Data Quality and Reporting Resource 5:

Documentation and Coding Playbook

©️ 2024 Kaiser Foundation Health Plan, Inc.

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This resource is part of the Data Quality & Reporting Implementation Guide, offering steps and activities to ensure your practice is capable of reporting valid and reliable data for selected population health measures. It is the first in the “Building the Foundation” series of implementation guides.

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Overview

The utility of performance measures depends upon accurate data that reflects the care and services patients receive. Through the Population Health Management Initiative (PHMI), community health centers (CHCs) will build capacity to compile and extract all internal data needed for reporting, ensuring no gaps. Accurate and timely medical coding of services provided in the CHC is essential to this process and to ensure efficient and accurate measure calculation.

This document defines the measure, assessment, documentation and coding standards aimed to meet numerator compliance with PHMI specifications for each core HEDIS measure for PHMI. In collaboration with the Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures, this document should be used as a starting point for improving the quality of data capture.

Measure-Specific Documentation and Coding Playbook for Core HEDIS Meaures for PHMI

For each core HEDIS measure for PHMI detailed in this playbook, the following categories and their definitions are included:

FIGURE 5.1: MEASURE-SPECIFIC DOCUMENTATION CATEGORIES WITH DESCRIPTION AND EXPLANATION


Category
Description & Explanation

Measure Definition
The high-level definition of the measure provides an understanding of the basic components needed to meet the criteria. It serves as a guide to review the medical record and understand if an assessment is being completed but not coded or captured.
The definition helps CHCs understand the specific types of assessments, tests or evaluations that must be completed to meet numerator compliance.

Documentation
Shows the specific pieces of documentation that need to be within the medical record to meet the criteria. Using these documentation criteria ensures the service is documented as a precursor to or in alignment with coding.
This helps CHC staff to understand how the provision of care, proper documentation in the medical record, and coding align and are used for measurement.

Standard Care Templates and Tools
A set of resource tools used to support CHCs in documenting the criteria that meets the standards for the provision of care for each measure. The standard care templates are tools that assist in ensuring accurate and complete documentation, including all critical assessments and elements necessary for compliance with the measure. Utilization of these ensures complete information for supplemental data in instances where necessary coding is missing and helps CHCs take advantage of opportunities to close care gaps and improve patient outcomes. This document references the critical elements that would be needed for a template of each measure and aligns these with and identifies where standard templates are required by the Department of Health Care Services (DHCS).

Exclusions
Some measures have exclusions or specific instances where an otherwise eligible patient would not be included in the measure. These exclusions may be documented in the medical record or coded, depending on the exclusion. Understanding the exclusions and how to properly document/code them will ensure that patients who are not intended to be within the measure are not improperly and adversely impacting measure performance.

Denominator
Defines each denominator to provide an understanding of the overall patient population that is applicable to the measure. The HEDIS Value Set Directory should be consulted for a complete list of denominator codes.

Numerator Billing Codes
Tables provide the applicable codes (e.g., CPT, CPT-II, ICD10CM) for the measure, and highlight, when relevant, the best codes to use (i.e., those that capture the most complete data). The tables provide a coding description to educate staff on the types of codes that would meet numerator compliance and ensure efficient and accurate measure calculation.

By understanding the assessments required for the measure and the documentation that aligns with them, CHCs are best positioned to understand the typical standard codes that should be used.

Best Practices for Medical Coding for Performance Measures

CHCs play a crucial role in the California safety net by providing care and services to an important and underserved patient population. To ensure performance measures are based on accurate data that reflect the care and services patients receive, coding must be completed and performed in a timely manner. CHCs can ensure success in performance measures by:

  • Knowing PHMI/HEDIS measures documentation requirements and specific parameters.
  • Providing appropriate care within the designated measure time frames.
  • Documenting all the care provided to patients, including dates of service clearly and accurately in the medical record.
  • Accurately and consistently documenting within standard data fields where applicable (see the Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures tool for more information).
  • Accurately and timely coding all claims/encounters, using HEDIS-specific billing codes when appropriate

Types of Codes Indicated in this Document

Measure-specific numerator billing coding include the following code types:

FIGURE 5.2: CODING TYPES


Code System
Description

CPT
Current Procedural Terminology (CPT®) codes are an American Medical Association (AMA)-led uniform system of coding medical services, including evaluation and management services.

CPT-II
Current Procedural Terminology (CPT®) Category-II (CPT-II) codes are supplemental tracking codes that support quality and performance measurement data collection. Unlike CPT codes, CPT-II codes also indicate the result of an assessment rather than indicating only an assessment was performed.

G-Codes/HCPCS
Healthcare Common Procedure Coding System (HCPCS) is produced by the Centers for Medicare and Medicaid Services (CMS) and is a standardized coding set for medical procedures, supplies, products, and services. G-codes are HCPCS codes used to report a patient’s functional limitation being treated.

ICD10CM
International Classification of Diseases (ICD)-10-CM codes classify diagnoses and reasons for visits. ICD-10-CM is published by the United States and based on the World Health Organization (WHO)’s ICD-10 codes.

LOINC
Logical Observation Identifiers Names and Codes (LOINC®) codes are clinical codes indicating laboratory test orders and results.

SNOMED CT US Edition
Systemized Nomenclature of Medicine – Clinical Terms United States Edition (SNOMED CT US Edition) are coded terms used within electronic health records to capture, record and share clinical data; gaining use in U.S. systems to be compliant with stage two of meaningful use.

UBREV
Uniform Billing Revenue (UBREV) codes are billing codes used by institutional providers.

Coding Playbook Process Guidelines

Working with practice coaches and subject matter experts (SMEs), CHCs should follow the below steps to understand the assessment, documentation and coding that meets the measure criteria. This process is a starting point for improving data capture quality and should align with the Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures.

Step 1: Understand current coding and documentation patterns.

  • Feedback from the CHC team should include, but not be limited to:
  • Information Technology (IT) and data team: to understand data sources and data flow to ensure all data available is being counted and calculated.
  • Providers and clinicians: to identify key opportunities to understand measure specifications and documentation tools/care templates/flow sheets/progress notes used with a focus on assessment and documentation that meet measure criteria.
  • Claims and coding staff: to understand the process for capturing the care and services and coding appropriately and completely.
  • Medical assistants (MAs) and reception staff: MAs and other key staff who work to check in patients, take vital signs and carry out the physician’s orders. The MAs are the key backbone to ensuring the details are addressed.

Step 2: Identify opportunities for improvement.

To develop a strong process for identifying gaps, defining the type of gap (data or service) and taking the effective steps to address each, CHCs should:

  • Educate providers and office staff on the core HEDIS measures for PHMI:
    • Who qualifies for the measure?
    • What assessment is required?
    • What documentation counts?
    • How to code and report this data?
  • Engage the providers and staff to utilize care templates and tools to ensure complete assessment and documentation is being done within the medical record, thereby improving the opportunity to have services properly coded.
  • Engage the data team to assess sources of data and identify any additional sources (e.g., HIE, lab vendors, registries, ADT feeds) that can further impact rates (see Data Quality and Reporting Resource 6: External Data Acquisition for process).
  • Engage the data team to develop and code a monthly internal process for tracking PHMI/HEDIS measures proactively for interventions and reporting.
  • Engage the claims and coding staff to improve coding practices, including coding specificity, to further capture detailed data such as result data with CPT-II codes rather than LOINC and CPT codes.
  • Engage the IT staff in understanding if any encounter clearinghouse is processing data and how to work with error/exception data to correct at the source.
  • Educate medical staff on the measures so they recognize opportunities to complete services when the patient comes in for other services.
  • Utilize the Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures tool as needed to identify opportunities to maximize use of standard data fields.

Step 3: Develop and solidify an ongoing process.

