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Pediatrics/Adolescents Management

Based on current NCQA HEDIS recommendations, your TO-DO LIST for pediatric and adolescent patients should include:

Administer immunizations based on age-recommended guidelines.
Complete a well-child visit at the age-recommended intervals.
Evaluate body mass index (BMI) percentile, counseling for nutrition and counseling for physical activity every year at the age-recommended well-visits.
Screen female young adults for chlamydia starting at age 16.

Why should you complete your TO-DO LIST?

It is an evidence-based, best practice and these actions are used to measure your quality performance.

Immunizations

Child hood Immunization Status (CIS) HEDIS Measure:

Population Defined for Child hood Immunization Status

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 2 years of age during the measurement year
Line of Business: Commercial, Medicaid

DESCRIPTION:	REQUIREMENT:
The percentage of children 2 years of age who had all of the recommended vaccines on or before their second birthday
4 Diphtheria, Tetanus, and Acellular Pertussis (DTaP)	Administer four DTaP vaccinations with different dates of service on or before the child’s second birthday. Vaccinations administered prior to 42 days after birth do not count.
3 Polio (IPV)	Administer three IPV vaccinations with different dates of service on or before the child’s second birthday. Vaccinations administered prior to 42 days after birth do not count
3 Haemophilus Influenza Type B (HiB)	Administer three HiB vaccinations with different dates of service on or before the child’s second birthday. Vaccinations administered prior to 42 days after birth do not count
4 Pneumococcal Conjugate (PCV)	Administer four pneumococcal conjugate vaccinations with different dates of service on or before the child’s second birthday. Vaccinations administered prior to 42 days after birth do not count
1 Chicken Pox (VZV)	Administer one VZV vaccination with a date of service on or between the child’s first and second birthdays or documented history of varicella zoster illness on or before the child’s second birthday.
1 Hepatitis A (HepA)	Administer one hepatitis A vaccination with a date of service on or between the child’s first and second birthdays or documented history of hepatitis A illness on or before the child’s second birthday.
2 Influenza (Flu)	Administer two influenza vaccinations, with different dates of service, on or before the child’s second birthday. Vaccinations administered prior to 6 months (180 days) after birth do not count. One of the two vaccinations can be an LAIV vaccination administered on the child’s second birthday. Do not count an LAIV vaccination administered before the child’s second birthday.
3 Hepatitis B (HepB)	Administer three hepatitis B vaccinations with different dates of service, on or before the child’s second birthday or documented history of hepatitis B illness on or before the child’s second birthday. One of the three vaccinations can be a new born he patitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth.
2-dose/3-dose Rotavirus (RV)	Administer any of the following on or before the child’s second birthday meet criteria: At least two doses of the two-dose rotavirus vaccine on different dates of service. At least three doses of the three-dose rotavirus vaccine on different dates of service. At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine all on different dates of service Vaccinations administered prior to 42 days after birth do not count.
1 Measles, Mumps, Rubella (MMR)	Any of the following meet criteria: Administer one MMR vaccination (Measles, Mumps and Rubella) on or between the child’s first and second birthdays. History of mumps illness, measles illness or rubella illness on or before the child’s second birthday. NOTE: All 3 criteria must be met for compliance.
Combination 10 (DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV, Flu)	Children who are numerator compliant for the following indicators: DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV, and Flu

Immunizations for Adolescents (IMA) HEDIS Measure:

Population Defined for Immunizations for Adolescents

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 13 years of age during the measurement year

Line of Business: Commercial, Medicaid

DESCRIPTION:	REQUIREMENT:
The percentage of adolescents 13 years of age who had all of the recommended vaccines by their 13th birthday. The measure calculates a rate for each vaccine and two combination rates.
Tdap	Administer one Tetanus, Diphtheria Toxoids and Acellular Pertussis (Tdap) vaccine on or between the member’s 10th and 13th birthdays.
Meningococcal serogroups A,C,W,Y	Administer one Meningococcal serogroups A, C, W, Y vaccine on or between the member’s 11th and 13th birthdays.
HPV	Administer three HPV vaccines with different dates of service on or between the member’s 9th and 13th birthdays or administer two HPV vaccines with dates of service at least 146 days apart on or between the member’s 9th and 13th birthdays.
Combination 1 (Menigococcal, Tdap)	Adolescents who are numerator compliant for both the Meningococcal serogroups A, C, W, Y and Tdap indicators
Combination 2 (Meningococcal, Tdap, HPV)	Adolescents who are numerator compliant for all three indicators Meningococcal serogroups A, C, W, Y, Tdap, and HPV

