Consumer Information Chartered Value Exchange
Health Plans Physician Resources Quality Ambulatory Measures
   Home About Us NewsEvents Links Contact Us
 
Physician Alliance OverviewEducational Resources10 NCQA Hedis Measures Description
Evidence-Based MedicineNYQA_HEDIS Specifications & Coding ToolsFAQ
NYQA HEDIS Measures Specification & Coding Tools

Reference:  NCQA 2008 Volume 2: Technical Specifications and HEDIS Electronic
Coding Tables

NYQA HEDIS Measures Specification & Coding Tools
The Adobe Acrobat Reader is a free download, and will allow you to view the Portable Document Format.
Click here to download the reader

Breast Cancer Screening Measure

DESCRIPTION- The percentage of women 40-69 years of age who had a mammogram to screen for breast cancer  during the measurement year and the year prior to the measurement year.

Diagnosis ICD – 9 Codes
 V 76.11, V76.12

Procedure ICD-9
87.36, 87.37

CPT Codes

76083, 76090-76092, 77055-77057

Exclusions Bilateral and Unilateral Mastectomy
Bilateral Mastectomy - CPT codes 19180, (19200, 19220, 19240, 19303-19307 with modifier .50 or modifier code 09950; ICD-9 Procedure codes 85.42, 85.44, 85.46 and 85.48)
Unilateral Mastectomy (members must have 2 separate occurrences on 2 different dates of service)
CPT codes (19180, 19200, 19220, 19240, 19303-19307;
ICD-9 Procedure codes 85.41, 85.43, 85.45, 85.47)

Chlamydia Screening in Women Measure

DESCRIPTION- The percentage of women 16-25 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.

Women who are sexually active:

Diagnosis ICD – 9 Codes
 042, 054.10, 054.11, 054.12, 054.19, 078.1, 078.88, 079.4, 079.51-079.53, 079.88, 079.98, 091-097, 098.0, 098.10, 098.11, 098.15-098.19, 098.2, 098.30, 098.31, 098.35-098.8, 099, 131, 614-616, 622.3, 623.4, 626.7, 628, 630-677, 795.0, 996.32, V01.6, V02.7, V02.8, V08, V15.7, V22-V28, V45.5, V61.5-V61.7, V69.2, V72.3, V72.4, V73.88, V73.98, V74.5, V76.2V 76.11, V76.12

Procedure ICD-9 Codes
69.01, 69.02, 69.51, 69.52, 69.7, 72-75, 97.24, 97.71, 97.73, 87.36, 87.37

CPT Codes
11975-11977, 57022, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58970, 58974, 58976, 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, 59850-59852, 59855-59857, 59866, 59870, 59871, 59897, 59898, 59899, 76801, 76805, 76811, 76813, 76815-76821, 76825-76828, 76941, 76945-76946, 80055, 81025, 82105, 82106, 82143, 82731, 83632, 83661-83664, 84163, 84702-84703, 86592-86593, 86631-86632, 87110, 87164, 87166, 87270, 87320, 87490-87492, 87590-87592, 87620-87622, 87660, 87800, 87801, 87808, 87810, 87850, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175, 88235, 88267,

Chlamydia Test CPT Codes

76813, 87110, 87270, 87270, 87320,87490,87491,87492, 87660, 87810, 87808

Exclusion - Members who had a pregnancy test during the measurement year, followed within seven days by either a prescription for Accutane or an x-rayThis exclusion does not apply to members who qualify based on services other than pregnancy test alone.

Pregnancy Test CPT codes 81025, 84702, 84703, WITH
Diagnostic Radiology CPT codes 70010-76499, Prescription for Accutane

Cervical Cancer Screening Measure

DESCRIPTION- The percentage of women 21-64 years of age who received one or more Pap tests to screen for cervical cancer.

Diagnosis ICD – 9 Codes
V72.32,V76.2

Procedure ICD-9 Codes
91.46

 CPT Codes

88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175

Exclusions  - Hysterectomy with no residual cervix

Codes to Identify Exclusions

CPT 51925, 56308, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58550-58554, 58951, 58953, 58954, 58956, 59135

ICD-9 Diagnosis 618.5, V67.01, V76.47

ICD-9 Procedure 68.4-68.8

Note:

  • Documentation of a “hysterectomy” does not meet the exclusion criteria. You must note hysterectomy with no residual cervix.
  • Count any cervical cancer screening method that includes collection and microscopic analysis of cervical cells. Lab results that state the sample was inadequate or that no cervical cells were collected is not considered appropriate screening.
  • Biopsies are not counted as they are considered diagnostic and therapeutic and not a screening tool.

Persistence of Beta - Blocker Treatment post AMI Measure

DESCRIPTION- The percentage of members 18 years of age and older who were hospitalized and discharged alive with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months ( 180 days) after discharge.