Practice coaches and SMEs should make recommendations that help coordinate/ align with ongoing processes for monthly data tracking with each CHC (described in the Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures). This process could include:

  • Actions to ensure proper medical record documentation and use of care templates. For example, building out or changing templates or implementation of additional DHCS-supported tools.
  • Actions to ensure proper coding:
    • Develop a process for capturing gaps in listing group/clinic/provider in electronic health record (EHR) data pulls that includes the utilization of this playbook and ID data; code appropriately for capture.
    • Develop a standardized file submission process and submission tool (see population-level standard data fields).
    • Educate IT contact for group/clinic/provider on population of file tool from EHR data to send data back.
    • Work with staff to set reminders and check gaps listing when patients are scheduled.
  • Develop policies and procedures as needed to ensure sustainability of ongoing processes. Policies and procedures for the CHC sites could include, but are not limited to, the following subjects:
    • Data sources and capture (includes a data sources log and cadence).
    • Coding best practices for completeness and accuracy.
    • Identification of care gaps.
    • Steps to address data gaps.
    • Steps to address service gaps.
    • Best practices in practice management.
    • Outreach to patients:
      • Reminder calls, emails, text messages, mailings.
      • Educational materials.
    • Episodic visit opportunities.
    • Pre-appointment preparations:
      • Review gaps.
      • Prepare orders.
    • Vital signs (not crossing legs, resting before taking, retaking high readings).
    • Utilization of template tools to support complete documentation.
      • Utilization of preferred codes.
      • Utilization of services that give longer time frames.Best practices in coding:

The Seven Core Measures Specifications for PHMI are detailed below.

Hemoglobin A1c Control for Patients With Diabetes (Poor Control >9%) [HBD]

Measure Description

The percentage of patients 18–75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year: HbA1c poor control (> 9%).

Documentation

Documentation in medical record or lab result must include a note indicating the date when the HbA1c test was performed and result or finding during the measurement year:

  • A1c.
  • HbA1c.
  • HgbA1c.
  • Hemoglobin A1c.
  • Glycohemoglobin A1c.
  • Glycohemoglobin.
  • Glycated hemoglobin.
  • Glycosylated hemoglobin.

Exclusions

  • Patients who did not have a diagnosis of diabetes in the measurement year or year prior and who had a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes.
  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.
  • Patients receiving palliative care in the measurement year.
  • Medicare patients 66 years of age and older as of December 31 of the measurement year who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.
    • Living long-term in an institution any time during the measurement year.
  • Patients 66 years of age and older as of December 31 of the measurement year with frailty and advanced illness during the measurement year. To identify patients with advanced illness, any of the following during the measurement year or the year prior to the measurement year meet criteria:
    • At least two outpatient visits, observation visits, emergency department visits or non-acute inpatient encounters on different dates of service with an advanced illness diagnosis.
    • At least one acute inpatient encounter with an advanced illness diagnosis.
  • Dispensed dementia medication:
    • Cholinesterase inhibitors, including Donepezil, Galantamine, and Rivastigmine.
    • Miscellaneous central nervous system agents, including Memantine.

Denominator

Diagnosis of diabetes in the measurement year and the year prior to the measurement year.

Numerator Billing Codes

All the codes below are used to capture the HbA1c test. The CPT-II codes are preferred because they represent the result as well as the test. The other allowable codes do not indicate the test result and could trigger the need for a medical record review.

FIGURE 5.3: HBA1C TESTS/CONTROL (CPT/CPT-II) (PREFERRED CODES IN BOLD)


Code
Service Completed Definition
Code System

Preferred Codes

3046F
HbA1c Test with Result >9%
CPT-II

Other Allowable Codes

83036
HbA1c test (code does not provide result).
CPT

83037
HbA1c test (code does not provide result).
CPT

17856-6
HbA1c test (Lab Code does not provide result).
LOINC

4548-4
HbA1c test (Lab Code does not provide result).
LOINC

4549-2
HbA1c test (Lab Code does not provide result).
LOINC

96595-4
HbA1c test (Lab Code does not provide result).
LOINC

43396009
HbA1c test (Lab Code does not provide result).
SNOMED

313835008
HbA1c test (Lab Code does not provide result).
SNOMED

451061000124104
Hemoglobin A1c greater than nine percent indicating poor diabetic control (finding).
SNOMED

Note: Additional HbA1c CPT-II codes identify patients who are not compliant with the measure (i.e., the codes indicate the patient’s HbA1c was in good control). While these codes would not meet the measure and are not identified in the table, the codes are valuable indicators of patients who should still be monitored to ensure continued good control:

  • 3044F; HbA1c test with result <7%.
  • 3045F; HbA1c test with result 7% - 9%.

Controlling High Blood Pressure [CBP]

Measure Description

The percentage of patients 18–85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year.

Documentation

Patients who had at least two visits on different dates of service with a diagnosis of hypertension during the measurement year or the year prior to the measurement year. Only one of the two visits may be a telephone visit, an online assessment or a telehealth visit. Any of the following combinations meet criteria:

  • Outpatient visit with or without a telehealth modifier, with any diagnosis of hypertension.
  • A telephone visit with any diagnosis of hypertension.
  • An online assessment with any diagnosis of hypertension.

Identify the most recent BP reading noted during the measurement year. The BP reading must occur on or after the date when the second diagnosis of hypertension occurred.

  • BP readings from remote monitoring devices that are digitally stored and transmitted to the provider may be included. There must be documentation in the medical record that clearly states the reading was taken by an electronic device, and results were digitally stored and transmitted to the provider.
  • Do not include BP readings:
    • Taken during an acute inpatient stay or an ED visit.
    • Taken on the same day as a diagnostic test or diagnostic/therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
    • Blood pressure taken by patient using a non-digital device such as a manual blood pressure cuff and stethoscope.

Exclusions

  • Patients with evidence of ESRD, dialysis, nephrectomy or kidney transplant at any time in the patient’s history or prior to the end of the measurement year.
  • Patients with a diagnosis of pregnancy during the measurement year.
  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.
  • Patients receiving palliative care in the measurement year.
  • Medicare patients 66 years of age and older as of December 31 of the measurement year who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.
    • Living long-term in an institution any time during the measurement year.
  • Patients 66 years of age and older as of December 31 of the measurement year with frailty and advanced illness during the measurement year. To identify patients with advanced illness, any of the following during the measurement year or the year prior to the measurement year meet criteria:
    • At least two outpatient visits, observation visits, ED visits, or non-acute inpatient encounters on different dates of service with an advanced illness diagnosis.
    • At least one acute inpatient encounter with an advanced illness diagnosis.
  • Dispensed dementia medication:
    • Cholinesterase inhibitors, including Donepezil, Galantamine, and Rivastigmine.
    • Miscellaneous central nervous system agents, including Memantine.

Denominator

Patients who had at least two visits on different dates of service with a diagnosis of hypertension during the first six months of the measurement year or the year prior to the measurement year.

Numerator Billing Codes

The codes below are used to capture a numerator-compliant blood pressure (BP) readings (i.e., below 140/90 mm Hg).

FIGURE 5.4: CBP NUMERATOR CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

Preferred Codes

3074F
Systolic pressure <130 mm Hg.
CPT-II

3075F
Systolic pressure 130-139 mm Hg.
CPT-II

3078F
Diastolic pressure <80 mm Hg.
CPT-II

3079F
Diastolic pressure 80-89 mm Hg.
CPT-II

Other Allowable Codes

75997-7
Systolic blood pressure by continuous non-invasive monitoring.
LOINC

8459-0
Systolic blood pressure - sitting.
LOINC

8460-8
Systolic blood pressure - standing.
LOINC

8461-6
Systolic blood pressure - supine.
LOINC

8480-6
Systolic blood pressure.
LOINC

8508-4
Brachial artery systolic blood pressure.
LOINC

8546-4
Brachial artery - left systolic blood pressure.
LOINC

8547-2
Brachial artery - right systolic blood pressure.
LOINC

89268-7
Systolic blood pressure - lying in L-lateral position.
LOINC

271649006
Systolic blood pressure (observable entity).
SNOMED

Note: Additional systolic/diastolic pressure CPT-II codes identify patients who are not compliant with the measure (i.e., the codes indicate the patient’s blood pressure is not in good control). While these codes would not meet the measure and are not identified in the table, the codes are valuable indicators of patients who need follow-up for high blood pressure in order to achieve numerator compliance and should be tracked:

  • 3077F; Systolic pressure >140 mm Hg.
  • 3080F; Diastolic pressure >90 mm Hg.

