CCO Incentive Measures

CCO Incentive Measures Quick Reference Guide For more information, visit https://www.oregon.gov/oha/hpa/analytics/pages/cco Baseline-Data.aspx MCA_ZZ216NR Effective 03/18/19

CCO Incentive Measures Quick Reference Guide Updated to reflect CCO 2019 Technical Specifications Trillium Community Health Plan strives to provide quality healthcare to our membership as measured through The Oregon Health Authority (OHA) Coordinated Care Organization (CCO) Incentive Metrics Program. We are proud to partner with your practice to continually improve the care and experience of Trillium members. When using this reference guide, please always follow State and/or CMS billing guidance and ensure the interventions are covered prior to submission. WHAT ARE THE INCENTIVE METRICS USED FOR? The Oregon Health Authority (OHA) Coordinated Care Organization (CCO) Incentive Metrics Program uses quality health metrics to demonstrate how well CCOs are improving the health of the communities they serve. Incentive metrics are integral to the success of the CCO model, encouraging health plans and their provider partners to develop innovative approaches to serve Oregon Health Plan members. These metrics measure quality of care, access to care, and health outcomes for individuals enrolled in CCOs. OHA develops the measures and awards funds from the quality pool to CCOs based on their annual performance on the measures. HOW CAN I IMPROVE MY CCO INCENTIVE MEASURE SCORES? Engage and establish care with members assigned to your practice. Submit accurate and timely claims data for each and every service rendered. Make sure that chart documentation reflects all services billed. Report all immunizations to the ALERT Immunization Information System. Incorporate surveillance codes into workflows. Participate with Trillium and community providers in various collaboratives to learn community best practices, participate in innovative work addressing social determinants of health, practice integration, ED utilization and more! QUESTIONS? CONTACT PROVIDER SERVICES AT: 1-877-600-5472 For more information, visit: https://www.oregon.gov/oha/hpa/analytics/pages/cco-baseline-data.aspx This guide has been updated with information from the July release of the 2019 Technical Specifications by OHA and is subject to change 1

ADOLESCENT WELL-CARE VISITS The percentage of enrolled members 12 21 years of age as of December 31 st of the measurement year who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. Documentation: A note indicating a visit to a provider, the date of well visit and evidence of all the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance (includes tobacco use, drugs & alcohol use, sexual activity, and depression screening-phq 9) Note: Services specific to the assessment or treatment of an acute or chronic condition do not count toward this measure. CPT HCPCS ICD - 10 12-17 years: 99384, 99394; G0438, G0439 Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, 18 years: 99385, 99395 Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5,Z02.6, Z02.71, Z02.82, Z76.1, Z76.2 ALCOHOL AND DRUG MISUSE: SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT) Members aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period. Two rates are reported for this measure: (1) The percentage of patients who received an age -appropriate screening, using a SBIRT screening tool approved by OHA, during the measurement period and had either a brief screen w ith a negative result or a full screen (2) The percentage of patients with a positive full screen who received a brief intervention, a referral to treatment, or both that is documented within 48 hours of the date of a positive screen. Screening in an ambulatory setting is required once per measurement year. This measure does not require screening to occur at all encounters. Approved SBIRT screening tools are available on the HSD -Approved Evidence-Based Screening Resources/Tools (SBIRT) page: https://www.oregon.gov/oha/hsd/amh/pages/eb -Tools.aspx The name of the screening tool used must be documented in the medical record, but it does not need to be captured in a queryable field. More details here: https://www.oregon.gov/oha/hpa/analytics/ccodata/2019 -specs-(sbirt)-final.pdf 2

