Pediatric Measures

Hello and welcome to the Results and Recognition Program. The topic, Pediatric Measures.

Here are the objectives; We will review the pediatric measures and the criteria to meet compliance for those measures, discuss the possible exclusions, and also review some suggested best practices that can help you be successful in closing those gaps in care.

Here are the incentivized R&R pediatric HEDIS measures, including the sub-measures. We will discuss each one in the following slides.

Now, there are some exclusions that may apply to certain measures and some that may apply to every measure.

A required exclusion for every measure pertains to hospice.

Newly added this year for all measures is a required exclusion for members who died during the measurement year.

If a member is to be excluded from a measure, there has to be clear documentation in the member's medical record as to the reason why, and the date of the occurrence.

For example, weight assessment and counseling for nutrition and physical activity for children and adolescents.

If we are looking to possibly exclude a member from this measure, based on the fact that she had a pregnancy, it must be clearly documented that the member was pregnant on or before December 31st of the measurement year.

As we review the measures, we will talk about the measures, the eligible population for each measure, the specific line of business it applies to, what specifically meets the measure for compliance, and if any exclusions that may apply.

You will hear the term measurement year.

This refers to the year in which we are collecting data from.

The measurement year starts January 1st and ends December 31st.

Childhood Immunization Status, CIS.

For Childhood Immunization Status Combo 10, the measure evaluates the percentage of children 2 years of age who had all immunizations on or before their 2nd birthday.

The eligible population are children who turned 2 years of age during the measurement year.

The line of business, Medicaid and Commercial.

For the member to be compliant, the child must receive the 10 different vaccines noted here, or documentation of history of the illness on or before the 2nd birthday, and all dates of service must be at least 14 days apart.

For the 3 Hepatitis B vaccines, one of those can be a newborn vaccine during the 8 days period from date of birth to 7 days after.

Here documentation is very important to capture this.

The 10 immunizations are; 4 DTaP, 3 IPV, 3 HiB, 4 PCV, and either a 2 or 3 dose Rotavirus series.

The child has to be at least 42 days of age before receiving any of these.

And, yes, NCQA is very specific with their timeframes and capturing this data.

For Rotavirus, it should specify on the immunization record if it is a 2 or 3 dose series that was given.

Rotateq is the 3 dose series, whereas Rotarix is a 2 dose series.

Now, if this is not specified by name or dose, it is assumed to be a 3 dose series.

Moving on, 2 flu vaccines between 6 months of age and the 2nd birthday.

Now, it is important to note that if 1 of the 2 flu vaccinations is the LAIV vaccination, which is the intranasal vaccine, this one has to be administered exactly on the child's 2nd birthday and not a day before.

Moving on, 1 MMR, 1 Varicella, and 1 Hep A between the 1st and 2nd birthdays.

Now, the exclusions have to be clearly documented in the medical record on or before the 2nd birthday.

The documentation must clearly indicate which vaccine, when it occurred, and the contraindication.

Another important thing to note is that parental refusal is not an exclusion.

That would actually be considered not compliant.

Some of the possible exclusions are HIV, severe combined immunodeficiency, to name a few.

Next is Childhood Immunization Status, Combo 7.

Now, this measure is being incentivized and it is very much like Combo 10. The only exception is, the flu vaccination is not included, so it's all vaccines, with the exception of the flu vaccine.

Immunizations for Adolescents, IMA.

This measure evaluates the percentage of adolescents 13 years of age who had 1 dose of Meningococcal vaccine and 1 Tdap vaccine, and have completed the human papilloma virus, HPV series, by his or her 13th birthday.

The eligible population are adolescents who turned 13 years of age during the measurement year.

The line of business, Medicaid and Commercial.

Now, there are 2 sub-measures.

For Combo 1 to be compliant, the member must receive the following immunizations, 1 meningococcal between their 11th and on or before their 13th birthday, and 1 Tdap between their 10th and on or before their 13th birthday.

Just to be clear DTaP, does not count towards Tdap. These are 2 separate vaccines. DTaP is for the pediatric population under the age of 7 and Tdap is for adolescents starting at age 11.

Something I find helpful is T for teens when dealing with Tdap.

For HPV to be compliant, the member needs to receive 2 or 3 vaccines with different dates of service between the 9th and 13th birthday.

There must be at least 146 days between the 1st and 2nd dose, if using the 2 dose vaccine.