Diagnosis ICD – 9 Codes
410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91

Beta – Blocker Medications
(Circle the medication(s)
patient is receiving)

  1. Noncardioselective Beta-blockers( carteolol, carvedilol, labetalol, nadolol,penbutolol, pindolol, prpranolol, timolol, sotalol)
  2. Cardioselective Beta-blockers ( acebutolol, atenolol, betaxolol, bisoprolol, metoprolol)
  3. Antihypertensive combinations
    atenolol- chlorthalidone,
    bendroflumethiazide-nadolol, bisoprolol-hydrochlorothiazide, hydro-
    chlorothiazide-propranolol, and hydrochlorothiazide - timolol

ICD-9 Code ExclusionsContraindications or previous adverse reaction to beta-blocker therapy

History of Asthma  493
Hypotension 458
Heart Block > 1 degree 426.0, 426.12, 426.13,
426.2-426.4, 426.51-426.54, 426.7
Sinus Bradycardia 427.81
COPD 491.2, 496, 506.4

Diabetic Care Measures

DESCRIPTION- The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:

  • Hemoglobin A1c (HbA1c) testing
  • HbA1c poor control (>9.0%)
  • HbA1c good control (<7.0%)
  • Eye exam (retinal) performed
  • LDL-C screening
  • LDL-C control (<100 mg/dL)
  • Medical attention for nephropathy

There are two methods to identify a diabetic member- either through a dispensed insulin  or oral hypoglycemics/antihyperglycemic pharmacy data or with claims encounter codes.

Diabetes Diagnosis ICD – 9 Codes
250, 357.2, 362.0, 366.41, 648.0

CPT Office Visit Codes
92002-92014, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456, 99499

Exclusions:

  • Exclude members with a diagnosis of polycystic ovaries (ICD-9 Diagnosis Code is 256.4) who do not have face-to-face encounters with a diagnosis of diabetes during or year prior to measurement year.
  • Exclude members with gestational (ICD-9 Diagnosis code is 648.8) or steroid – induced diabetes (ICD9 Diagnosis codes are 251.8, 962.0) who do not have face-to-face encounters with a diagnosis of diabetes during or year prior to measurement year.

Measure

Description

Codes
HbA1c Testing

Defined as one test performed during
measurement year as identified by claim encounter or laboratory data.

CPT - 83036, 83037

 CPT  II- 3044F,3045F, 3046F,3047F
Eye Exam

An eye screening for diabetic retinal disease includes diabetics who have had one of the following: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) or a negative retinal exam by an eye careprofessional in the year prior to the measurement year.

Note: Blindness is not an exclusive for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind, but require a retinal exam, and those who are completely blind and therefore do not require an exam.

ICD-9 Diagnosis – V72.0
CPT - 67028, 67030, 67031, 67036, 67038-67040, 67101, 67105, 67107, 67108, 67110, 67112, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245

CPT II – 2022F,2024F,2026F,3072F
LDL-C Screening A LDL-C test performed during the measurement year as identified by claim/encounter or automated laboratory data.

CPT 80061,83700,83704,83715,83716,83721

CPT II – 3048F,3049F,3050F
Urine Protein Screening A positive urine macroalbumin test in the measurement year as documented by claim /encounter or laboratory data. Note: “trace “urine macroalbumin test results are not considered numerator-compliant.

CPT –
81000-81003,81005

CPT II – 3060F,3061F, 3062F

Appropriate Treatment for Children with Upper Respiratory Infection
Measure (URI)

DESCRIPTION- The percentage of children 3 months – 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.

Diagnosis ICD – 9 Codes

 
Acute Nasopharyngitis

(common cold) 460

URI

465
465.0
465.8
465.9

CPT Codes  

Office Visits
99201-99205, 99211- 99215,
99217-99220, 99241-99245,
99381-99385, 99391-99395,
99401-99404, 99411, 99412,
99420, 99429, 99499

 

Appropriate Testing for Children with Pharyngitis Measure

DESCRIPTION- The percentage of children 2-18 years of age who were diagnosed
with Pharyngitis, dispensed an antibiotic (as evidenced by a dispensed antibiotic prescription on or during the 3 days after the episode date and received a group A streptococcus (strep) test for the episode.

Diagnosis ICD – 9 Codes

Pharyngitis

462
Acute Tonsillitis   463
Strep.Sore Throat  034.0
CPT Codes
Office Visits
99201-99205, 99211- 99215,99217-99220, 99241-99245,
99382-99385, 99392-99395,
99401-99404, 99411, 99412,
99420, 99429, 99499

Group A Streptococcus Tests

87070, 87071, 87081, 87430, 87650-87652, 87880

 


Health Plans / Physician Alliance Resources / Quality Ambulatory Measures
The NYQA is supported in part by the New York State Department of Health Pay for Performance Demonstration Grant.
The NYQA is supported in part by the New York State Health Foundation.