Prenatal and Postpartum Care (Postpartum Care) [PPC]

Measure Description

The percentage of deliveries of live births that had a postpartum visit on or between seven and 84 days after delivery.

Note: HEDIS date ranges of live births are redefined for PHMI to accommodate quarterly reporting:

  • Quarter 1: live births on or between January 6 of the prior year and January 5 of the current year.
  • Quarter 2: live births on or between April 7 of the prior year and April 6 of the current year.
  • Quarter 3: live births on or between July 8 of the prior year and July 7 of the current year.
  • Quarter 4: live births on or between October 8 of the prior year and October 7 of the current year.

Documentation

Documentation of a postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other PCP on or between seven and 84 days after delivery. Must include a note indicating the date when a postpartum visit occurred and one of the following:

  • Pelvic exam.
  • Evaluation of weight, BP, breasts and abdomen:
    • Notation of “breastfeeding” is acceptable for the “evaluation of breasts” component.
    • Notation of “abdominal wound healing” is acceptable for abdominal assessment.
  • Notation of postpartum care including but not limited to:
    • Postpartum care, postpartum check, six-week check.
    • Preprinted “Postpartum Care” form in which information was documented during the visit.
    • Perineal or cesarean incision wound check.
    • Screening for depression, anxiety, tobacco use, substance use disorder or preexisting mental health disorders.
    • Glucose screening for patients with diabetes.
    • Documentation of any of the following topics:
      • Infant care or breastfeeding.
      • Resumption of intercourse, birth spacing or family planning.
      • Sleep/fatigue.
      • Resumption of physical activity and attainment of health weight.

Care Templates

Care templates that can help to capture documentation related to postpartum visits including those that comply with and include components of American College of Obstetrics and Gynecology (ACOG) recommendations[1] or the Comprehensive Perinatal Services Program (CPSP) Postpartum Assessment and Individualized Care Plan form.[2] CHCs with CPSP providers can utilize these forms to ensure proper postpartum visit information is captured.

Exclusions

  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.

Denominator

Deliveries of live births.

Note: HEDIS date ranges of live births are redefined for PHMI to accommodate quarterly reporting:

  • Quarter 1: live births on or between January 6 of the prior year and January 5 of the current year
  • Quarter 2: live births on or between April 7 of the prior year and April 6 of the current year
  • Quarter 3: live births on or between July 8 of the prior year and July 7 of the current year
  • Quarter 4: live births on or between October 8 of the prior year and October 7 of the current year

Numerator Billing Codes

All the codes below are used to identify a postpartum visit, and each would count as numerator-positive within time frames.

FIGURE 5.5: PPC NUMERATOR CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

59400
Postpartum care visit.
CPT

59410
Postpartum care visit.
CPT

59510
Postpartum care visit.
CPT

59515
Postpartum care visit.
CPT

59610
Postpartum care visit.
CPT

59614
Postpartum care visit.
CPT

59618
Postpartum care visit.
CPT

59622
Postpartum care visit.
CPT

57170
Postpartum care visit.
CPT

58300
Postpartum care visit.
CPT

59430
Postpartum care visit.
CPT

88141
Cytopathology, cervical or vaginal (any reporting system); requires interpretation by physician; used to report smears that require separate interpretation by a physician.
CPT

88142
Cytopathology screening procedures
CPT

88143
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation.
CPT

88147
Cytopathology screening procedures.
CPT

88148
Cytopathology screening procedures.
CPT

88150
Cytopathology screening procedures.
CPT

88152
Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision, describes an improved technology using optical imaging equipment to routinely evaluate negative smears.
CPT

88153
Cytopathology screening procedures.
CPT

88164
Cytopathology screening procedures.
CPT

88165
Cytopathology screening procedures.
CPT

88166
Cytopathology screening procedures.
CPT

88167
Cytopathology, slides, cervical or vaginal (the Bethesda System).
CPT

88174
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation.
CPT

88175
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation.
CPT

99501
Postpartum care visit.
CPT

0503F
Postpartum care visit (prenatal).
CPT-II

G0101
Cervical or vaginal cancer screening; pelvic and clinical breast examination.
HCPCS

G0123
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation; screening by cytotechnologist under physician supervision.
HCPCS

G0124
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation requiring interpretation by physician.
HCPCS

G0141
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening requiring interpretation by physician.
HCPCS

G0143
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation with manual screening and rescreening by cytotechnologist under physician supervision.
HCPCS

G0144
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation with screening by automated system under physician supervision.
HCPCS

G0145
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin-layer preparation, with screening by automated system and manual rescreening under physician supervision.
HCPCS

G0147
Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision.
HCPCS

G0148
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening.
HCPCS

P3000
Screening Papanicolaou smear, cervical or vaginal, up to three smears by technician under physician supervision.
HCPCS

P3001
Screening Papanicolaou smear, cervical or vaginal, up to three smears requiring interpretation by physician.
HCPCS

Q0091
Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.
HCPCS

Z01.411
Encounter for gynecological examination (general, routine) with abnormal findings.
ICD10CM

Z01.419
Encounter for gynecological examination (general, routine) without abnormal findings.
ICD10CM

Z01.42
Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear.
ICD10CM

Z30.430
Encounter for insertion of intrauterine contraceptive device.
ICD10CM

Z39.1
Encounter for care and examination of lactating mother.
ICD10CM

Z39.2
Encounter for routine postpartum follow-up.
ICD10CM

10524-7
Microscopic observation (identifier) in cervix by cyto stain.
LOINC

18500-9
Microscopic observation (identifier) in cervix by cyto stain, thin prep.
LOINC

19762-4
General categories (interpretation) of cervical or vaginal smear or scraping by cyto stain.
LOINC

19764-0
Statement of adequacy [Interpretation] of Cervical or vaginal smear or scraping by cyto stain.
LOINC

19765-7
Microscopic observation (identifier) in cervical or vaginal smear or scraping by cyto stain.
LOINC

19766-5
Microscopic observation (identifier) in cervical or vaginal smear or scraping by cyto stain narrative.
LOINC

19774-9
Cytology study comment test result, cervical or vaginal smear or scraping by cyto stain.
LOINC

33717-0
Cervical and/or vaginal cytology study.
LOINC

47527-7
Cytology report of cervical or vaginal smear or scraping by cyto stain, thin prep.
LOINC

47528-5
Cytology report of cervical or vaginal smear or scraping by cyto stain.
LOINC

