Measure Name: COPD Spirometry Evaluation Measure Code: SPR Lab Data: N

Transcription

1 Measure Name: COPD Spirometry Evaluation Owner: NCQA (SPR) Measure Code: SPR Lab Data: N Rule Description: Applicable Provider Specialty: General Criteria Summary The percentage of patients aged 42 years and older as of the measurement period end date with a new diagnosis of or newly active chronic obstructive pulmonary disease (COPD), who received appropriate spirometry testing to confirm the diagnosis. Family Practice, Internal Medicine, Mixed Specialties Clinic, Pulmonary Disease 1. Measurement period: 1 year prior to measurement period end date 2. Continuous enrollment: From 2 years (730 days) prior to the index event date through 6 months (180 days) after the index event date 3. Anchor date: 6 months (180 days) after the index event 4. Gaps in enrollment: One 45-day gap allowed in each year prior to the index event date and in the 6 months after the index event date 5. Medical coverage: Yes 6. Drug coverage: No 7. Attribution time frame: 1 day, index event (there can be multiple providers on this date) 8. Exclusions apply: No 9. Age range: 42+ years 10. Intake period: 6 months prior to measurement period start date through 6 months prior to measurement period end date Summary of changes for In the denominator the following codes were added: HCPCS codes G0463 and T1015. These are all outpatient visit types Denominator Description: All patients aged 42 years and older as of the measurement period end date with a new diagnosis of or newly active chronic obstructive pulmonary disease (COPD) Eligibility Criteria Condition Description # Evnt Detailed Criteria Field Name Dimen Table Name Fact Table Name Timeframe Age is 42 years or older Age in Years >= 42 age_years demog eligibility At the end of the measurement year AND Has medical coverage Coverage Indicator Medical = Y medical_covg _ind plan eligibility From 2 years (730 days) prior to the index event date through 6 months (180 days) after the index event date Page 1

2 Claim Criteria Condition Description # Evnt Detailed Criteria Field Name Dimen Table Name At least one face-to-face encounter with a diagnosis of COPD (If the patient had more than one diagnosis of COPD, include only the first one as the index event date) AND No visits for COPD during the 2 years (730 days) prior to the index event date 1 Diagnosis code = COPD, Emphysema, or Chronic Bronchitis Value Sets AND (CPT Procedure Code = Outpatient, Observation, ED, or Acute Inpatient Value Sets OR Revenue Code UB = Outpatient, Observation, or Acute Inpatient Value Sets) dx_cd dx any_dx Fact Table Name fac_dtl prof_clm proc_cd proc fac_dtl prof_clm fac_revenue_ cd Timeframe From 6 months prior to the measurement period start date through 6 months prior to the measurement period end date 1 Use the same criteria specified above to identify COPD visit or admission From 2 years (730 days) to 1 day prior to the index event date. For an acute inpatient visit, use the admission date. proc fac_dtl Exclusion Criteria: None Numerator Description: For each patient who meets the denominator criteria, those who received a spirometry evaluation during the 2 years (730 days) prior to the index event date through 6 months (180 days) after the index event date Condition Description # Evnt Detailed Criteria Field Name Dimen Table Name A spirometry evaluation performed Fact Table Name 1 CPT Code = Spirometry Value Set proc_cd proc fac_dtl prof_clm Timeframe During the 2 years (730 days) prior to the index event date through 6 months (180 days) after the index event date Notes: 1. New for Fall In 2014, new Value Sets for codes were implemented. Outpatient revenue codes 057x-059x were removed. 3. In 2015, following codes were added to the denominator: HCPCS codes G0463 and T1015. These are all outpatient visit types. Page 2

3 APPENDIX COPD Value Set ICD-9-CM Diagnosis Chronic Obst Asthma NOS 496 ICD-9-CM Diagnosis Chronic Airway Obstruct NEC Emphysema Value Set 492.0, ICD-9-CM Diagnosis Emphysematous Chronic Bronchitis Value Set 491.0, 491.1, , 491.8, ICD-9-CM Diagnosis Chronic Bronchitis Spirometry Value Set CPT Breathing Capacity Test 94014, CPT Patient Recorded Spirometry CPT Review Patient Spirometry 94060, CPT Evaluation of Wheezing CPT Respiratory flow volume loop CPT Pulmonary Stress Test/Simple Outpatient Value Set CPT Office/Outpatient Visit - New CPT Office/Outpatient Visit Established CPT Office Consultation CPT Home Visit - New Patient CPT Home Visit - Est 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 E/M visit, new age Page 3