AMBULATORY CARE: EMERGENCY DEPARTMENT UTILIZATION Each visit that does not result in an inpatient encounter is counted once. Count multiple ED visits on the same date of service as one visit. Measured per 1,000 member months. Mental health and chemical dependency services are excluded. ED VALUE SET CPT UB REVENUE ED PROCEDURE CODE VALUE SET CPT 99281-99285 0450, 0451, 0452, 0456, 0459, 0981 10021-69990 (Total of 5,790 CPT codes are included in the HEDIS 2019 ED Procedure Code Value Set) With: POS: 23 ASSESSMENTS WITHIN 60 DAYS FOR CHILDREN IN DHS CUSTODY Members age 0-17 in DHS custody within 60 days of the notification date. Required assessments for children entering DHS custody: <12 months old: Physical exam 1 3 years olds: Physical and dental exam 4-17 years old: Physical, dental, and mental health exam. PHYSICAL HEALTH ASSESSMENT CODES DENTAL HEALTH ASSESSMENT CODES MENTAL HEALTH ASSESSMENT CODES Outpatient and office evaluation and management codes: 99201-99205, 99212-99215 Preventative visits: 99381-99384, 99391-99394 Annual wellness visits: G0438, G0439 Dental diagnostic codes (clinical oral evaluations): D0100-D0199 Psychological assessment and intervention codes: 90791 90792, 96101 96102, H0031, H1011. Mental health assessment, by non-physician with CANS assessment: H2000-TG (modifier must be included). Behavioral health; long-term residential (nonmedical, non-acute care in a residential treatment program where stay is typically longer than 30 days): H0019 (Use of this code counts as both mental and physical health assessment for children in PRTS) Psychiatric health facility service, per diem: H2013 Community psychiatric supportive treatment program, per diem: H0037 3

CAHPS COMPOSITE: ACCESS TO CARE The CAHPS 5.0H Getting Care Quickly Composite is based on two items from the CAHPS adult survey and two from the child survey: Got care right away for illness/injury/condition as soon as you/child needed. Got an appointment for routine care as soon as you/child needed. Note: OHA includes both always and usua lly as valid responses for the numerator. Starting in 2018, there are separate benchmarks for children and adults. CCOs must achieve the separate benchmarks or improvement targets for both children and adults to qualify for credit on this measure. CHILDHOOD IMMUNIZATION STATUS Children 2 years of age who had the following on or before their second birthday: 4 DTaP (Diphtheria, Tetanus and Pertussis) 3 HiB (Haemophilus Influenza Type B) 3 Hepatitis B 3 IPV (Inactivated Polio) 1 MMR (Measles, Mumps, Rubella) 1 VZV (Varicella Zoster) OHA uses CVX codes in ALERT IIS data. While ALERT IIS does include MMIS claims/encounter data as one of the registry data sources, OHA does not directly calculate the measure from the MMIS/DSSURS claim/encounter data and the CPT/ICD codes in the coding section are provided for reference only. CPT CODES CVX CODES DTaP (4 vaccines): 90698, 90700, 90721, 90723; IPV (3 vaccines): 90698, DTaP: 20, 50, 106, 107, 110, 120; 90713, 90723; IPV:10, 89, 110, 120 HIB (3 vaccines): 90644-90648, 90698, 90721, 90748 HIB: 17, 46-51, 120, 148 Hep B (3 vaccines): 90723, 90740, 90744, 90747, 90748; HCPCS: G0010 Hep B: 08, 44, 45, 51, 110; VZV (1 vaccine): 90710, 90716 VZV: 21, 94; MMR (1 vaccine): 90707, 90710 MMR: 03, 94; Measles: 90705 Measles: 05; Measles/Rubella: 90708; Measles/Rubella: 04; Rubella: 90706; Mumps: 90704; Rubella: 06; Hep A (1 vaccine): 90633; Mumps:07; Pneumococcal conjugate (4 vaccines): 90669 (7 valent), 90670 (13 Hep A: 31, 83, 85; valent), -HCPCS: G0009; Pneumococcal conjugate: 100 (7 valent), 133 (13 valent), 152; Influenza (2 vaccines): 90655, 90657, 90661, 90662, 90673, 90685, Influenza: 88, 135, 90686, 90687, 90688; HCPCS: G0008; 140, 141, 150 153, 155, 161, Rotavirus: 2 doses-90681; 3 doses-90680 Rotavirus:119 (2 doses), 116 (3 doses), 122; ICD10: 3E0234Z 4