133906008
Postpartum care (regime/therapy).
SNOMED

133907004
Episiotomy care (regime/therapy).
SNOMED

168406009
Severe dyskaryosis on cervical smear cannot exclude invasive carcinoma (finding).
SNOMED

168407000
Cannot exclude glandular neoplasia on cervical smear (finding).
SNOMED

168408005
Cervical smear - atrophic changes (finding).
SNOMED

168410007
Cervical smear - borderline changes (finding).
SNOMED

168414003
Cervical smear - inflammatory change (finding).
SNOMED

168415002
Cervical smear - no inflammation (finding).
SNOMED

168416001
Cervical smear - severe inflammation (finding).
SNOMED

168424006
Cervical smear - koilocytosis (finding).
SNOMED

169762003
Postnatal visit (regime/therapy).
SNOMED

169770008
Postnatal - eighth day visit (regime/therapy).
SNOMED

169771007
Postnatal - ninth day visit (regime/therapy).
SNOMED

169772000
Postnatal - tenth day visit (regime/therapy).
SNOMED

171149006
Screening for malignant neoplasm of cervix (procedure).
SNOMED

250538001
Dyskaryosis on cervical smear (finding).
SNOMED

268543007
Cancer cervix - screening done (finding).
SNOMED

269957009
Cervical smear result (finding).
SNOMED

269958004
Cervical smear - negative (finding).
SNOMED

269959007
Cervical smear - mild dyskaryosis (finding).
SNOMED

269960002
Cervical smear - severe dyskaryosis (finding).
SNOMED

269961003
Cervical smear - moderate dyskaryosis (finding).
SNOMED

269963000
Cervical smear - viral inflammation unspecified (finding).
SNOMED

275805003
Viral changes on cervical smear (finding).
SNOMED

281101005
Smear: no abnormality detected - no endocervical cells (finding).
SNOMED

309081009
Abnormal cervical smear (finding).
SNOMED

310841002
Cervical smear - mild inflammation (finding).
SNOMED

310842009
Cervical smear - moderate inflammation (finding).
SNOMED

384634009
Postnatal maternal examination (procedure).
SNOMED

384635005
Full postnatal examination (procedure).
SNOMED

384636006
Maternal postnatal six-week examination (procedure).
SNOMED

408883002
Breastfeeding support (regime/therapy).
SNOMED

408884008
Breastfeeding support management (procedure).
SNOMED

408886005
Breastfeeding support assessment (procedure).
SNOMED

409018009
Postpartum care assessment (procedure).
SNOMED

409019001
Postpartum care management (procedure).
SNOMED

416030007
Cervicovaginal cytology - low-grade squamous intraepithelial lesion (finding)
SNOMED

416032004
Cervicovaginal cytology normal or benign (finding)
SNOMED

416033009
Cervicovaginal cytology: High grade squamous intraepithelial lesion or carcinoma (finding).
SNOMED

416107004
Cervical cytology test (procedure).
SNOMED

417036008
Liquid-based cervical cytology screening (procedure).
SNOMED

431868002
Initiation of breastfeeding (regime/therapy).
SNOMED

439074000
Dysplasia on cervical smear (finding).
SNOMED

439776006
Cervical Papanicolaou smear positive for malignant neoplasm (finding).
SNOMED

439888000
Abnormal cervical Papanicolaou smear (finding).
SNOMED

440085006
Home visit for postpartum care and assessment (procedure).
SNOMED

440623000
Microscopic examination of cervical Papanicolaou smear (procedure).
SNOMED

441087007
Atypical squamous cells of undetermined significance on cervical Papanicolaou smear (finding).
SNOMED

441088002
Atypical squamous cells on cervical Papanicolaou smear cannot exclude high-grade squamous intraepithelial lesion (finding).
SNOMED

441094005
Atypical endocervical cells on cervical Papanicolaou smear (finding).
SNOMED

441219009
Atypical glandular cells on cervical Papanicolaou smear (finding).
SNOMED

441667007
Abnormal cervical Papanicolaou smear with positive human papillomavirus deoxyribonucleic acid test (finding).
SNOMED

700399008
Cervical smear - borderline change in squamous cells (finding).
SNOMED

700400001
Cervical smear - borderline change in endocervical cells (finding).
SNOMED

717810008
Routine postpartum follow-up (regime/therapy).
SNOMED

1155766001
Nuclear abnormality in cervical smear (finding).
SNOMED

448651000124104
Microscopic examination of cervical Papanicolaou smear and human papillomavirus deoxyribonucleic acid detection cotesting (procedure).
SNOMED

62051000119105
Low-grade squamous intraepithelial lesion on cervical Papanicolaou smear (finding).
SNOMED

62061000119107
High-grade squamous intraepithelial lesion on cervical Papanicolaou smear (finding).
SNOMED

98791000119102
Cytological evidence of malignancy on cervical Papanicolaou smear (finding).
SNOMED

Colorectal Cancer Screening [COL]

Measure Description

The percentage of patients 45-75 years of age who have had an appropriate screening for colorectal cancer.

Documentation

Medical records must include a note indicating the date when the colorectal cancer screening was performed.

  • A result is not required if the documentation is clearly part of the medical history. ƒ Fecal occult blood test (FOBT/iFOBT) completed during the measurement year.
  • Flexible sigmoidoscopy completed during the measurement year or four years prior to the measurement year.
  • Colonoscopy completed during the measurement year or nine years prior to the measurement year.
    • Abbreviations are not acceptable (e.g., Colo 2014, Col 2014). The documentation needs to include the full name (e.g., colonoscopy) and the date rendered.
  • CT colonography during the measurement year or four years prior to the measurement year.
  • FIT-DNA test during the measurement year or two years prior to the measurement year.

Exclusions

Either of the following any time during the patient’s history through December 31 of the measurement year:

  • Colorectal cancer.
  • Total colectomy

FIGURE 5.6: COL EXCLUSION CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

G0213-G0215, G0231
Colorectal cancer exclusion
G-Code/HCPCS

C18.0-C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z85.048
Colorectal cancer exclusion
ICD10CM

44150-44153, 44155-44158, 44210-44212
Total colectomy exclusion
CPT

0DTE0ZZ, 0DTE4ZZ
0DTE7ZZ, 0DTE8ZZ
Total colectomy exclusion
ICD10CM

Additional exclusions:

  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.
  • Patients receiving palliative care in the measurement year.
  • Medicare patients 66 years of age and older as of December 31 of the measurement year who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.
    • Living long-term in an institution any time during the measurement year.
  • Patients 66 years of age and older as of December 31 of the measurement year with frailty and advanced illness during the measurement year. To identify patients with advanced illness, any of the following during the measurement year or the year prior to the measurement year meet criteria:
    • At least two outpatient visits, observation visits, ED visits or non-acute inpatient encounters on different dates of service with an advanced illness diagnosis.
    • At least one acute inpatient encounter with an advanced illness diagnosis.
    • Dispensed dementia medication.
      • Cholinesterase inhibitors, including Donepezil, Galantamine, and Rivastigmine.
      • Miscellaneous central nervous system agents, including Memantine.

Denominator

Patients aged 45-75 years.

Numerator Billing Codes

All the codes below are used to capture a screening for colorectal cancer and would be numerator-compliant within time frames. Depending upon the type of screening used, the patient can be compliant with preventive guidelines for longer periods of time without needing a rescreening.

FIGURE 5.7: COL NUMERATOR CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

82270
FOBT (annually).
CPT

82274
FOBT (annually).
CPT

G0328
FOBT (annually).
G-Code/HCPCS

12503-9
Hemoglobin, gastrointestinal (presence) in stool - fourth specimen.
LOINC

12504-7
Hemoglobin, gastrointestinal (presence) in stool - fifth specimen.
LOINC

14563-1
Hemoglobin, gastrointestinal (presence) in stool - first specimen.
LOINC

14564-9
Hemoglobin, gastrointestinal (presence) in stool - second specimen.
LOINC

14565-6
Hemoglobin, gastrointestinal (presence) in stool - third specimen.
LOINC

2335-8
Hemoglobin, gastrointestinal (presence) in stool.
LOINC

27396-1
Hemoglobin, gastrointestinal (mass/mass) in stool.
LOINC

27401-9
Hemoglobin, gastrointestinal (presence) in stool - sixth specimen.
LOINC

27925-7
Hemoglobin, gastrointestinal (presence) in stool - seventh specimen.
LOINC

27926-5
Hemoglobin, gastrointestinal (presence) in stool - eighth specimen.
LOINC

29771-3
Hemoglobin, gastrointestinal, lower (presence) in stool by immunoassay.
LOINC

56490-6
Hemoglobin, gastrointestinal, lower (presence) in stool by immunoassay - second specimen.
LOINC

56491-4
Hemoglobin, gastrointestinal, lower (presence) in stool by immunoassay - third specimen.
LOINC

57905-2
Hemoglobin, gastrointestinal,lower (presence) in stool by Immunoassay - first specimen.
LOINC

58453-2
Hemoglobin, gastrointestinal, lower (mass/volume) in stool by immunoassay.
LOINC

80372-6
Hemoglobin, gastrointestinal (presence) in stool by rapid immunoassay.
LOINC

