arkansas State PCMH
•
Metric 6 (CHF on beta blockers)
•
Metric 7 (Antibiotic treatment for URI)
•
Metric 9 (Diabetes and statin medications)
Metrics that are reported under Activities
•
Metrics 13-15: These metrics are included on the portal under “3 month
activities” and “13 month activities”. Clinics are required to collect and report
their own data. These metrics are for informational purposes and may be used
as a reference point.
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Quality Metrics
Quality Metric 1: Percentage of patients who turned 15 months old during the performance period who
received at least four wellness visits in their first 15 months
Numerator
Denominator
Codes
Children in the denominator who
received four or more well-child
visits during their first 15 months of
life
All children that are 15 months
during the measurement year
(age 15 months through 26
months on the report end date)
and have continuous medical
coverage
CPT: 99381, 99382, 99391,
99392, 99461
Diagnosis codes:
ICD-9: V20.2, V70.0, V70.3,
V70.5, V70.6, V70.8, V70.9
ICD-10: Z00.10, Z00.111,
Z00.121, Z00.129, Z76.2,
Z00.8, Z23
Target: At least 70%
Domain: Use of Services
Measures: NQF 1392, HEDIS, PQRS, Arkansas State PCMH
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Quality Metrics
Quality Metric 2: Percentage of patients 3-6 years of age who had one or more well-child visits during the
measurement year
Numerator
Denominator
Codes
Children who received at least one
well-child visit with a PCP in the last
reported 12 months
All children that are 3-6 years old
during the measurement year
and have continuous medical
coverage
CPT: 99382, 99383, 99392,
99393
Diagnosis codes:
ICD-9: V20.2, V70.0, V70.3,
V70.5, V70.6, V70.8, V70.9
ICD-10: Z00.121 & Z00.129,
Target: At least 67%
Domain: Use of Services
Measures: NQF 1516, HEDIS, PQRS, Arkansas State PCMH
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Quality Metrics
Quality Metric 3: Percentage of patients 12-21 years of age who had one or more well-care visits during the
measurement year
Numerator
Denominator
Codes
Members who had at least one
comprehensive well-care visit with a
primary care practitioner (PCP) or
an obstetrics and gynecology
(OB/GYN) practitioner in the last
reported 12 months
All males and females that are
12-21 years old at the end of the
reporting period and have
continuous medical coverage
CPT: 99383-99385, 9939399395
Diagnosis codes:
ICD-9:V20.2, V70.0, V70.3,
V70.5, V70.6, V70.8, V70.9
ICD-10:
Z00.00, Z00.01, Z00.121,
Z00.129, Z01.411, Z01.419
Target: At least 45%
Domain: Use of Services
Measures: HEDIS, Arkansas State PCMH
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Quality Metrics
Quality Metric 4: Percentage of patients 6-12 years of age with an ambulatory prescription dispensed for
ADHD medication that was prescribed by their PCMH, who had a follow-up visit within 30 days by any
practitioner with prescribing authority
Numerator
Denominator
Includes the ADHD patients who had an outpatient,
intensive outpatient or partial hospitalization followup visit with prescribing provider during the 30 days
after the initial ADHD prescription.
All children 6 years of age at the start of the
measurement period and 12 years of age as of
10 months prior to end of measurement period.
Building events for ADHD prescriptions (with pre
and post script windows).
* This is not a medication adherence measure; therefore,
we are only looking at the initial prescription fill and follow
up appointment.
See page 21 for more details.
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Quality Metrics
ADHD Follow Up
ADHD Medications: (HEDIS) Reference by NCQA
Description
CNS stimulants
 amphetamine-dextroamphetamine
 atomoxetine
 dexmethylphenidate
Prescription
 dextroamphetamine
 lisdexamfetamine
 methamphetamine
 methylphenidate
ICD-9: 314.01
ICD-10: F90.1, F90.2, F90.9
Other Codes:
90791, 90792, 90801, 90802, 90804- 90819, 90821- 90824, 90826, 90827-90829, 90832-90834, 90836- 90840, 90845,
90847, 90849, 90853, 90857, 90862, 90875, 90876, 96150-96154, 98960-98962, 99078, 9920199205, 99211-99215, 99217-99223, 99231-99233, 99238, 99239, 99241-99245, 99251-99255, 99341-99345, 9934799350, 99383, 99384, 99393, 99394, 99401-99404, 99411,
99412, 99510 / G0155, G0176,G0177,G0409-G0411/ H0002, H0004, H0031,H0034-H0037, H0039, H0040, H2000,
H2001, H2010, H2011-H2020 / M0064 / S0201, S9480, S9484, S9485
Target: At least 36%
Domain: Process/ Effective Communication
Measures: CMS 136v5, NQF# 0108, HEDIS, PQRS 366, Arkansas State PCMH
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Quality Metrics
Quality Metric 5: Percentage of patients prescribed appropriate asthma medications
Numerator
Denominator
Codes
The number of patients in the
denominator who were dispensed
at least one prescription for an
asthma controller medication
during the measurement year
Patients who were identified as
having *persistent asthma with a
visit during the measurement
period, who also had medical
benefits throughout 24 months
before the measurement end
date and pharmacy benefits 12
months before the measurement
end date
ICD-9: 493.00 - 493.92
ICD-10: J45.3-J45.52
*Persistent asthma-at least four asthma medication dispensing events where leukotriene modifiers or
antibody inhibitors were the sole asthma medication dispensed in that year. The patient must also
have at least one diagnosis of asthma during the same year.