4 99391 CPT Per Pm Reeval - Est Pat - Inf CPT Prev Visit - Est - Age CPT Prev Visit - Est - Age CPT Preventive E/M visit, established age CPT Preventive Counseling - Indiv 99411, CPT Preventive Counseling - Group CPT Health Risk Assessment Test CPT Unlisted Preventive Service CPT Work Related Disability Exam CPT Disability Examination 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 All-inclusive clinic visit 0510 UB Revenue Code CLINIC 0511 UB Revenue Code CHRONIC PAIN CL 0512 UB Revenue Code DENTAL CLINIC 0513 UB Revenue Code PSYCH CLINIC 0514 UB Revenue Code OB-GYN CLINIC 0515 UB Revenue Code PEDS CLINIC 0516 UB Revenue Code URGENT CLINIC 0517 UB Revenue Code FAMILY CLINIC 0519 UB Revenue Code OTHER CLINIC 0520 UB Revenue Code FREESTAND CLINIC 0521 UB Revenue Code RURAL/CLINIC 0522 UB Revenue Code RURAL/HOME 0523 UB Revenue Code FR/STD FAMILY CLINIC 0526 UB Revenue Code FR/STD URGENT CLINIC 0527 UB Revenue Code FR/STD URGENT CLINIC 0528 UB Revenue Code FR/STD URGENT CLINIC 0529 UB Revenue Code OTHER FR/STD CLINIC 0982 UB Revenue Code PRO FEE/OUTPT 0983 UB Revenue Code PRO FEE/CLINIC Page 4

5 Observation Value Set CPT Observation care ED Value Set CPT Emergency Dept Visit 0450 UB Revenue Code EMERG ROOM 0451 UB Revenue Code ER/EMTALA 0452 UB Revenue Code ER/BEYOND EMTALA 0456 UB Revenue Code URGENT CARE 0459 UB Revenue Code OTHER EMER ROOM 0981 UB Revenue Code PRO FEE/ER Acute Inpatient Value Set CPT Initial Hospital Care CPT Subsequent Hospital Care 99238, CPT Hospital Discharge Day CPT Inpatient Consultation UB Revenue Code Critical Care - First Hour 0100 UB Revenue Code ALL INCL R&B/ANC 0101 UB Revenue Code ALL INCL R&B 0110 UB Revenue Code ROOM-BOARD/PVT 0111 UB Revenue Code MED-SUR-GY/PVT 0112 UB Revenue Code OB/PVT 0113 UB Revenue Code PEDS/PVT 0114 UB Revenue Code PSYCH/PVT 0119 UB Revenue Code OTHER/PVT 0120 UB Revenue Code ROOM-BOARD/SEMI 0121 UB Revenue Code MED-SUR-GY/2BED 0122 UB Revenue Code OB/2BED 0123 UB Revenue Code PEDS/2BED 0124 UB Revenue Code PSYCH/2BED 0129 UB Revenue Code OTHER/2BED 0130 UB Revenue Code ROOM-BOARD/3&4BED Page 5

6 0131 UB Revenue Code MED-SUR-GY/3&4BED 0132 UB Revenue Code OB/3&4BED 0133 UB Revenue Code PEDS/3&4BED 0134 UB Revenue Code PSYCH/3&4BED 0139 UB Revenue Code OTHER/3&4BED 0140 UB Revenue Code ROOM-BOARD/PVT/DLX 0141 UB Revenue Code MED-SUR-GY/PVT/DLX 0142 UB Revenue Code OB/PVT/DLX 0143 UB Revenue Code PEDS/PVT/DLX 0144 UB Revenue Code PSYCH/PVT/DLX 0149 UB Revenue Code OTHER/PVT/DLX 0150 UB Revenue Code ROOM-BOARD/WARD 0151 UB Revenue Code MED-SUR-GY/WARD 0152 UB Revenue Code OB/WARD 0153 UB Revenue Code PEDS/WARD 0154 UB Revenue Code PSYCH/WARD 0159 UB Revenue Code OTHER/WARD 0160 UB Revenue Code R&B 0164 UB Revenue Code R&B/STERILE 0167 UB Revenue Code R&B/SELF 0169 UB Revenue Code R&B/OTHER 0200 UB Revenue Code ICU 0201 UB Revenue Code ICU/SURGICAL 0202 UB Revenue Code ICU/MEDICAL 0203 UB Revenue Code ICU/PEDS 0204 UB Revenue Code ICU/PSTAY 0206 UB Revenue Code ICU/INTERMEDIATE 0207 UB Revenue Code ICU/BURN CARE 0208 UB Revenue Code ICU/TRAUMA 0209 UB Revenue Code ICU/OTHER 0210 UB Revenue Code CORONARY CARE 0211 UB Revenue Code CCU/MYO INFARC 0212 UB Revenue Code CCU/PULMONARY 0213 UB Revenue Code CCU/TRANSPLANT 0214 UB Revenue Code CCU/INTERMEDIATE 0219 UB Revenue Code CCU/OTHER Page 6

7 0720 UB Revenue Code DELIVROOM/LABOR 0721 UB Revenue Code LABOR 0722 UB Revenue Code DELIVERY ROOM 0723 UB Revenue Code CIRCUMCISION 0724 UB Revenue Code BIRTHING CENTER 0729 UB Revenue Code OTHER/DELIV-LABOR 0800 UB Revenue Code RENAL DIALYSIS 0801 UB Revenue Code DIALY/INPT 0802 UB Revenue Code DIALY/INPT/PER 0803 UB Revenue Code DIALY/INPT/CAPD 0804 UB Revenue Code DIALY/INPT/CCPD 0809 UB Revenue Code DIALY/INPT/OTHER 0987 UB Revenue Code PRO FEE/HOS VIS Page 7