104435004
Screening for occult blood in feces (procedure).
SNOMED

441579003
Measurement of occult blood in stool specimen using immunoassay (procedure).
SNOMED

442067009
Measurement of occult blood in two separate stool specimens (procedure).
SNOMED

442516004
Measurement of occult blood in three separate stool specimens (procedure).
SNOMED

442554004
Guaiac test for occult blood in feces specimen (procedure).
SNOMED

442563002
Measurement of occult blood in single stool specimen (procedure).
SNOMED

59614000
Occult blood in stools (finding).
SNOMED

167667006
Fecal occult blood - negative (finding).
SNOMED

389076003
Fecal occult blood - trace (finding).
SNOMED

45330-45335
Flexible sigmoidoscopy (every five years).
CPT

45337-45338
Flexible sigmoidoscopy (every five years).
CPT

45340-45342
Flexible sigmoidoscopy (every five years).
CPT

45345-45347
Flexible sigmoidoscopy (every five years).
CPT

45349
Flexible sigmoidoscopy (every five years).
CPT

45350
Flexible sigmoidoscopy (every five years).
CPT

G0104
Flexible sigmoidoscopy (every five years).
G-Code/HCPCS

44441009
Flexible fiber-optic sigmoidoscopy (procedure).
SNOMED

396226005
Flexible fiber-optic sigmoidoscopy with biopsy (procedure).
SNOMED

425634007
Diagnostic endoscopic examination of lower bowel and sampling for bacterial overgrowth using fiber-optic sigmoidoscope (procedure).
SNOMED

841000119107
History of flexible sigmoidoscopy (situation).
SNOMED

44388-44394
Colonoscopy (every 10 years).
CPT

44397
Colonoscopy (every 10 years).
CPT

44401-44408
Colonoscopy (every 10 years).
CPT

45355
Colonoscopy (every 10 years).
CPT

45378-45393
Colonoscopy (every 10 years).
CPT

45398
Colonoscopy (every 10 years).
CPT

G0105
Colonoscopy (every 10 years).
G-Code/HCPCS

G0121
Colonoscopy (every 10 years).
G-Code/HCPCS

45.22
Endoscopy of large intestine through artificial stoma.
ICD9

45.23
Colonoscopy.
ICD9

45.25
Closed (endoscopic) biopsy of large intestine.
ICD9

45.42
Endoscopic polypectomy of large intestine.
ICD9

45.43
Endoscopic destruction of other lesion or tissue of large intestine.
ICD9

8180007
Fiberoptic colonoscopy through colostomy (procedure).
SNOMED

12350003
Colonoscopy with rigid sigmoidoscope through colotomy (procedure).
SNOMED

25732003
Fiberoptic colonoscopy with biopsy (procedure).
SNOMED

34264006
Intraoperative colonoscopy (procedure).
SNOMED

73761001
Colonoscopy (procedure).
SNOMED

174158000
Open colonoscopy (procedure).
SNOMED

174185007
Diagnostic fiber-optic endoscopic examination of colon and biopsy of lesion of colon (procedure).
SNOMED

235150006
Total colonoscopy (procedure).
SNOMED

235151005
Limited colonoscopy (procedure).
SNOMED

275251008
Diagnostic endoscopic examination of colon using fiber-optic sigmoidoscope (procedure).
SNOMED

367535003
Fiber-optic colonoscopy (procedure).
SNOMED

443998000
Colonoscopy through colostomy with endoscopic biopsy of colon (procedure).
SNOMED

444783004
Screening colonoscopy (procedure).
SNOMED

446521004
Colonoscopy and excision of mucosa of colon (procedure).
SNOMED

446745002
Colonoscopy and biopsy of colon (procedure).
SNOMED

447021001
Colonoscopy and tattooing (procedure).
SNOMED

709421007
Colonoscopy and dilatation of stricture of colon (procedure).
SNOMED

710293001
Colonoscopy using fluoroscopic guidance (procedure).
SNOMED

711307001
Colonoscopy using X-ray guidance (procedure).
SNOMED

789778002
Colonoscopy and fecal microbiota transplantation (procedure).
SNOMED

851000119109
History of colonoscopy (situation).
SNOMED

74261-74263
CT colonography (every five).
CPT

60515-4
CT colon and rectum with air contrast PR.
LOINC

72531-7
CT colon and rectum with contrast IV and with air contrast PR.
LOINC

79069-1
CT colon and rectum for screening without contrast IV and with air contrast PR.
LOINC

79071-7
CT colon and rectum without contrast IV and with air contrast PR.
LOINC

79101-2
CT colon and rectum for screening with air contrast PR.
LOINC

82688-3
CT colon and rectum without and with contrast IV and with air contrast PR.
LOINC

418714002
Virtual computed tomography colonoscopy (procedure).
SNOMED

81528
FIT-DNA (Every three years).
CPT

77353-1
Noninvasive colorectal cancer DNA and occult blood screening (interpretation) in stool narrative.
LOINC

77354-9
Noninvasive colorectal cancer DNA and occult blood screening (presence) in stool.
LOINC

708699002
Stool DNA-based colorectal cancer screening positive (finding).
SNOMED

Well-Child Visits in the First 30 Months of Life (First 15 Months) [WC30]

Measure Description

Children who turned 15 months old during the measurement year and have at least six well-child visits with a PCP during their first 15 months of life.

Documentation

The well-child visit must occur with a PCP, but the PCP does not have to be the clinician assigned to the child. Documentation must include all five of the following components (examples are provided for each):

  • Health history:
    • Personal medical or surgical history.
    • Social history.
    • Family history.
    • Medications, history of allergies and immunization history (all three must be combined).
    • Statement of no problems under history or no new problems from last visit is acceptable.
  • Physical developmental history:
    • Documentation of physical developmental milestones appropriate for age.
    • Developing appropriately for age, normal growth and development.
    • Can throw a ball, run and play in the playground at school, etc.
    • Tanner stage.
  • Mental developmental history:
    • Documentation of mental milestones appropriate for age.
    • Verbalizes well and understands instructions.
    • Competent with fork and spoon.
    • Responds appropriately to commands.
  • Complete physical exam.
  • Health education/anticipatory guidance:
    • Physical and oral health, healthy eating and physical activity.
    • Safety belt.
    • Nutrition.
    • Anticipatory guidance handouts given with evidence of discussion.
    • Anticipatory guidance given with evidence of discussion.
    • Anticipatory guidance with evidence of parental counseling on anticipatory guidance.
    • Counseling/education factors reviewed.

Care Templates

Care templates that can help capture documentation related to well-child visits include DHCS Staying Health Assessment Questionnaires[3] or the Bright Futures/American Academy of Pediatrics periodicity schedule.[4]

Exclusions

  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.

Denominator

All patients who turned 15 months of age during the measurement year.

Numerator Billing Codes

All the codes below are used to capture well-child visits. The visits PHMI is focused on must occur prior to 15 months of age. The codes below would be inclusive of all components of assessments and documentation specified above. It is critical to be sure to use the correct age specific code for the exam being done.