Well-Child visits

Well-Child Visits in the First 30 Months of Life (W30) HEDIS Measure:

Population Defined for Well-Child Visits in the First 30 months of Life

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 15 and 30 months old during the measurement year
Line of Business: Commercial, Medicaid

DESCRIPTION:	REQUIREMENT:
The percentage of members who had the appropriate number of well-child visits with a PCP during the last 15 months. The following rates are reported: Well-Child Visits in the First 15 Months. Children who turned 15 months old during the measurement year. Well-Child Visits for Age 15 Months–30 Months. Children who turned 30 months old during the measurement year.	Perform the indicated number well-child visits with evidence of all of the following: A health history A physical developmental history A mental developmental history A physical exam Health education/anticipatory guidance The well-child visit must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child.
Well-Child Visits in the First 15 Months	Six or more well-child visits on different dates of service on or before the 15-month birthday.
Well-Child Visits for Age 15 Months–30 Months	Two or more well-child visits on different dates of service between the child’s 15-month birthday plus 1 day and the 30-month birthday.

Well-Visit Recommendation:

The recommended well-visit intervals for the first 15-months of life include the following: Newborn, 3-5 days, by 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, and 15 months¹.
The recommended well-visit intervals for age 15 months-30 months of life include the following: 18 months, 24 months, 30 months¹.

Child and Adolescent Well-Care Visits (WCV) HEDIS Measure:

Population Defined for Child and Adolescent Well-Care Visits

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 3-21 years of age as of December 31 of the measurement year

Line of Business: Commercial, Medicaid

DESCRIPTION:

REQUIREMENT:

Percent of members 3-21 years of age who had at least one comprehensive well-care visit with a PCP or an Ob/Gyn practitioner during the measurement year

Perform at least one comprehensive well-care visit with a PCP or Ob/Gyn practitioner during the measurement year with documentation evidence of all of the following:

A health history
A physical developmental history
A mental developmental history
A physical exam
Health education/anticipatory guidance

The well-care visit must occur with a PCP or an OB/GYN practitioner, but the practitioner does not have to be the practitioner assigned to the member.

Recommendations:

The recommended well-visit intervals for 3-21 years of life include one annual well-visit¹.

Counseling

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) HEDIS Measure:

Population Defined for Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 3-17 years of age as of December 31 of the measurement year Line of Business: Commercial, Medicaid

DESCRIPTION:	REQUIREMENT:
BMI Percentile (WCC-B): Percent of members 3-17 years of age who had an outpatient visit with a PCP or Ob/Gyn and who had evidence of BMI percentile during the measurement year	Documentation must include height, weight and BMI percentile during the measurement year. The height, weight and BMI percentile must be from the same data source. A BMI percentile BMI percentile plotted on BMI percentile age-growth chart
Counseling for Nutrition (WCC-N): Percent of members 3-17 years of age who had an outpatient visit with a PCP or Ob/Gyn and who had evidence of counseling for nutrition during the measurement year	Documentation must include a note indicating the date and at least one of the following: Discussion of current nutrition behaviors Checklist indicating nutrition was addressed Counseling or referral for nutrition education Member received educational materials on nutrition during a face-to-face visit Anticipatory guidance for nutrition Weight or obesity counseling
Counseling for Physical Activity (WCC-P): Percent of members 3-17 years of age who had an outpatient visit with a PCP or Ob/Gyn and who had evidence of counseling for physical activity during the measurement year	Documentation must include a note indicating the date and at least one of the following: Discussion of current physical activity behaviors Checklist indicating physical activity was addressed Counseling or referral for physical activity Member received educational materials on physical activity during a face-to-face visit Anticipatory guidance specific to the child’s physical activity Weight or obesity counseling

Screenings

Chlamydia Screening in Women (CHL) HEDIS Measure:

Population Defined for Chlamydia Screening in Women

(NCQA HEDIS guidelines, Measurement Year (MY) 2022)

Members who turn 16-24 years of age during the measurement year
Line of Business: Commercial, Medicaid

DESCRIPTION:	REQUIREMENT:
Percent of women 16-24 years of age who were identified as sexually active* and who had at least one test for chlamydia during the measurement year *Sexually active as determined by one of the following: claim/encounter for pregnancy test and/or dispensed prescription contraceptives	Perform at least one chlamydia test during the measurement year.

