Family Practice, Internal Medicine, Gastroenterology, Multispecialty Physician Group, Infectious Disease

Transcription

1 Measure : Hepatitis C: Viral Load Test Owner: NQF 0584: Rule 426 Measure Code: HEP Lab Data: N Measure : This measure identifies patients with Hepatitis C (HCV) who began HCV antiviral therapy during the measurement year and had HCV Viral Load testing within 6 months (180 days) prior to initiation of antiviral therapy. Measure Specialist Provider Types: Family Practice, Internal Medicine, Gastroenterology, Multispecialty Physician Group, Infectious Disease General Criteria Summary 1. Measurement period: 1 year prior to measurement period end date 2. Continuous enrollment: Medical coverage is during the measurement year and the prior year and drug coverage is during the measurement year 3. Anchor date: measurement period end date (ie. December 31 of calendar year) 4. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment 5. Medical coverage: Yes 6. Drug coverage: Yes 7. Attribution time frame: Measurement year and the prior year 8. Exclusions apply: Yes 9. Age range: 18 years or older as of the end of the measurement year Summary of changes for In the denominator the following codes were added: HCPCS codes G0463 and T1015. These are all outpatient visit types. 2. Update Peginterferon drug list (24 NDCs added) and Ribavirin drug list (31 NDCs added / 2 removed) to November 2014 Redbook Denominator : All patients aged 18 years or older as of the end of the measurement year who had a diagnosis of Hepatitis C (HCV) and who started HCV antiviral therapy during the measurement year Inclusion Criteria: All patients aged 18 years or older as of the end of the measurement year who had: Two or more diagnoses of Hepatitis C from an outpatient setting, where at least one diagnosis must occur prior to the measurement year OR One or more diagnosis of Hepatitis C from an emergency room setting or inpatient setting anytime prior to the measurement year AND One or more prescription for Peg-interferons AND one or more prescription for Ribavarin both during the measurement year, saving the earliest instance of either prescriptions as the initiation of antiviral therapy Page 1

2 Eligibility Criteria Condition Age is 18 years or older # Evnt Detailed Criteria Field Dimen Fact Timeframe Age in Years >= 18 age_years Demog eligibility As of the end of measurement year Claim Criteria Condition At least two face-toface encounters with different dates of service, in an outpatient or observation setting, with a diagnosis of Hepatitis C (At least one diagnosis must occur prior to the measurement year) OR At least one face-toface encounter in an inpatient or emergency room setting with a diagnosis of Hepatitis C AND One or more prescription for Peginterferons AND # Evnt 2 (dx must be on same claim as proc or rev code) 1 (dx must be on same claim as proc or rev code) Detailed Criteria Field Dimen Any Diagnosis Code = Hepatitis C Value Set And (CPT Procedure Code = Outpatient, Observation Value Set or HCPCS Procedure Code = Outpatient, Observation Value Set or dx_cd Page 2 dx any_dx Fact fac_hdr proc_cd proc fac_dtl Revenue Code UB =Outpatient Value Set) fac_revenue_cd proc fac_dtl Any Diagnosis Code = Hepatitis C Value Set And (CPT Procedure Code = Nonacute Inpatient, Acute Inpatient, ED Value Set Or Revenue Code UB = Nonacute Inpatient, Acute Inpatient, ED Value Set) 1 NDC Code = HEP-D 2014 Peginterferons Drug List and dx_cd dx any_dx fac_hdr proc_cd proc fac_dtl fac_revenue_cd proc fac_dtl Timeframe Anytime prior to or during the measurement year Anytime prior to the measurement year ndc_nbr_cd drug drug_clm During the measurement year (save the earliest instance of either prescription as the

3 one or more prescription for Ribavarin (No prescriptions prior to the measure year) NDC Code = HEP-E 2014 Ribavarin Drug List ndc_nbr_cd drug drug_clm initiation of antiviral therapy) Exclusion Criteria: Patients who have had inpatient hospitalization anytime prior to the initiation of antiviral therapy Condition Inpatient hospitalization # Evnt Detailed Criteria Field Dimen 1 Revenue Code UB = Nonacute Inpatient, Acute Inpatient Value Set Or HCPCS code = Nonacute Inpatient, Acute Inpatient Value Set Fact Timeframe fac_revenue_cd proc fac_dtl Anytime prior to the initiation of antiviral therapy proc_cd proc fac_dtl Continuous Enrollment Criteria: Patients continuously enrolled with medical coverage during the measurement year and the prior year. Drug coverage is during the measurement year Condition # Evnt Detailed Criteria Field Dimen Fact Timeframe Continuous enrollment Continuous Enrollment is 12 out of 12 months During the measurement year and the prior year AND Has medical coverage Coverage Indicator Medical = Y medical_covg_ind plan eligibility During the measurement year and the prior year AND Has drug coverage Coverage Indicator Drug = Y drug_covg_ind plan eligibility During the measurement year Numerator : Patients in the denominator who had an HCV Viral Load test within 6 months (180 days) prior to initiation of antiviral therapy. Inclusion Criteria: Patients in the denominator who had an HCV Viral Load test within 6 months (180 days) prior to initiation of antiviral therapy. Page 3