FIGURE 5.8: WC30 NUMERATOR CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

99381-99385
Well visit.
CPT

99391-99395
Well visit.
CPT

99461
Well visit - initial newborn exam.
CPT

G0438
Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit.
G-Code/HCPCS

G0439
Annual wellness visit; includes a personalized prevention plan of service (PPS), subsequent visit.
G-Code/HCPCS

S0302
Completed early periodic screening diagnosis and treatment (EPSDT) service (list in addition to code for appropriate evaluation and management service).
HCPCS

Z00.110
Health examination for newborn under eight days old.
ICD10CM

Z00.111
Health examination for newborn eight to 28 days old.
ICD10CM

Z00.121
Encounter for routine child health examination with abnormal findings.
ICD10CM

Z00.129
Encounter for routine child health examination without abnormal findings.
ICD10CM

Z00.2
Encounter for examination for a period of rapid growth in childhood.
ICD10CM

Z76.1
Encounter for health supervision and care of foundling.
ICD10CM

Z76.2
Encounter for health supervision and care of other healthy infants and children.
ICD10CM

103740001
Periodic physical examination (procedure).
SNOMED

170099002
Child examination - birth (procedure).
SNOMED

170107008
Child examination - 10 days (procedure).
SNOMED

170114005
Child examination - six weeks (procedure).
SNOMED

170123008
Child eight to nine months examination (procedure).
SNOMED

170250008
Child three months examination (procedure).
SNOMED

170254004
Child one year examination (procedure).
SNOMED

170263002
Child six months examination (procedure).
SNOMED

170272005
Child 21 months examination (procedure).
SNOMED

170300004
Child eight weeks examination (procedure).
SNOMED

170309003
Child seven months examination (procedure).
SNOMED

171417004
Preschool child health examination (procedure).
SNOMED

243788004
Child examination (procedure).
SNOMED

268563000
Child health medical examination (procedure).
SNOMED

410620009
Well child visit (procedure).
SNOMED

410621008
Well child visit - newborn (procedure).
SNOMED

410622001
Child examination - two weeks (procedure).
SNOMED

410623006
Well child visit - two weeks (procedure).
SNOMED

410624000
Well child visit - two months (procedure).
SNOMED

410625004
Child four months examination (procedure).
SNOMED

410626003
Well child visit - four months (procedure).
SNOMED

410627007
Well child visit - six months (procedure).
SNOMED

410628002
Well child visit - nine months (procedure).
SNOMED

410629005
Well child visit - 12 months (procedure).
SNOMED

410630000
Child 15 month examination (procedure).
SNOMED

410631001
Well child visit - 15 months (procedure).
SNOMED

442162000
Child six to eight weeks examination (procedure).
SNOMED

783260003
Child 15 year examination (procedure).
SNOMED

446301000124108
Well child visit - newborn less than eight days old (procedure).
SNOMED

446381000124104
Well child visit - newborn eight to 28 days old (procedure).
SNOMED

Childhood Immunization Status (Combo 10) [CIS]

Measure Description

Percentage of children who reach two years of age in the measurement year who have had all the required immunizations:

  • 4 DTAP (diphtheria, tetanus, acellular pertussis).
  • 3 IPV (polio).
  • 1 MMR (measles, mumps, rubella).
  • 3 HIB (haemophilus influenza type B).
  • 3 HEP B (hepatitis B).
  • 1 VZV (chicken pox).
  • 4 PCV (pneumococcal conjugate).
  • 1 HEP A (hepatitis A).
  • 2 or 3 RV (rotavirus - 2 Rotarix; 3 Rota Teq).
  • 2 Influenza (flu).

Documentation

Documentation of immunization must include:

  • A note indicating the name of each specific antigen and date of immunization on or before the second birthday.

Acceptable documentation includes:

  • Evidence of immunizations given elsewhere (e.g., state immunization registry or hospital of birth).
  • Certificate of immunization prepared by authorized health care provider or agency including the specific dates and types of immunizations administered.
  • Note indicating patient received HEP B at delivery or in the hospital.
  • Immunization history pulled/transcribed from the immunization registry.
  • Documentation of the immunization being given in the record with the route and location of the injection site.

Care Templates

Care templates should align with the Bright Futures/American Academy of Pediatrics Immunization Schedule by Age[5] for the periodicity of immunizations, which is endorsed by DHCS for Medi-Cal and the Child Health and Disability Prevention (CHDP) program.

Exclusions

Patients who had any of the following on or before their second birthday:

  • Severe combined immunodeficiency.
  • Immunodeficiency.
  • HIV.
  • Lymphoreticular cancer, multiple myeloma or leukemia.
  • Intussusception.
  • Patients in hospice or using hospice services during the measurement year.
  • Patients who died in the measurement year.

Specific immunizations can be excluded (but this does not exclude the need for other immunizations) due to:

  • Allergic reaction to the vaccine or other contraindication.
  • History of illness (for measles, mumps, rubella, chicken pox, hepatitis A, hepatitis B). Note: Parent refusal does not meet compliance for any vaccines.

Denominator

Patients who turn two years of age during the measurement year.

Numerator Billing Codes

The codes below are used to capture the different immunizations required to meet measure compliance. Although there is no preferred code, the office can use combination antigens that benefit the patient with a smaller volume of injections. The combination codes count for all antigens within the combination. These combination codes for antigens are bolded in the table below.

FIGURE 5.9: CIS NUMERATOR CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

90698, 90700, 90721, 90723
DTaP
CPT

90698, 90713, 90723
IPV
CPT

90707, 90710
MMR
CPT

90644-90648, 90698, 90721, 90748
HIB
CPT

17, 46-51, 120, 148
HIB
CVX

3E0234Z
HEP B Newborn
ICD10CM

90723, 90740, 90744, 90747, 90748
HEP B
CPT

G0010
HEP B
G-Code/HCPCS

90670, 90732
PCV
CPT

90710, 90716
VZV
CPT

90633
HEP A
CPT

90655, 90657, 90661, 90662, 90673, 90685, 90687, 90688
Flu
CPT

G0008
Flu
G-Code/HCPCS

90681
Rotavirus (two dose schedule)
CPT

90680
Rotavirus (three dose schedule)
CPT

60660, 60672
LAIV
CPT

Depression Screening and Follow-Up for Adolescents and Adults [DSF-E]

Measure Description

The percentage of patients 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received followup care.

  • Sub-measure 1: Depression Screening. The percentage of patients who were screened for clinical depression using a standardized instrument.
  • Sub-measure 2: Follow-Up on Positive Screen. The percentage of patients who received follow-up care within 30 days of a positive depression screen finding.

Documentation

Documentation to identify numerator 1/denominator 2 (i.e., a patient screened for clinical depression with a positive result using a standard assessment instrument that has been normalized) and validated for the appropriate patient population (i.e., adolescents aged < 17 yrs or adults aged 18+ yrs). Eligible screening instruments with thresholds for positive findings include:


Instrument
Positive Value
Population

Patient Health Questionnaire (PHQ-9)
Total score ≥ 10
Adolescent; adult.

Patient Health Questionnaire Modified for Teens (PHQ-9M)
Total score ≥ 10
Adolescent.

Patient Health Questionnaire-2 (PHQ-2)1
Total score ≥ 3
Adolescent; adult

Beck Depression Inventory-Fast Screen (BDI-FS)1
Total score ≥ 8
Adolescent; adult

Beck Depression Inventory (BDI-II)
Total score ≥ 20
Adult.

Center for Epidemiologic Studies Depression Scale-Revised (CESD-R)
Total score ≥ 17
Adolescent; adult.

Duke Anxiety-Depression Scale (DUKE-AD)
Total score ≥ 30
Adult.

Edinburgh Postnatal Depression Scale (EPDS)
Total score ≥ 10
Adolescent; adult.

Geriatric Depression Scale Short Form (GDS)1
Total score ≥ 5
Adult.

Geriatric Depression Scale Long Form (GDS)
Total score ≥ 10
Adult.

My Mood Monitor (M-3)
Total score ≥ 5
Adult.

PROMIS Depression
Total score (T Score) ≥ 60
Adolescent; adult.

Clinically Useful Depression Outcome Scale (CUDOS)
Total score ≥ 31
Adult.

Documentation to identify numerator 2 (i.e., patients who received follow-up care on or up to 30 days after the date of the first positive screen (31 total days). Any of the following on or up to 30 days after the first positive screen:

  • An outpatient, telephone, e-visit or virtual check-in follow-up visit with a diagnosis of depression or other behavioral health condition.
  • A depression case management encounter that documents assessment for symptoms of depression or a diagnosis of depression or other behavioral health condition.
  • A behavioral health encounter, including assessment, therapy, collaborative care or medication management.
  • A dispensed antidepressant medication.

OR

Documentation of additional depression screening on a full-length instrument indicating either no depression or no symptoms that require follow-up (i.e., a negative screen) on the same day as a positive screen on a brief screening instrument (e.g., brief screens include PHQ-2, BDI-FS, GDS Short Form). For example, if there is a positive screen resulting from a PHQ-2 score, documentation of a negative finding from a PHQ-9 performed on the same day qualifies as evidence of follow-up.