Exclusion(s): (1)Exclude patients who had any diagnosis of Emphysema, COPD, Chronic Bronchitis
(Obstructive Chronic Bronchitis Value Set, Chronic Respiratory Conditions Due To Fumes/Vapors Value
Set), Cystic Fibrosis or Acute Respiratory Failure any time during the patient’s history through the end of
the measurement year (e.g., December 31).
Target: At least 85%.
Domain: Effectiveness of Care
Measure Number: CMS 126v4, HEDIS, NQF 0036 (retired measure), PQRS 311, Arkansas State PCMH
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Asthma Controller Medications
Quality Metrics
Description
Prescriptions
Antiasthmatic combinations
Dyphylline-guaifenesin
Guaifenesin-theophylline
Omalizumab
Antibody inhibitor *
Inhaled steroid combinations
Inhaled corticosteroids
Leukotriene modifiers*
Long-acting, inhaled beta-2 agonists
Mast cell stabilizers
Methylxanthines
Short-acting, inhaled beta-2
Agonists
(This is a quick reliever medication class,
not controllers. These should not be used
for this metric.)
Budesonide-formoterol
Fluticasone- salmeterol
Mometasone-formoterol
Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone CFC free
Mometasone
Triamcinolone
Montelukast • Zafirlukast • Zileuton
Arformoterol
Salmeterol
Formoterol
Cromolyn
Aminophylline
Dyphylline
Theophylline
Albuterol
Levalbuterol
Metaproterenol
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Note:
1. For Antibody inhibitors
or Leukotriene
modifiers to be
considered a
“controller”
medication, there has
to be a prescription
dispensed at least 4
times during the
measurement year.
2. Also, there would
need to be no other
asthma medications
prescribed along with
either of those two
medication classes for
them to count as the
sole controller
medication.
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Quality Metrics
Quality Metric 6: Percentage of CHF patients age 18 and over on beta blockers specifically recommended
for CHF management *
Numerator
Denominator
Codes
Includes the CHF patients in the
denominator who filled a betablocker-containing prescription for
CHF during the last 120 days of the
report period.
All males and females that
are 18 years or older at the
end of the report period,
with medical benefits
throughout the 12 months
prior to end of report period
and pharmacy benefits for
6 months prior to end of
report period. Also, during
the 24 months prior to end
of report period, patient has
two or more encounters
that are at least 14 days
apart, where CHF is the
diagnosis* (encounters can
be office visit, ER visit,
Inpatient or Outpatient)
ICD- 9:
402.01, 402.11, 402.91, 404.01,
404.11, 404.91, 428.0, 428.1,
428.20, 428.22,428.30, 428.32,
428.40, 428.42, 428.9
ICD- 10:
I11.0, I13.0, I50.1, I50.20, I50.22,
I50.30, I50.32, I50.40, I50.42, I50.9
* Not only as a primary diagnosis
*Beta blockers to include for CHF:
• Bisoprolol fumarate
• Metoprolol tartrate
• Metoprolol succinate
• Carvedilol
• Bisoprolol & hydrochlorothiazide
• Metoprolol tartrate &
hydrochlorothiazide
• Metoprolol succinate &
hydrochlorothiazide
Exclusions and other measure details can be found on pg. 25.
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Quality Metrics
Quality Metric 6
Exclusions:
1.
Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., low
blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive
inotropic agent, allergy, intolerance, other medical reasons)
2.
Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient
declined, other patient reasons)
3.
Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other
reasons attributable to the healthcare system)
These exclusions are noted in the NQF standards.