Table CHL-A: Prescriptions to Identify Contraceptives

DESCRIPTION:	PRESCRIPTION:
Contraceptives	Desogestrel-ethinyl estradiol Dienogest-estradiol multiphasic Drospirenone-ethinyl estradiol Drospirenone-ethinyl estradiol-levomefolate biphasic Ethinyl estradiol-ethynodiol Ethinyl estradiol-etonogestrel Ethinyl estradiol-levonorgestrel Ethinyl estradiol-norelgestromin	Ethinyl estradiol-norethindrone Ethinyl estradiol-norgestimate Ethinyl estradiol-norgestrel Etonogestrel Levonorgestrel Medroxyprogesterone Mestranol-norethindrone Norethindrone
Diaphragm	Diaphragm
Spermicide	Nonxynol 9

How does your completion of the TO-DO LIST get recorded?

Refer to Coding Tables.

Resources available for you and your patients:

¹Recommendations for Preventive Pediatric Health Care, Bright Futures/American Academy of Pediatrics
CDC Immunization Vaccine Schedule
New Blood Lead Level Information,Centers for Disease Control and Prevention

References:

Child hood Immunization Status, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications
Immunizations for Adolescents, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications
¹Recommendations for Preventive Pediatric Health Care, Bright Futures/American Academy of Pediatrics
Well-Child Visits in the First 30 Months of Life, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications
Child and Adolescent Well-Care Visits, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications
Chlamydia Screening in Women, NCQA HEDIS Measurement Year (MY) 2022 Tech Specifications

Coding Tables

Childhood Immunization Status (CIS) HEDIS Measure Billing Codes:

DTaP

DTaP Immunization

CVX 20 50 106 107 110 120 146

DTaP Vaccine Procedure

CPT 90697 90698 90700 90723

SNOMED CT US Edition 170395004 170396003 170397007 170399005 170400003 170401004 170402006 310306005 310307001 310308006 312870000 313383003 390846000 390865008 399014008 412755006 412756007 412757003 412762002 412763007 412764001 414001002 414259000 414620004 415507003 415712004 770608009 770616000 770617009 770618004 787436003 787438002 866158005 866159002 866226006 428251000124104 571571000119105 572561000119108 16290681000119103 16298561000119108

HIB B

Haemophilus Influenzae Type B (HiB) Immunization

CVX 17 46 47 48 49 50 51 120 146 148

Haemophilus Influenzae Type B (HiB) Vaccine Procedure

CPT 90644 90647 90648 90697 90698 90748

SNOMED CT US Edition 127787002 170343007 170344001 170345000 170346004 310306005 310307001 310308006 312869001 312870000 414001002 414259000 415507003 415712004 770608009 770616000 770617009 770618004 786846001 787436003 787438002 16292241000119109

HEP A

Hepatitis A (Illness)

ICD10CM B15.0 B15.9

SNOMED CT US Edition 16060001 18917003 25102003 40468003 43634002 79031007 111879004 165997004 206373002 278971009 310875001 424758008 428030001 105801000119103

Hepatitis A Immunization

CVX 31 83 85

Hepatitis A Vaccine Procedure

CPT 90633

SNOMED CT US Edition 170378007 170379004 170380001 170381002 170434002 170435001 170436000 170437009 243789007 312868009 313188000 313189008 314177003 314178008 314179000 394691002 412742005 412743000 871752004 871753009 871754003 571511000119102

HEP B

Hepatitis B (Illness)

ICD10CM B16.0 B16.1 B16.2 B16.9 B17.0 B18.0 B18.1 B19.10 B19.11

SNOMED CT US Edition 1116000 13265006 26206000 38662009 50167007 53425008 60498001 61977001 66071002 76795007 111891008 165806002 186624004 186626002 186639003 235864009 235865005 235869004 235871004 271511000 313234004 406117000 424099008 424340000 442134007 442374005 446698005 838380002 153091000119109