Care Templates

While acceptable care templates could include any of the above screening instruments, the PHQ-2 and PHQ-9 are commonly used, are available at no cost in multiple languages,[6] and allow for screening and follow-up to occur on the same day.

Exclusions

  • Patients with a history of bipolar disorder at any time during the patient’s history through the end of the year prior to the measurement period.
  • Patients with depression that start during the year prior to the measurement period.
  • Patients in hospice or using hospice services any time during the measurement period.

Denominators

Patients 12 years of age and older at the start of the measurement period (denominator 1) with a positive depression screen finding (denominator 2).

Note: HEDIS date ranges of positive depression screen findings are redefined for PHMI to accommodate quarterly reporting:

  1. Quarter 1: screening between April 1 of the prior year and March 1 of the current year.
  2. Quarter 2: screening between July 1 of the prior year and June 1 of the current year.
  3. Quarter 3: screening between October 1 of the prior year and September 1 of the current year.
  4. Quarter 4: screening between January 1 of the prior year and December 1 of the current year.

Denominator 2 Billing Codes

All of the codes below are used to identify a positive screen finding (i.e., a diagnosis of depression).

FIGURE 5.10: DSF-E DENOMINATOR 2 CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

F01.51
Vascular dementia with behavioral disturbance.
ICD10CM

F32.0
Major depressive disorder, single episode, mild.
ICD10CM

F32.1
Major depressive disorder, single episode, moderate.
ICD10CM

F32.2
Major depressive disorder, single episode, severe without psychotic features.
ICD10CM

F32.3
Major depressive disorder, single episode, severe with psychotic features.
ICD10CM

F32.4
Major depressive disorder, single episode, in partial remission.
ICD10CM

F32.5
Major depressive disorder, single episode, in full remission.
ICD10CM

F32.81
Premenstrual dysphoric disorder.
ICD10CM

F32.89
Other specified depressive episodes.
ICD10CM

F32.9
Major depressive disorder, single episode, unspecified.
ICD10CM

F32.A
Depression, unspecified.
ICD10CM

F33.0
Major depressive disorder, recurrent, mild.
ICD10CM

F33.1
Major depressive disorder, recurrent, moderate.
ICD10CM

F33.2
Major depressive disorder, recurrent, severe, without psychotic features.
ICD10CM

F33.3
Major depressive disorder, recurrent, severe, with psychotic symptoms.
ICD10CM

F33.40
Major depressive disorder, recurrent, in remission, unspecified.
ICD10CM

F33.41
Major depressive disorder, recurrent, in partial remission.
ICD10CM

F33.42
Major depressive disorder, recurrent, in full remission.
ICD10CM

F33.8
Other recurrent depressive disorders.
ICD10CM

F33.9
Major depressive disorder, recurrent, unspecified.
ICD10CM

F34.1
Dysthymic disorder.
ICD10CM

F34.81
Disruptive mood dysregulation disorder.
ICD10CM

F34.89
Other specified persistent mood disorders.
ICD10CM

F43.21
Adjustment disorder with depressed mood.
ICD10CM

F43.23
Adjustment disorder with mixed anxiety and depressed mood.
ICD10CM

F53.0
Postpartum depression.
ICD10CM

F53.1
Puerperal psychosis.
ICD10CM

O90.6
Postpartum mood disturbance.
ICD10CM

O99.340
Other mental disorders complicating pregnancy, unspecified trimester.
ICD10CM

O99.341
Other mental disorders complicating pregnancy, first trimester.
ICD10CM

O99.342
Other mental disorders complicating pregnancy, second trimester.
ICD10CM

O99.343
Other mental disorders complicating pregnancy, third trimester.
ICD10CM

O99.344
Other mental disorders complicating childbirth.
ICD10CM

O99.345
Other mental disorders complicating the puerperium.
ICD10CM

832007
Moderate major depression (disorder).
SNOMED

2506003
Early onset dysthymia (disorder).
SNOMED

2618002
Chronic recurrent major depressive disorder (disorder).
SNOMED

3109008
Secondary dysthymia, early onset (disorder).
SNOMED

14183003
Chronic major depressive disorder, single episode (disorder).
SNOMED

15193003
Severe recurrent major depression with psychotic features, mood-incongruent (disorder).
SNOMED

15639000
Moderate major depression, single episode (disorder).
SNOMED

18818009
Moderate recurrent major depression (disorder).
SNOMED

19527009
Single episode of major depression in full remission (disorder).
SNOMED

19694002
Late onset dysthymia (disorder).
SNOMED

20250007
Severe major depression, single episode with psychotic features, mood-incongruent (disorder).
SNOMED

25922000
Major depressive disorder, single episode with postpartum onset (disorder).
SNOMED

28475009
Severe recurrent major depression with psychotic features (disorder).
SNOMED

33078009
Severe recurrent major depression with psychotic features, mood-congruent (disorder).
SNOMED

35489007
Depressive disorder (disorder).
SNOMED

36170009
Secondary dysthymia, late onset (disorder).
SNOMED

36474008
Severe recurrent major depression without psychotic features (disorder).
SNOMED

36923009
Major depression, single episode (disorder).
SNOMED

38451003
Primary dysthymia, early onset (disorder).
SNOMED

38694004
Recurrent major depressive disorder with atypical features (disorder).
SNOMED

39809009
Recurrent major depressive disorder with catatonic features (disorder).
SNOMED

40379007
Mild recurrent major depression (disorder).
SNOMED

40568001
Recurrent brief depressive disorder (disorder).
SNOMED

42925002
Major depressive disorder, single episode with atypical features (disorder).
SNOMED

48589009
Minor depressive disorder (disorder).
SNOMED

63778009
Major depressive disorder, single episode with melancholic features (disorder).
SNOMED

66344007
Recurrent major depression (disorder).
SNOMED

67711008
Primary dysthymia, late onset (disorder).
SNOMED

69392006
Major depressive disorder, single episode with catatonic features (disorder).
SNOMED

71336009
Recurrent major depressive disorder with postpartum onset (disorder).
SNOMED

73867007
Severe major depression with psychotic features (disorder).
SNOMED

75084000
Severe major depression without psychotic features (disorder).
SNOMED

75837004
Mood disorder with depressive features due to general medical condition (disorder).
SNOMED

76441001
Severe major depression, single episode without psychotic features (disorder).
SNOMED

77486005
Mood disorder with major depressive-like episode due to general medical condition (disorder).
SNOMED

77911002
Severe major depression, single episode with psychotic features, mood-congruent (disorder).
SNOMED

78667006
Dysthymia (disorder).
SNOMED

79298009
Mild major depression, single episode (disorder).
SNOMED

81319007
Severe bipolar II disorder, most recent episode major depressive without psychotic features (disorder).
SNOMED

83176005
Primary dysthymia (disorder).
SNOMED

84760002
Schizoaffective disorder, depressive type (disorder).
SNOMED

85080004
Secondary dysthymia (disorder).
SNOMED

87512008
Mild major depression (disorder).
SNOMED

191610000
Recurrent major depressive episodes, mild (disorder).
SNOMED

191611001
Recurrent major depressive episodes, moderate (disorder).
SNOMED

191613003
Recurrent major depressive episodes, severe with psychosis (disorder).
SNOMED

191616006
Recurrent depression (disorder).
SNOMED

191659001
Atypical depressive disorder (disorder).
SNOMED

192080009
Chronic depression (disorder).
SNOMED

231504006
Mixed anxiety and depressive disorder (disorder).
SNOMED

231542000
Depressive conduct disorder (disorder).
SNOMED

268621008
Recurrent major depressive episodes (disorder).
SNOMED

319768000
Recurrent major depressive disorder with melancholic features (disorder).
SNOMED

320751009
Major depression, melancholic type (disorder).
SNOMED

370143000
Major depressive disorder (disorder).
SNOMED

430852001
Severe major depression, single episode with psychotic features (disorder).
SNOMED

442057004
Chronic depressive personality disorder (disorder).
SNOMED

Numerator 2 Billing Codes

All of the codes below are used to identify follow-up care to a positive screen and would be compliant for follow-up within the 30-day timeframe.