4 Condition # Evnt Detailed Criteria Field Dimen Fact Timeframe HCV viral load test 1 CPT Procedure Code = HCV Viral Load Tests Value Set proc_cd proc fac_dtl Within 6 months (180 days) prior to the initiation of antiviral therapy Notes: 1. In their 2014 specs, NCQA replaced all coding table references with value set references. We removed the place of service requirement with revenue code since this was done for the diabetes measures. a. In the denominator, the following code changes were made: CPT codes and (visits) were added; HCPCS codes G0402, G0438, and G0439 (visits) were added; revenue codes (home health), , 080*, and 088 (dialysis) were deleted; and, place of service codes were deleted. 2. In their 2015 specs, NCQA added the following codes in the denominator: HCPCS codes G0463 and T1015. These are all outpatient visit types. Appendix Hepatitis C Value Set Code Code Type ICD-9 Diagnosis Chrnc Hpt C w Hepat Coma ICD-9 Diagnosis Chrnc Hpt C wo Hpat Coma ICD-9 Diagnosis Hpt C wo Hepat Coma NOS ICD-9 Diagnosis Hpt C w Hepatic Coma NOS V02.62 ICD-9 Diagnosis Hepatitis C Carrier Outpatient Value Set Page 4

5 Code Code Type CPT New patient, office or other outpatient service CPT Established patient, office or other outpatient service CPT Hospital observation services, observation care discharge services CPT Office or other outpatient consultations, New or established patient CPT Home services, New patient CPT Home services, Established patient CPT Init Pm E/M - New Pat - Inf CPT Init Pm E/M - New Pat 1-4 Yrs CPT Prev Visit - New - Age CPT Preventive medicine services, years, new patient CPT Per Pm Reeval - Est Pat - Inf CPT Prev Visit - Est - Age CPT Prev Visit - Est - Age CPT Preventive medicine services, years, established patient CPT Preventive medicine, individual counseling, new or established, 15 min CPT Preventive medicine, individual counseling, new or established, 30 min CPT Preventive medicine, individual counseling, new or established, 45 min CPT Preventive medicine, individual counseling, new or established, 60 min CPT Preventive medicine, group counseling, 30 min CPT Preventive medicine, group counseling, 60 min CPT Other preventive medicine services, administration and interpretation CPT Other preventive medicine services, unlisted 99455, CPT Work related or medical disability evaluation services G0402 HCPCS Initial preventive physical; f-f visit, new G0438 HCPCS Annual wellness visit; personalized prevention plan, initial G0439 HCPCS Annual wellness visit; personalized prevention plan, subsequent G0463 HCPCS Hospital outpatient clinic visit for assessment and management of a patient T1015 HCPCS Clinic visit/encounter, all-inclusive 0510 UB Revenue CLINIC 0511 UB Revenue CHRONIC PAIN CL 0512 UB Revenue DENTAL CLINIC 0513 UB Revenue PSYCH CLINIC 0514 UB Revenue OB-GYN CLINIC 0515 UB Revenue PEDS CLINIC 0516 UB Revenue URGENT CLINIC 0517 UB Revenue FAMILY CLINIC Page 5

6 0519 UB Revenue OTHER CLINIC 0520 UB Revenue FREESTAND CLINIC 0521 UB Revenue RURAL/CLINIC 0522 UB Revenue RURAL/HOME 0523 UB Revenue FR/STD FAMILY CLINIC 0526, 0527, 0528 UB Revenue FR/STD URGENT CLINIC 0529 UB Revenue OTHER FR/STD CLINIC 0982 UB Revenue PRO FEE/OUTPT 0983 UB Revenue PRO FEE/CLINIC Observation Value Set Code Code Type CPT Observation Care Discharge CPT Observation Care Nonacute Inpatient Value Set Code Code Type CPT Initial Nursing facility care, New or established patient CPT Initial Nursing facility care, New or established patient CPT Initial Nursing facility care, New or established patient CPT Subsequent nursing facility care 99315, CPT Nursing facility discharge services CPT Other Nursing facility services CPT Domiciliary, rest home or custodial care services, New patient CPT Domiciliary, rest home or custodial care services, established patient 0118 UB Revenue REHAB/PVT 0128 UB Revenue REHAB/2BED 0138 UB Revenue REHAB/3&4 BED 0148 UB Revenue REHAB/PVT/DLX 0158 UB Revenue REHAB/WARD 0190 UB Revenue SUBACUTE 0191 UB Revenue SUBACUTE/LEVEL I 0192 UB Revenue SUBACUTE/LEVEL II 0193 UB Revenue SUBACUTE/ LEVEL III Page 6