CIGARETTE SMOKING PREVALENCE (EHR measure) Rate 1: Unique members 13 years old or older who had a qualifying visit, and had their smoking and/or tobacco use status recorded as structured data. Rate 2 & 3: Of those with a smoking and/or tobacco use status, how many are (2) cigarette smokers and/or (3) tobacco users. EHR data for this measure must be submitted on a quarterly basis to Trillium. Note: The standard for recording smoking status is part of the Common Clinical Data Set, and it remains the same in both the 2014 Edition and 2015 Edition certification criteria. Resources: Common Clinical Data Set: https://www.healthit.gov/sites/default/files/commonclinicaldataset_ml_11-4-15.pdf ecqm specifications for Performance/Reporting Year 2019: https://ecqi.healthit.gov/ecqm/measures/cms138v7 COLORECTAL CANCER SCREENING Members age 51-75 years as of December 31st of the measurement year. Those members who received one or more of the following screenings: Colonoscopy performed Jan. 1 Dec. 31, 2019 of measurement year and 9 prior years. Flexible Sigmoidoscopy performed Jan 1 Dec. 31, 2019 of measurement year and 4 prior years. Fecal Occult Blood Test (FOBT) and Fecal Immun ochemical Test (FIT) during the measurement year. FIT-DNA performed Jan. 1 Dec. 31, 2019 and two prior years. CT Colonography performed Jan. 1 Dec. 31, 2019 of measurement year and 4 prior years. A note indicating the date the test was performed. A result is not required if the documentation is clearly part of the medical history section of the record. If it is not clear, the result or finding must also be pr esent. Note: Digital rectal exams do not count. EXCLUSIONS: Those with diagnosis of colore ctal cancer or total colectomy. Medicare members 66 years of age and older living in long -term institutional settings. Members 66 years of age and older with frailty (Frailty Value Set) and advanced illness during the measurement year. TYPE OF TEST CPT HCPCS FOBT 82270, 82274 G0328 Flexible Sigmoidoscopy 45330-45335, 45337, 45342, 45345-45347, 45349, 45350 G0140 Colonoscopy 44388-44394, 44397, 44401-44408, 45355, G0105, G0121 45378-45393, 45398 FIT-DNA/ Cologuard 81528 G0464 CT Colonography 74261-74263 CONTROLLING HIGH BLOOD PRESSURE (EHR measure) Denominator is patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period. Compliance is identified as patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure <140 mmhg and diastolic blood pressure <90 mmhg) during the measurement period. EHR data for this measure must be submitted on a quarterly basis to Trillium. ecqm specifications for Performance/Reporting Year 2019: https://ecqi.healthit.gov/ecqm/measures/cms165v7 5

DENTAL SEALANTS ON PERMANENT MOLARS FOR CHILDREN Unduplicated number of children ages 6-9 and 10-14 who received a sealant on a permanent molar tooth, as defined by HCPCS code D1351 (CDT code D1351), during the measurement year. Sealants can be placed by any dental professional for whom placing a sealant is within his or her scope of practice. OHA CCO incentive measure specifications align with EPSDT Form CMS-416 and do not use taxonomy codes in the calculation. CODES Dental Claims CDT Code: D1351 with Tooth Number 1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31, 32 OR Medical Claims CDT Code: D1351 DEPRESSION SCREENING AND FOLLOW-UP PLAN (EHR measure) Patients screened for depression on the date of the encounter, using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen. Denominator is all patients aged 12 years and older with at least one eligible encounter during the measurement period. Screening is required once per measurement period, not all encounters. Note: Due to a change in the value sets for Additional evaluation for adolescent and adult, PHQ9 as a follow-up to a positive PHQ2 no longer counts as additional evaluation and cannot be counted for numerator compliance. EHR data for this measure must be submitted on a quarterly basis to Trillium. ecqm specifications for Performance/Reporting Year 2019: https://ecqi.healthit.gov/ecqm/measures/cms2v8 DEVELOPMENTAL SCREENING IN THE FIRST 36 MONTHS OF LIFE Children must be screened using a developmental screening tool at three different times in the first three years of life in the context of routine well-child visits or when a concern is raised through standardized developmental surveillance. The denominator is children who turn 1, 2, or 3 years of age in the measurement year and had continuous enrollment in a CCO for the 12 months prior to their birthdate, regardless if they had a medical/clinical visit or not in the measurement year. Reimbursement for the compliant screening code 96110 is based on the provider s time reviewing the results and interpreting the findings with the family. Conducting the screening, alone, is not sufficient to bill for the service. Resource: Core Set of Children s Health Care Quality Measures https://www.medicaid.gov/medicaid/quality-of-care/downloads/medicaid-and-chip-child-core-set-manual.pdf 6

