Association between NCQA Patient-Centered Medical Home Recognition for Primary Care Practices and Quality of Care for Children with Disabilities and Special Health Care Needs. APPENDIX D: Specifications for Outcome Measures

01/01/2014

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  
1 month Excluded
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
  CPT Codes
(OT file)
ICD-9 Diagnosis Codes
(OT file)
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.
NOTE:
  1. Other codes not included in the HEDIS measure for wellness visits, but which are included in Bright Future's coding recommendations, include codes for preventive medicine counseling or risk reduction interventions for individuals (99401-99404) and for groups (99411-99412), smoking and tobacco use cessation counseling (99406-99407), and alcohol and substance abuse screening (99408-99409). Additionally, there are diagnosis codes for contraceptive surveillance and routine gynecologic examination (V72.31) not included in the HEDIS measure.

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
  Inclusions Exclusions
CPT code 99281-99285 90801-90899
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)  
99241-99245 11 (office)
99341-99350 12 (home)
99381-99429 22 (outpatient hospital)
90281-99091 26 (military treatment facility)
99500-99607 34 (hospice)
  49 (independent clinic)
  50 (federally-qualified health center)
  72 (rural health clinic)

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