Target: At least 49%
Domain: Effectiveness of Care/Prevention and Treatment
Measure Number: CMS 144v4, NQF 0083, HEDIS, PQRS 008 GPRO HF-6, Arkansas State PCMH
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Quality Metrics
Quality Metric 7: Percentage of children who received appropriate treatment for an Upper Respiratory
Infection (URI)
Numerator
Denominator
Patients who were dispensed antibiotic
medication on or within 3 days after an
outpatient or ED encounter for upper respiratory
infection (URI) during the intake period (a higher
rate is better). The measure is reported as an
inverted rate
All children age 3 months as of July 1 of the
year prior to the measurement year to 18 years
as of June 30 of the measurement year who
had an ED or outpatient visit with only a
diagnosis of nonspecific upper respiratory
infection (URI) during the intake period (July 1st
of the year prior to the measurement year to
June 30th of the measurement year).
*The measure is reported as an inverted rate
(e.g. 1- numerator/denominator) to reflect the
number of children that were not dispensed an
antibiotic
Refer to pg. 27 for codes, exclusions, and other metric detail.
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Quality Metrics
Quality Metric 7
AHFS
081206, 081212,
081216, 081218,
081220, 081224,
081228, 082400,
812120, 812240
ICD
CPT
Primary or secondary
diagnosis codes:
– ICD-9: 460xx, 4640x,
46410, 46420, 4650x,
4658x, 4659x
– ICD-10: J00, J04.0,
J04.10, J04.2, J06.0,
J06.9
99201, 99202,
99203, 99204,
99205, 99211,
99212, 99213,
99214, 99215,
99241,99242,
99243, 99244,
99245, 99281,
99282, 99283,
99284, 99285
HCPCS with Modifiers
T1015 with modifier 1 = U1,
T1015 with modifier 1 = U2,
T1015 with modifier 1 = U5,
T1015 with modifier 2 = U1,
T1015 with modifier 2 = U2,
T1015 with modifier 2 = U5,
T1015 with modifier 3 = U1,
T1015 with modifier 3 = U2,
T1015 with modifier 3 = U5,
T1015 with modifier 4 = U1,
T1015 with modifier 4 = U2,
T1015 with modifier 4 = U5,
T1015 with modifiers 1-4 = 00
Exclusion(s): (1) ED visits that result in inpatient admission, (2) Episode Dates where a new or refill
prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on
the Episode Date, (3) Episode Dates where the member had a claim/encounter with a competing
diagnosis on or 3 days after the Episode Date, (4) Exclude all events after the first eligible event
Target: No more than 65%.
Domain: Effectiveness of Care
Measure Number: CMS 154v4, NQF 0069, HEDIS, PQRS 065, Arkansas State PCMH
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Quality Metrics
Quality Metric 8: Percentage of Diabetes patients who complete annual HbA1C, between 18-75 years of
age
Numerator
Denominator
Codes
Patients included in the
denominator who had an HbA1c
test performed during the
measurement year
Patients 18-75 years of age by the
end of the measurement year
who had a diagnosis of diabetes
(type 1 or type 2)
Diagnosis codes:
ICD-9: 250.00-250.93
ICD-10z: E08 - E13
CPT Codes: 83036 (A1c)
CPT II codes:
3044F HbA1c <7
3045F HbA1c 7.0-9.0
3046F HbA1c >9
Exclusion(s): (1) A diagnosis of polycystic ovaries, in any setting, any time in the patient’s history through
December 31 of the measurement year. (2) A diagnosis of gestational or steroid-induced diabetes, in
any setting, during the measurement year or the year prior to the measurement year
Target: At least 78%
Domain: Effectiveness of Care: Comprehensive Diabetes Care
Measure Number: NQF 0057, HEDIS, Arkansas State PCMH
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Quality Metrics
Quality Metric 9: Percentage of patients with Diabetes and Coronary Artery Disease that are currently taking
a statin
Numerator
Denominator
Codes
Individuals in the denominator
with at least one prescription
for a statin or one or more
claims with a procedure code
for lipid-lowering therapy
and no claim with a code for
exclusions due to medical
reasons, patient reasons, or
system reasons
All patients at the end of the report
period with medical benefits throughout
the 12 months prior to the end of the
report period and 6 months of
pharmacy coverage, who have a
diagnosis of DM and CAD (Acute
myocardial infarction or Ischemic heart
disease) and had a professional
encounter or facility event during the
measurement period
NDC code-Michigan
Quality Improvement
Consortium 2012 Statin Drug
List:
(http://www.mqic.org/pdf/
MQIC_Statins_2015.pdf)
Diagnosis codes for DM(see
previous page)
Diagnosis codes for CAD:
ICD-9: 414.01, ICD-10: I25.10
Exclusion(s): (1) Individuals with a diagnosis of polycystic ovaries who do not have a visit with a diagnosis
of diabetes in any setting during the measurement period. (2) Individuals with a diagnosis of gestational
diabetes or steroid-induced diabetes who do not have a visit with a diagnosis of diabetes mellitus in any
setting during the measurement period (these are exclusions due to medical reasons)
Target: At least 70%