7 0194 UB Revenue SUBACUTE/ IV 0199 UB Revenue SUBACUTE/OTHER 0524 UB Revenue FR/STD FAMILY CLINIC 0525 UB Revenue FR/STD FAMILY CLINIC 0550 UB Revenue SKILLED NURSING 0551 UB Revenue SKILLED NUR/VISIT 0552 UB Revenue SKILLED NUR/HOUR 0559 UB Revenue SKILLED NURS/OTHER 0660 UB Revenue RESPITE CARE 0661 UB Revenue RESPITE NURSE 0662 UB Revenue RESPITE /AID/HMEMKE/COMP 0663 UB Revenue RESPITE/DAILY 0669 UB Revenue RESPITE/CARE Acute Inpatient Value Set Code Code Type CPT Initial hospital services, new or established patient CPT Subsequent hospital care 99238, CPT Hospital discharge services CPT Inpatient consultations, new or established patient CPT Critical care, evaluation and management 0100 UB Revenue ALL INCL R&B/ANC 0101 UB Revenue ALL INCL R&B 0110 UB Revenue ROOM-BOARD/PVT 0111 UB Revenue MED-SUR-GY/PVT 0112 UB Revenue OB/PVT 0113 UB Revenue PEDS/PVT 0114 UB Revenue PSYCH/PVT 0119 UB Revenue OTHER/PVT 0120 UB Revenue ROOM-BOARD/SEMI 0121 UB Revenue MED-SUR-GY/2BED 0122 UB Revenue OB/2BED 0123 UB Revenue PEDS/2BED 0124 UB Revenue PSYCH/2BED 0129 UB Revenue OTHER/2BED 0130 UB Revenue ROOM-BOARD/3&4BED Page 7

8 0131 UB Revenue MED-SUR-GY/3&4BED 0132 UB Revenue OB/3&4BED 0133 UB Revenue PEDS/3&4BED 0134 UB Revenue PSYCH/3&4BED 0139 UB Revenue OTHER/3&4BED 0140 UB Revenue ROOM-BOARD/PVT/DLX 0141 UB Revenue MED-SUR-GY/PVT/DLX 0142 UB Revenue OB/PVT/DLX 0143 UB Revenue PEDS/PVT/DLX 0144 UB Revenue PSYCH/PVT/DLX 0149 UB Revenue OTHER/PVT/DLX 0150 UB Revenue ROOM-BOARD/WARD 0151 UB Revenue MED-SUR-GY/WARD 0152 UB Revenue OB/WARD 0153 UB Revenue PEDS/WARD 0154 UB Revenue PSYCH/WARD 0159 UB Revenue OTHER/WARD 0160 UB Revenue R&B 0164 UB Revenue R&B/STERILE 0167 UB Revenue R&B/SELF 0169 UB Revenue R&B/OTHER 0200 UB Revenue ICU 0201 UB Revenue ICU/SURGICAL 0202 UB Revenue ICU/MEDICAL 0203 UB Revenue ICU/PEDS 0204 UB Revenue ICU/PSTAY 0206 UB Revenue ICU/INTERMEDIATE 0207 UB Revenue ICU/BURN CARE 0208 UB Revenue ICU/TRAUMA 0209 UB Revenue ICU/OTHER 0210 UB Revenue CORONARY CARE 0211 UB Revenue CCU/MYO INFARC 0212 UB Revenue CCU/PULMONARY 0213 UB Revenue CCU/TRANSPLANT 0214 UB Revenue CCU/INTERMEDIATE 0219 UB Revenue CCU/OTHER 0720 UB Revenue DELIVROOM/LABOR Page 8

9 0721 UB Revenue LABOR 0722 UB Revenue DELIVERY ROOM 0723 UB Revenue CIRCUMCISION 0724 UB Revenue BIRTHING CENTER 0729 UB Revenue OTHER/DELIV-LABOR 0987 UB Revenue PRO FEE/HOS VIS ED Value Set Code Code Type CPT Emergency services, new or established patient 0450 UB Revenue EMERG ROOM 0451 UB Revenue ER/EMTALA 0452 UB Revenue ER/BEYOND EMTALA 0456 UB Revenue URGENT CARE 0459 UB Revenue OTHER EMER ROOM 0981 UB Revenue PRO FEE/ER HEP-D: Codes to Identify Peg-interferons NDC Code NDC Code NDC Code HEP-E: Codes to Identify Ribavirin Page 9

10 NDC Code NDC Code NDC Code NDC Code NDC Code HCV Viral Load Tests Value Set Code Code Type CPT Hepatitis C - RNA - Quant Page 10