1. Preventive Care Measures: Wellness Visits
Inclusion Criteria: For children under a year old at the end of the measurement year, all those continuously enrolled since 31 days after birth with no more than one gap in enrollment of 45 days or less. For children between the ages of one and 18 at the end of the measurement year, all those continuously enrolled for the full year with no more than one gap in enrollment of 45 days or less.
Exclusion Criteria: In MAX OT claims files, exclude lines with a CPT code between 70000 and 89999 (lab and imaging claims).
|TABLE D.1. Number of Expected EPSDT Wellness Visits During Year, by Child Age|
|Age at End of Measurement Year||Number of Expected Visits|
|2 - 3 months||1 visit|
|4 - 5 months||2 visits|
|6 - 8 months||3 visits|
|9 - 11 months||4 visits|
|12 - 13 months||5 visits|
|14 months||4 visits|
|15 months||5 visits|
|16 - 20 months||4 visits|
|21 - 26 months||3 visits|
|27 - 35 months||2 visits|
|36 months - 18 years||1 visit|
|SOURCE: Bright Futures Periodicity Schedule for EPSDT Visits.|
For all children, assess whether they had at least one well-child visit during the year. For children ages 0-35 months, calculate the share of expected wellness visits that occurred in the past year. If the number of well-child visits exceeds the expected number of well-child visits, as identified in Table D.1 for any given child, replace proportion with 100 percent.
|TABLE D.2. CPT and ICD-9 Diagnosis Codes for Well-Baby, Well-Child, and Well-Adolescent Visitsa|
|ICD-9 Diagnosis Codes
|Well-Baby Visits||99381, 99382, 99391, 99392, 99432, 99461||V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9|
|Well-Child Visits||99382, 99383, 99392, 99393||V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9|
|Well-Adolescent Visits||99383-99385, 99393-99395||V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9|
|SOURCE: CHIPRA Core Measures 10, 11, and 12. Note that lab and imaging claims (based on procedure codes) and types of service that indicate a non-professional claim are NOT considered in identifying well-baby, well-child, or well-adolescent visits.
2. Any Emergency Department Visits
This measure counts all ED visits, except those for mental health or substance abuse treatment. It also eliminates double-counting by only counting only one ED claim per child per day, regardless of the number of claims that the visit generated. Note that any claim meeting an exclusion criteria means the entire ED visit for that day should be excluded, even if other claims for that child on that day meet the inclusion criteria without meeting any of the exclusion criteria.
|TABLE D.3. Identifying ED Visits in MAX IP and OT Claims Files|
|UB revenue code||045x, 0981|
|CPT code AND POS||(CPT code 10040-69979) AND POS of 23|
|Principal diagnosis code||290-316, 960-979|
|Secondary diagnosis code||291-292, 303-305|
|ICD-9 procedure code||94.26, 94.27, 94.6|
|Other||Do not count more than 1 visit per child per day, regardless of the number of claims|
|SOURCE: CHIPRA Core Measure 18.|
3. Any Preventable or Avoidable ED Visits
Using the NYU Algorithm,1 count any ED visit (identified using the inclusion and exclusion criteria in Table III.7) where the diagnosis code has a 70 percent or greater chance of being: (1) non-emergent; (2) emergent but primary care treatable; or (3) emergent but preventable or avoidable. These are cases where NE+EPCT+EDCNPA>0.7 in the algorithm output. Additionally, count any ED visit where the primary diagnosis matches one of the diagnosis codes in Table D.4, even if it is not preventable in the NYU algorithm. If there are multiple claims for an ED visits in a single day (for example, both professional and facility claims relating to the same visit), then use the diagnosis codes on the facility claim (TOS=11) to determine whether the visit was preventable. (However, if only professional claims are available for the visit on that day, use the diagnosis codes on those claims.) Only one claim per ED visit should be evaluated in determining whether the visit was preventable.
|TABLE D.4. Pediatric Diagnoses Indicating Potential Avoidable ED Visit|
|Condition||ICD-9-CM Diagnosis Code|
|Asthma||493 (include all 493.xx)|
|Influenza, other viral symptoms||079, 480, 487, 780|
|Otitis media||381, 382, 384, 385|
|Allergic symptoms (including skin)||471, 472, 477, 690, 691, 692, 693, 695|
|Minor muscular/skeletal or sports injury||840, 841, 842, 843, 844, 845, 846, 847, 848, 910, 911, 913, 914, 915, 916, 917, 918, 919, 923, 924, 955, 956|
|Preventive, immunization, or well-child care||V03, V04, V05, V06, V07, V20, V67, V68, V69, V70|
|SOURCE: Eyal Ben-Isaac, Sheree Schrager, Matthew Keef, and Alex Chen. "National Profile of Non-emergent Pediatric Emergency Department Visits." Pediatrics, 2010, 125: 454.|
4. Any Inpatient Admissions
Using MAX IP file, de-duplicate interim claims with the same admission date, provider ID, and child ID (the end of service date may vary). Create flag for any inpatient admission. Exclude all stays for newborn infants and all mental health and substance abuse stays, identified using the diagnosis codes in Table D.5.
|TABLE D.5. Exclusions for Inpatient Stay Counts|
|Condition||ICD-9-CM Diagnosis Code||Diagnosis Position|
|Liveborn infants||V30-V39||Primary diagnosis|
|Health status codes||V87-V91||Primary diagnosis|
|Mental health condition||290-316||Primary diagnosis|
|Poisoning/overdose with alcohol or drug dependence or abuse||960-979 (primary) with 291-292 or 303-305 (secondary)||Primary diagnosis with secondary diagnosis|
|SOURCE: HEDIS 2010 Inpatient Utilization measure.|
5. Number of Ambulatory Care-Sensitive Inpatient Admissions
Inclusion Criteria: All children aged 3 months or older.