DIABETES: HbA1c POOR CONTROL (EHR measure) Patients whose most recent HbA1c level >9% (during measurement year), or if there are no HbA1c tests performed and results documented during the measurement period. Denominator is patients 18-75 years of age who had a diagnosis of diabetes during or any time prior to the measurement period and who received a qualifying outpatient service during the measurement period. EHR data for this measure must be submitted on a quarterly basis to Trillium. ecqm specifications for Performance/Reporting Year 2019: https://ecqi.healthit.gov/ecqm/measures/cms122v7 DISPARITY MEASURE: ED UTILIZATION AMONG MEMBERS WITH MENTAL ILLNESS Number of ED visits when the member experiencing mental illness is enrolled with the CCO. Each visit that does not result in an inpatient encounter is counted once. Count multiple ED visits on the same date of service as one visit. OHA uses claims with a 36-month rolling look back period to identify members who had two or more visits with any of the diagnoses in the Members Experiencing Mental Illness Value Set. Measured per 1,000 member months of the adult members who are identified as having experienced mental illness. Exclusions: Mental health and chemical dependency services and members identified in hospice via claims. For more details including the Oregon-specific definition for identifying individuals with mental illness: https://www.oregon.gov/oha/hpa/analytics/ccodata/2019-specs-(disparity)-final.pdf ED Value Set UB Revenue CPT 99281-99285 0450, 0451, 0452, 0456, 0459, 0981 OR ED Procedure Code CPT 10021-69990 (Total of 5,790 CPT codes are included in the HEDIS 2019 ED Procedure Code Value Set). POS Value Set POS: 23 See measure spec for Members Experiencing Mental Illness Value Set. 7

EFFECTIVE CONTRACEPTIVE USE AMONG WOMEN AT RISK OF UNINTENDED PREGNANCY All women ages 15-50 as of Dec. 31 of the measurement year who were continuously enrolled in a CCO for the 12-month measurement period. Women in the denominator with evidence of female sterilization anytime throughout the claims history in OHA s system, or one of the following methods of contraception during the measurement year: IUD, implant, contraception injection, contraceptive pills, patch, ring, or diaphragm. Women who had claims indicating female sterilization will be compiled into a female sterilization permanent numerator table using all OHP claims history back to 2002 and give numerator credits to the CCO where member is continuously enrolled. See tech spec for Denominator Exclusions and Numerator Table: https://www.oregon.gov/oha/hpa/analytics/ccodata/2019-specs-(effective-contraceptive-use)-final-v2-20190305.pdf NDC table: https://www.oregon.gov/oha/hpa/analytics/pages/cco-baseline-data.aspx Permanent Exclusion and Numerator Table: https://www.oregon.gov/oha/hpa/analytics/ccodata/2018-ecu-permanent-exclusion- Numerator-Template.xlsx 8

FOLLOW-UP CARE AFTER BEHAVIORAL HEALTH H OSPITALIZATION WITHIN SEVEN DAYS (TCHP measure, Behavioral Health Only) Members are considered assigned when either (A) two or more Substance Use Disorder (SUD) encounters or (B) three or more Mental Health encounters occur within the measurement year. Once a member meets A or B, they are considered to be assigned to that clinic. A member can be assigned to multiple clinics if they meet the assignment criteria listed above at more than one clinic. Visits are defined using appropriate behavioral health or chemical dependency taxonomies and diagnosis codes. Discharges for members age 6 years of age and above who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, reflected by the following codes, within 7 days of discharge, and on the date of discharge. CPT Stand Alone Visits 98960-98962, 99078, 99201-99205, 99211-99215,99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510, 90846, 90791, 90792, 90832-90834, 90836-90838 HCPCS G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0006, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2021, H2022, M0064, S0201,S9480, S9484, S9485, T1015, T1016 Group 1 Value Set 90839, 90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876 Group 2 Value Set 99221-99223, 99231-99233, 99238, 99239, 99251-99255 With POS: 02, 52, 53 With POS: 02, 03, 05, 07, 09, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 UB Revenue Group 1 0513, 0900-0905, 0907, 0911-0917, 0919 UB Revenue Group 2 A visit to a non-behavioral health facility in conjunction with a principal diagnosis code from an ICD-9 code in the [Mental Illness Value Set]. 0510, 0515-0517, 0519-0523, 0526-0529, 0982, 0983 TCM 7 Day Value Set 99496 Telehealth Modifier 95, GT FOLLOW-UP CARE WITHIN 14 DAYS OF INITIAL ASSESSMENT (TCHP measure, Behavioral Health Only ) A success is counted for each unique member seen. Members are considered assigned when either (A) two or more Substance Use Disorder (SUD) encounters or (B) three or more Mental Health encounters occur within the measurement year. Once a member has had either A or B occur, they are considered to be assigned to that clinic. A member can be assigned to multiple clinics, if they meet the above assignment criteria at more than one clinic. Visits are defined using appropriate behavioral health or chemical dependency taxonomies and diagnosis codes. CPT HCPCS 90791, 96150 H0031, H0001, H0002 9