Domain: Effectiveness of Care: Comprehensive Diabetes Care
Measure Number: NQF 2712, HEDIS, Arkansas State PCMH
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Quality Metrics
Quality Metric 10: Percentage of a practice’s high priority patients who have been seen by any PCP within
their PCMH at least twice in the past 12 months
Numerator
Denominator
The number of those high priority patients with 2 of
the required visit types and criteria with their
attributed PCMH
Patients designated as high priority by practices
according to Activity A
Codes:
CPT- 99201-99499
Other-Place of Service = 11
–Count each distinct visit with attributed PCMH as one visit
–Visits occurring on the same day do not count as multiple visits
–Provider specialty must be either 001, 008, 011, 037, or 038
Target: At least 76%
Domain: Utilization
Measure Number: Arkansas State PCMH
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Quality Metrics
Quality Metric 11: Percentage of patients who had an acute inpatient hospital stay who were seen by a
health-care provider within 10 days of discharge
Numerator
Denominator
Patients with inpatient stays who meet
the criteria below with any provider,
within 10 days of discharge
Patients with an inpatient stay during the measurement period
• CPT: 99201 - 99499
• Place of Service = 11
• Defined as patient with a DRG assigned on the claim
• Logic takes into account transfers and does not count them as
a separate inpatient stay from the original event
Inclusion(s):
 Hospitalizations with a discharge date that occur within the start of the performance period and
10 days before the end of the performance period are included in the denominator
Exclusion(s):
 Excludes stays with the following DRGs for childbirth: 0765, 0766, 0767, 0768, 0774, 0775
Target: At least 40%
Domain: Care Coordination
Measure Number: Arkansas State PCMH
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Quality Metrics
Quality Metric 12: Percentage of patients age18 years and older who were prescribed chronic Alprazolam
(Xanax) during the measurement period
Numerator
Denominator
Codes
The number of patients in the
denominator who had a minimum
of 4 pharmacy claims (minimum
drug quantity of 15 mg or more) for
a drug with Alprazolam (Xanax)
description (per HIC3 code) during
the measurement year.
Patients 18 years of age or older,
for whom prescriptions were
written during the measurement
period
HIC3: H2F and contains the
description of “Alprazolam”
Target: No more than12%. (Clinics will NOT be responsible until notified. See pg. 15 for details)
Domain: Effectiveness of Care
Measure Number: Arkansas State PCMH
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Quality Metrics
The following Quality Metrics are reported under Activity B on the PCMH portal.
(Refer to pages 6-8 for details.)
•
•
•
Quality Metric 13: Percentage of patients 18-85 years of age who had a diagnosis of
hypertension and whose blood pressure was adequately controlled (<140/90mmHg)
during the measurement period.
Quality Metric 14: Percentage of patients 18-75 years of age with diabetes (type 1 or type
2) whose most recent HbA1C level during the measurement period was greater than 9.0%
(poor control) or was missing the most recent result, or an HbA1C test was not done during
the measurement period.
Quality Metric 15: Percentage of patients 3-17 years of age who had an outpatient visit
with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had
evidence of height, weight, and body mass index (BMI) percentile documentation during
the measurement period.
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2016 Summary of Changes
New Activities
New Quality Metrics
3 month- Quarterly CQM reports
Metric 7: Antibiotics and URI
12 month-Vaccination practice
Metric 10: PCP visit for high priority*
12 month-Care plans for high priority patients *
Metric 11: Hospital discharge follow up*
13 month- Quarterly CQM reports
Metric 12: Xanax prescriptions
Metric 13: Hypertension-controlled
Metric 14: Diabetes-poor control
Metric 15: BMI
*Measures that were listed under “Practice Support” in the PCMH 2015 year
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Resources
Agency for Healthcare Research and
Quality (AHRQ)
http://qualitymeasures.ahrq.gov/
The Healthcare Effectiveness Data
and Information Set (HEDIS)
http://www.ncqa.org/HEDISQualityMeasurement.aspx
Healthcare Common Procedure
Coding System (HCPCS)
https://www.cms.gov/Medicare/Coding/HCPCSRelease
CodeSets/HCPCS-Quarterly-Update.html
National Quality Forum (NQF)
http://www.qualityforum.org/Home.aspx
National Drug Code Directory (NDC)
http://www.fda.gov/Drugs/InformationOnDrugs/ucm142
438.htm
Disclosure: This resource focuses exclusively on Arkansas Blue Cross Blue Shield 2016 PCMH and
may not include information included in other programs. This is meant to be an instrument to
clinics and is not all-inclusive of every code or circumstance.
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