Using MAX IP file, de-duplicate interim claims with the same admission date, provider ID, and child ID (the end of service date may vary). Exclude all stays for newborn infants and all mental health and substance abuse stays, identified using the diagnosis codes in Table D.5. Create flag for ambulatory care-sensitive inpatient admissions where inpatient claims meet the inclusion and exclusion criteria in Table D.6. Evaluate each claim for each of the four types of admissions separately; an exclusion diagnosis or procedure means that claim should not be count towards the specific type of admission in the row but does not mean the claim might not count towards a different type of ambulatory care-sensitive admission. The inclusion and exclusion diagnoses refer to primary diagnoses except where otherwise noted. The child must be at least as old as the minimum age specified at the time of the claim in order for that claim to be counted.
|TABLE D.6. Inclusion and Exclusion Criteria for Ambulatory Care-Sensitive Inpatient Admissions|
|Type of Admission||Inclusion Diagnoses||Exclusion Diagnoses||Exclusion Procedure Codes||Minimum Age at Time of Claim|
|Asthma admissions||493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90-493.92||277.00-277.09, 516.61-516.69, 747.21, 748.3, 748.4, 748.5, 748.6, 748.8, 748.9, 750.3, 759.3, 770.7||2 years|
|Diabetes short-term complication admissions||250.10-250.13, 250.20-250.23, 250.30-250.33||5 years|
|Urinary tract infection admission||590.1, 590.11, 590.2, 590.3, 590.8, 590.81, 590.9, 595.0, 599.0||593.70-593.73, 753.0, 753.10-753.17, 753.19, 753.20-753.23, 753.29, 753.3, 753.4, 753.5, 753.6, 753.8, 753.9, (any diagnosis of 571.2 or 571.5 or 571.6 AND any diagnosis of 572.2 or 572.4)||335, 336, 375, 410, 505.1, 505.9, 528.0-528.3, 528.5, 528.6, 556.9||3 months|
|Gastroenteritis admissions||008.61-008.69, 008.8, 009.0-009.3, 558.9 as primary diagnosis OR (276.50-276.52 as primary diagnosis AND 008.61-008.69, 008.8, 009.0-009.3, 558.9 as secondary diagnosis)||535.70, 535.71, 538, 555.0-555.9, 556.0-556.9, 558.1-558.3, 558.41, 558.42, 579.0-579.9, 003.0, 004.0-004.3, 004.8, 004.9, 005.0-005.4, 005.8, 005.81, 005.89, 005.9, 006.0- 006.2, 007.0-007.5, 007.8, 007.9, 008.00-008.04, 008.09, 008.1-008.4, 008.41-008.47, 008.49, 008.5, 112.85||3 months|
|SOURCE: AHRQ QI, Pediatric Quality Indicators Overall Composite #90.|
6. Follow-Up Ambulatory Visit within 30 Days of ED Visit
For all kids with at least one ED visit between January and November, count the number of ED visits where the child was still enrolled in Medicaid in the next month. Note that the denominator is the number of ED visits in the first 11 months of the year and not the number of children. Count the number of ED visits in the denominator that were followed within 30 days by a non-inpatient visit to any provider in the OT file, identified in one of two ways: (1) using both the type of service (TOS) and place of service (POS) as shown in Table D.7. To be included, a claim must match to at least one of the TOS values AND one of the POS values. Exclude lab/imaging claims (CPT codes 70000-89999). Or (2) using procedure codes that represent ambulatory E&M visits and POS as shown in Table D.7a. To be included, a claim must match to at least one procedure code AND one of the POS values. Exclude lab/imaging claims.
|TABLE D.7. Inclusions for Follow-Up Visit|
|Type of Service||AND ANY:||Place of Service|
|08 (physician services)||05-08 (Indian Health Service or tribal facilities)|
|10 (other licensed practitioners)||11 (office)|
|12 (clinic services)||12 (home)|
|13 (home health services)||22 (outpatient hospital)|
|33 (rehabilitative services)||26 (military treatment facility)|
|34 (physical or occupational therapy)||34 (hospice)|
|35 (hospice services)||49 (independent clinic)|
|36 (nurse midwife)||50 (federally-qualified health center)|
|37 (nurse practitioner)||72 (rural health clinic)|
7. Follow-Up Ambulatory Care Visit within 30 Days of Inpatient Admission
For all kids with at least one inpatient hospital visit between January and November, count the number of visits where: (1) the child was still enrolled in Medicaid in the next month; (2) the child was discharged home (exclude transfers); and (3) there is not another inpatient admission within 30 days of discharge. Count the number of inpatient stays in the denominator that were followed within 30 days by a non-inpatient visit to any provider in the OT file, identified using both the TOS and POS as shown in Table D.7 and Table D.7a. To be included, a claim must match to at least one of the values AND one of the POS values.
|TABLE D.7a. Inclusions for Follow-Up Visit|
|CPT Code||AND ANY:||Place of Service|
|99201-99215||05-08 (Indian Health Service or tribal facilities)|
|99381-99429||22 (outpatient hospital)|
|90281-99091||26 (military treatment facility)|
|49 (independent clinic)|
|50 (federally-qualified health center)|
|72 (rural health clinic)|