Hepatitis B Immunization

CVX 08 44 45 51 110 146

Hepatitis B Vaccine Procedure

CPT 90697 90723 90740 90744 90747 90748

HCPCS G0010

SNOMED CT US Edition 16584000 170370000 170371001 170372008 170373003 170434002 170435001 170436000 170437009 312868009 396456003 770608009 770616000 770617009 770618004 786846001 787438002 572561000119108

Newborn Hepatitis B Vaccine Administered

ICD10PCS 3E0234Z 99.55

POLIO

Inactivated Polio Vaccine (IPV) Immunization

CVX 10 89 110 120 146

Inactivated Polio Vaccine (IPV) Procedure

CPT 90697 90698 90713 90723

SNOMED CT US Edition 310306005 310307001 310308006 312869001 312870000 313383003 390865008 396456003 412762002 412763007 412764001 414001002 414259000 414619005 414620004 415507003 415712004 416144004 416591003 417211006 417384007 417615007 786846001 866186002 866227002 868266002 868267006 868268001 868273007 868274001 868276004 868277008 870670004 572561000119108 16290681000119103

FLU

Influenza Immunization

CVX 88 140 141 150 153 155 158 161

Influenza Vaccine Procedure

CPT 90655 90657 90661 90673 90685 90686 90687 90688 90689

HCPCS G0008

SNOMED CT US Edition 86198006 786847005 787016008

Influenza Virus LAIV Immunization

CVX 111 149

Influenza Virus LAIV Vaccine Procedure

CPT 90660 90672

MMR

Measles, Mumps and Rubella (MMR) Immunization

CVX 03 94

Measles, Mumps and Rubella (MMR) Vaccine Procedure

CPT 90707 90710

SNOMED CT US Edition 38598009 170433008 432636005 433733003 150971000119104 571591000119106 572511000119105

Mumps (Illness)

ICD10CM B26.0 B26.1 B26.2 B26.3 B26.81 B26.82 B26.83 B26.84 B26.85 B26.89 B26.9

SNOMED CT US Edition 10665004 17121006 31524007 31646008 36989005 40099009 44201003 63462008 72071001 74717002 75548002 78580004 89231008 89764009 111870000 161420006 235123001 236771002 237443002 240526004 240527008 240529006 371112003 105821000119107

Measles (Illness)

ICD10CM B05.0 B05.1 B05.2 B05.3 B05.4 B05.81 B05.89 B05.9

SNOMED CT US Edition 14189004 28463004 38921001 60013002 74918002 111873003 161419000 18

Immunizations for Adolescents (IMA) HEDIS Measure Billing Codes:

HPV

HPV Immunization

CVX 62 118 137 165

HPV Vaccine Procedure

CPT 90649 90650 90651

SNOMED CT US Edition 428570002 428741008 428931000 429396009 734152003 734154002 99501000119107 140611000119104 16300531000119107

MENINGOCOCCAL

Meningococcal Immunization

CVX 32 108 114 136 147 167 203

Meningococcal Vaccine Procedure

CPT 90619 90733 90734

SNOMED CT US Edition 390892002 428271000124109

Tdap

Tdap Immunization

CVX 115

Tdap Vaccine Procedure

CPT 90715

SNOMED CT US Edition 428251000124104

Well-Child Visits in the First 30 Months of Life (W30) HEDIS Measure Billing Codes:

Well-Care

CPT 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 99461

HCPCS G0438 G0439 S0302 S0610 S0612 S0613

ICD10CM Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 Z00.129 Z00.2 Z00.3 Z01.411 Z01.419 Z02.5 Z76.1 Z76.2

SNOMED CT US Edition 103740001 170099002 170107008 170114005 170123008 170132005 170141000 170150003 170159002 170168000 170250008 170254004 170263002 170272005 170281004 170290006 170300004 170309003 171387006 171394009 171395005 171409007 171410002 171416008 171417004 243788004 268563000 270356004 401140000 410620009 410621008 410622001 410623006 410624000 410625004 410626003 410627007 410628002 410629005 410630000 410631001 410632008 410633003 410634009 410635005 410636006 410637002 410638007 410639004 410640002 410641003 410642005 410643000 410644006 410645007 410646008 410647004 410648009 410649001 410650001 442162000 783260003 444971000124105 446301000124108 446381000124104 669251000168104 669261000168102 669271000168108 669281000168106

Child and Adolescent Well-Care Visits (WCV) HEDIS Measure Billing Codes:

Well-Care

CPT 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 99461

HCPCS G0438 G0439 S0302 S0610 S0612 S0613

ICD10CM Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 Z00.129 Z00.2 Z00.3 Z01.411 Z01.419 Z02.5 Z76.1

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) HEDIS Measure Billing Codes:

BMI Percentile

ICD10CM Z68.51 Z68.52 Z68.53 Z68.54

LOINC 59574-4 59575-1 59576-9

Nutrition Counseling

CPT 97802 97803 97804

HCPCS G0270 G0271 G0447 S9449 S9452 S9470

ICD10CM Z71.3

SNOMED CT US Edition 11816003 61310001 183059007 183060002 183061003 183062005 183063000 183065007 183066008 183067004 183070000 183071001 226067002 266724001 275919002 281085002 284352003 305849009 305850009 305851008 306163007 306164001 306165000 306626002 306627006 306628001 313210009 370847001 386464006 404923009 408910007 410171007 410177006 410200000 429095004 431482008 443288003 609104008 698471002 699827002 699829004 699830009 699849008 700154005 700258004 705060005 710881000 14051000175103 428461000124101 428691000124107 441041000124100 441201000124108 441231000124100 441241000124105 441251000124107 441261000124109 441271000124102 441281000124104 441291000124101 441301000124100 441311000124102 441321000124105 441331000124108 441341000124103 441351000124101 445291000124103 445301000124102 445331000124105 445641000124105

Physical Activity Counseling

HCPCS G0447 S9451

ICD10CM Z02.5 Z71.82

SNOMED CT US Edition 103736005 183073003 281090004 304507003 304549008 304558001 310882002 386291006 386292004 386463000 390864007 390893007 398636004 398752005 408289007 410200000 410289001 410335001 429778002 710849009 435551000124105

Chlamydia Screening in Women (CHL) HEDIS Measure Billing Codes:

Chlamydia Tests

CPT 87110 87270 87320 87490 87491 87492 87810

LOINC 14463-4 14464-2 14467-5 14474-1 14513-6 16600-9 21190-4 21191-2 21613-5 23838-6 31775-0 31777-6 36902-5 36903-3 42931-6 43304-5 43404-3 43405-0 43406-8 44806-8 44807-6 45068-4 45069-2 45075-9 45076-7 45084-1 45091-6 45095-7 45098-1 45100-5 47211-8 47212-6 49096-1 4993-2 50387-0 53925-4 53926-2 557-9 560-3 6349-5 6354-5 6355-2 6356-0 6357-8 80360-1 80361-9 80362-7 91860-7

SNOMED CT US Edition 104175002 104281002 104282009 104290009 117775008 121956002 121957006 121958001 121959009 122173003 122254005 122321005 122322003 134256004 134289004 171120003 285586000 310861008 310862001 315087006 315094009 315095005 315099004 390784004 390785003 395195000 398452009 399193003 407707008 442487003 707982002

Supplemental Data Requirements

CIS

Immunization record, documentation from NJIIS, or progress notes with dates of administration on or before child’s second birthday

IMA

Immunization record, documentation from NJIIS, or progress notes with dates of administration on or before child’s 13th birthday

WCC

BMI: Documentation of weight, height and BMI Percentile, or BMI percentile plotted on age-growth BMI chart.
Nutrition Counseling: Documentation must include a note indicating the date and nutritional counseling in the measurement year
Physical Activity Counseling: Documentation must include a note indicating the date and physical activity counseling in the measurement year

CHL

Dated lab report or progress note showing screening performed in measurement year

General Notes

The most accurate method to submit data for clinical quality gap closure is through correct coding. Supplemental data submission can be used for gap closure when information is not received through coding. All supplemental data must be signed and dated by a treating physician, nurse practitioner or physician assistant. All dates must include month, day and year.

Patient name and birthdate needs to be on all supplemental documentation. If birthdate is not officially on a report, it needs to be either written on the document and signed by the physician, or a demographic cover sheet should be included as an additional page with the submission.

To learn more about your practice’s current HEDIS performance for this or other measures, or for assistance in compliance with the HEDIS guidelines, please contact Horizon Healthy Journey: 1-844-754-2451.

Reference: NCQA HEDIS Measurement Year (MY) 2022 Technical Specs CPT® is a registered trademark of the American Medical Association.