MEMBERS WITH BOTH BEHAVIORAL HEALTH AND A PCP PREVENTIVE VISIT (TCHP measure, Behavioral Health Only) A success is counted per unique member when that member has both a BH and a PCP preventive visit within the calendar year. CPT 99381-99429 10

ORAL EVALUATIONS FOR ADULTS WITH DIABETES Members age 18 and above as of December 31 of the measurement year with diabetes identified from claim/encounter data or pharmacy data, during the measurement year or the year prior to the measurement year. Members who received a comprehensive, periodic or periodontal oral evaluation in the measurement year. Exclusions: Members identified with gestational diabetes or steroid-induced diabetes, but who do not have a diagnosis of diabetes in any care settings. DENTAL CLAIMS CDT CODES D0120, D0150, D0180 11

PATIENT-CENTERED PRIMARY CARE HOME ENROLLMENT Percent of CCO members enrolled in PCPCHs by tier, using the following formula: [(Tier 1 members*1) + (Tier 2 members*2) + (Tier 3 members*3) + (Tier 4 members *4) + (5 STAR members *5)]/(Total CCO enrollment*5) Reported on a quarterly basis to state based on self-report from CCOs. Total CCO enrollment via MMIS/DSSURS. Clinic Primary Care Patient Centered Home (PCPCH) tier status as of Dec. 31, 2019 will be used to determine the incentive metrics payment, by clinic site, as follows: PCPCH Tier 5 will receive 110% of their earned incentive PCPCH Tier 4 will receive 105% of their earned incentive PCPCH Tier 3 will receive 90% of their earned incentive Review the Provider Update, CCO Metrics Payment Methodology 2019 for detailed incentive payment information. Note: Given the length of time it might take for site visits for 5 STAR designation to be completed, OHA is including a grace period for the final CY 2019 reporting. Specifically, if CCOs have practices that have applied for 5 STAR designation by December 31, 2019 that have not yet received a site visit, please notify Trillium so that we may provide this information as part of the Q4 reporting. PRENATAL AND POSTPARTUM CARE Note: The CCO incentive measure and quality pool payments are tied to the Postpartum Care rate; however, CCOs must submit data for both prenatal and postpartum care to be eligible to earn any quality pool funds associated with the measure. Denominator is all live birth deliveries between Nov. 6 of the year prior and Nov. 5 of the measurement year. Postpartum rate: a postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other PCP for a pelvic exam or postpartum care on or between 21 and 56 days after delivery. Documentation in the medical record must include a note indicating the date on which a postpartum visit occurred and one of the following: Pelvic exam, or Evaluation of weight, blood pressure, breasts and abdomen, or Notation of postpartum care, including, but not limited to the following: o Notation of postpartum care, PP care, PP check, or 6-week check o A preprinted Postpartum Care form in which information was documented during the visit. A Pap test alone is acceptable for the Postpartum Care measure. Exclusions: Members in hospice and members with no confirmed live birth. 12

WEIGHT ASSESSMENT AND COUNSELING IN CHILDREN AND ADOLESCENTS Documentation of an outpatient visit with a PCP or OB/GYN for members 3 17 years of age and who had: 1. Height, weight, and BMI percentile recorded 2. Counseling for nutrition 3. Counseling for physical activity Note: Because BMI norms for youth vary with age and sex, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. Rate is created by using a simple average across all 3 reported rates. Exclusions: Pregnancy and hospice. EHR data for this measure must be submitted on a quarterly basis to Trillium. ecqm specifications for Performance/Reporting Year 2019: https://ecqi.healthit.gov/ecqm/measures/cms155v7 Additional Guidance: Counseling for nutrition o The discussion must be related to daily nutritional habits. Services that don t count: Notes of health education, anticipatory guidance without specific mention of nutrition; counseling/education before or after the measurement year; no notes for counseling/education on nutrition and diet; or, a physical exam finding alone (e.g., well-nourished) because it doesn t indicate counseling for nutrition. Counseling for physical activity or referral for physical activity o Services that do not count: Developmental milestones discussion, cleared for gym class, health education, anticipatory guidance, or computer or TV time or anticipatory guidance related solely to safety without specific mention of physical activity; counseling/education before or after the measurement year; or, no notes for counseling/education on physical activity. Services specific to the assessment or treatment of an acute or chronic condition do not count toward the Counseling for Nutrition and Counseling for Physical Activity indicators, for example, decreased appetite as a result of an acute or chronic condition. 13