FIGURE 5.11: DSF-E NUMERATOR 2 CLAIMS/ENCOUNTER CODES


Code
Service Completed Definition
Code System

99366
Medical team conference.
CPT

99492-99494
Behavioral Health Integration (BHI).
CPT

G0512
Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month.
HCPCS

T1016
Case management, each 15 minutes.
HCPCS

T1017
Targeted case management, each 15 minutes.
HCPCS

T2022
Case management, per month.
HCPCS

T2023
Targeted case management; per month.
HCPCS

182832007
Procedure related to management of drug administration (procedure).
SNOMED

225333008
Behavior management (regime/therapy).
SNOMED

385828006
Health promotion management (procedure).
SNOMED

386230005
Case management (procedure).
SNOMED

409022004
Dispensing medication management (procedure).
SNOMED

410216003
Communication care management (procedure).
SNOMED

410219005
Personal care management (procedure).
SNOMED

410328009
Coping skills case management (procedure).
SNOMED

410335001
Exercises case management (procedure).
SNOMED

410346003
Medication action/side effects case management (procedure).
SNOMED

410347007
Medication setup case management (procedure).
SNOMED

410351009
Relaxation/breathing techniques case management (procedure).
SNOMED

410352002
Rest/sleep case management (procedure).
SNOMED

410353007
Safety case management (procedure).
SNOMED

410354001
Screening case management (procedure).
SNOMED

410356004
Signs/symptoms, mental/emotional case management (procedure).
SNOMED

410360001
Spiritual care case management (procedure).
SNOMED

410363004
Support group case management (procedure).
SNOMED

410364005
Support system case management (procedure).
SNOMED

410366007
Wellness case management (procedure).
SNOMED

416341003
Case management started (situation).
SNOMED

416584001
Case management ended (situation).
SNOMED

424490002
Medication prescription case management (procedure).
SNOMED

425604002
Case management follow up (procedure).
SNOMED

737850002
Day care case management (procedure).
SNOMED

98960-98962
Education and training for patient self-management.
CPT

98966-98969
Non-face-to-face non-physician telephone services.
CPT

98970-98972
Online digital assessment and management service.
CPT

99078
Group patient education service.
CPT

99201-99205
New patient office visit for evaluation and management.
CPT

99211-99215
Established patient office visit for evaluation and management.
CPT

99217-99220
Observation care.
CPT

99241-99245
Outpatient consultation involving evaluation and management.
CPT

99341-99345
New patient home services.
CPT

99347-99350
Established patient home services.
CPT

99381-99387
New patient preventive medicine services.
CPT

99391-99397
Established patient preventive medicine services.
CPT

99401-99404
Preventive medicine, individual counseling services.
CPT

99411-99412
Preventive medicine, group counseling services.
CPT

99421-99423
Non-face-to-face online digital evaluation and management service.
CPT

99441-99444
Non-face-to-face telephone services.
CPT

99457
Remote physiologic monitoring treatment management services.
CPT

99483
Cognitive assessment and care plan services.
CPT

G0071
Payment for communication technology-based services for five minutes or more of a virtual (nonface-to-face) communication between a rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or FQHC patient, or five minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner occurring in lieu of an office visit; RHC or FQHC only.
HCPCS

G0463
Hospital outpatient clinic visit for assessment and management of a patient.
HCPCS

G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related evaluation and management (E/M) service provided within the previous seven days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
HCPCS

G2012
Brief communication technology-based service (e.g. virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services provided to an established patient not originating from a related E/M service provided within the previous seven days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion.
HCPCS

G2061
Qualified non-physician healthcare professional online assessment and management service for an established patient for up to seven days; cumulative time during the seven days: five to 10 minutes.
HCPCS

G2062
Qualified non-physician healthcare professional online assessment and management service for an established patient for up to seven days’ cumulative time during the seven days: 11-20 minutes.
HCPCS

G2063
Qualified non-physician healthcare professional online assessment and management service for an established patient for up to seven days; cumulative time during the seven days: 21 or more minutes.
HCPCS

G2250
Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.
HCPCS

G2251
Brief communication technology-based service (e.g. virtual check-in) by a qualified healthcare professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of clinical discussion.
HCPCS

G2252
Brief communication technology-based service (e.g. virtual check-in) by a physician or other qualified healthcare professional who can report evaluation and management services provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.
HCPCS

T1015
Clinic visit/encounter, all-inclusive.
HCPCS

42137004
Reevaluation of established psychiatric patient (procedure).
SNOMED

50357006
Evaluation and management of patient at home (procedure).
SNOMED

86013001
Periodic reevaluation and management of healthy individual (procedure).
SNOMED

90526000
Initial evaluation and management of healthy individual (procedure).
SNOMED

108220007
Evaluation and/or management - new patient (procedure).
SNOMED

108221006
Evaluation and/or management - established patient (procedure).
SNOMED

185317003
Telephone encounter (procedure).
SNOMED

185389009
Follow-up visit (procedure).
SNOMED

281036007
Follow-up consultation (procedure).
SNOMED

314849005
Telephone contact by consultant (procedure).
SNOMED

386472008
Telephone consultation (procedure).
SNOMED

386473003
Telephone follow-up (procedure).
SNOMED

390906007
Follow-up encounter (procedure).
SNOMED

401267002
Telephone triage encounter (procedure).
SNOMED

406547006
Urgent follow-up (procedure).
SNOMED

870191006
Follow-up for depression (procedure).
SNOMED

510
Outpatient clinic - general.
UBREV

513
Outpatient clinic - psychiatric clinic.
UBREV

516
Outpatient clinic - urgent care clinic.
UBREV

517
Outpatient clinic - family practice clinic.
UBREV

519
Outpatient clinic - other.
UBREV

520
Freestanding clinic - general.
UBREV

521
Freestanding clinic - RHC/FQHC.
UBREV

522
Freestanding clinic - home visit by RHC/FQHC practitioner.
UBREV

523
Freestanding clinic - family practice clinic.
UBREV

526
Freestanding clinic - urgent care clinic.
UBREV

527
Freestanding clinic - VNS to patient home in a home health shortage area.
UBREV

528
Freestanding clinic - visit by RHC/FQHC practitioner to other nonRHC/FQHC site.
UBREV

529
Freestanding clinic - other.
UBREV

982
Professional fees - outpatient services.
UBREV

983
Professional fees - clinic.
UBREV

 

 

Endnotes

  1. American College of Obstetricians and Gynecologists. Optimizing Postpartum Care; [June 2016]. Available from: https://www.acog.org/clinical/clinical-guidance/ committee-opinion/articles/2018/05/optimizing-postpartum-care. 
  2. Comprehensive Perinatal Services Program. CPSP Postpartum Assessment and Individualized Care Plan; [cited 2023 July 13]. Available from: https://www.cdph.ca.gov/Programs/CFH/DMCAH/CPSP/CDPH%20Document%20Library/CPSPPostpartumAssessmentandCarePlan.pdf 
  3. California Department of Health Care Services. Staying Healthy Assessment Questionnaires; [cited 2023 July 13]. Available from: https://www.dhcs.ca.gov/formsandpubs/forms/Pages/StayingHealthyAssessmentQuestionnaires.aspx. 
  4. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Dupage County, Illinois: AAP; 2023 [cited 2023 July 13]. Available from: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf?_%20ga=2.88959003.1886797139.1676338816-747761308.1676338815. 
  5. American Academy of Pediatrics. Immunization Schedules for 2023. Dupage County, Illinois: AAP; 2023 [cited 2023 July 13]. Available from: https:// publications.aap.org/redbook/pages/immunization-schedules?autolog%20 incheck=redirected?autologincheck=redirected. 
  6. Spitzer RL, Williams JBW, Kroenke K. PHQ Screeners. New York: Pfizer Inc.; 2023 [cited 2023 July 13]. Available from: https://www.phqscreeners.com/