Meeting compliance for CIS and IMA.

A note indicating the name of the specific antigen or combination vaccine and the date of the immunization. Documentation of anaphylaxis due to a specific vaccine.

Documented history of the illness as relating to the vaccine.

A certificate of immunization prepared by an authorized health care provider or agency, including the specific dates and types of immunization administered.

MMR, Hep B, Varicella, or Hep A seropositive test result.

Rotavirus vaccine administration must indicate if it is a 2 or 3 dose series.

Notation that the member is up-to-date with all immunizations does not meet compliance.

Best practices for CIS and IMA.

Schedule appointments to coincide with required time frames for immunization administration.

Use your electronic medical record EMR system to set reminder flags.

During visits, talk to parents about the importance of having their children immunized. Be sure that your medical record includes immunization history from all sources.

Utilize the HEDIS recommended codes to ensure these gaps are closed.

Update the New Jersey Immunization Information System registry.

Chlamydia Screening in Women, CHL.

This measure evaluates the percentage of women 16 to 24 years of age who were identified as sexually active during the measurement year by either pharmacy data dispensing event or contraceptives, or a claim for a pregnancy test.

To be compliant, the member must have at least one chlamydia test during the measurement year.

The testing can be done by either urine or swab.

If done at another office, you can submit that to get credit, such as a GYN visit.

Now, we know that contraceptives are prescribed for reasons other than preventing pregnancy.

However, whether the member is sexually active or not, if a contraceptive is prescribed, that member will be falling into the measure.

Now, one of the exclusions are for members in the eligible population who had a pregnancy test alone, may be excluded if they were prescribed isotretinoin on the date of the pregnancy tests or 6 days after the pregnancy tests.

Another possible exclusion is if the member had an X-ray on the date of the pregnancy test or the 6 days after the pregnancy test.

As we know, some X-rays require a member to get a pregnancy test prior to getting an X-ray. In both the examples, pregnancy tests were ordered for reasons other than sexual activity.

Best practices for CHL.

Adopt urine screening of all women in this age range to eliminate the need for pelvic exam. Screening should occur with or without symptoms.

Screenings should also occur at any visit where oral contraceptives, sexually transmitted diseases, or urinary symptoms are discussed.

Create an environment conducive to sexual history taking and develop a tool for taking this history.

Establish a process for obtaining chlamydia screening results from the OBGYN providers participating in the member's care.

Lead Screening in Children, LSC.

Here, the measure evaluates the percentage of children 2 years of age during the measurement year, who had 1 or more capillary or venous blood tests for lead poisoning by his or her 2nd birthday.

The eligible population are members turning 2 years of age during the measurement year.

The line of business, Medicaid.

What meets the measure? At least 1 capillary or venous blood test on or before the child's 2nd birthday as documented through either administrative data or medical record review.

Lead Screening in Children - State Requirements.

So the State contract states providers will have a compliance rate of greater than 80% for 2 consecutive 6 months periods for lead level tests.

The eligible population are children 9 months to 19 months of age during the measurement year.

The line of business, Medicaid.

So what meets the measure?

Required testing by the State of New Jersey at 12 and 24 months of age. There has to be a capillary or venous blood test documented either through administrative data or medical record review.

So with this measure, it's broken down into two rates.

The first rate are all children between 9 months and 18 months of age, and here at Horizon, the targeted age is 12 months to receive a lead test.

And then the second rate is between 18 months and 26 months of age, and the targeted age is 24 months.

Please understand that if you close the State requirements, you will automatically close the NCQA requirement.

Lead risk assessment questionnaire.

The questionnaire is used to screen and capture early lead exposure before it can do irreversible harm.

A lead risk assessment questionnaire should be performed for lead toxicity at every periodic visit between the ages of 6 months to 6 years of age.

If the answers to any of the 10 questions are yes or don't know, a child is considered at high risk for high doses of lead exposure and a blood level should be attained.

If the answers to all the questions are no, a child is considered at low risk for high doses of lead exposure.

A child's risk category can change with each administration of the lead risk assessment questionnaire.

This form on the right is a lead risk assessment questionnaire that can be found on our Horizon website, or your practice may have a similar form.

This verbal risk assessment should be performed for lead toxicity at every periodic visit, again, to remind you between the ages of 6 months to 6 years of age.

MedTox testing kits.

In office collection of blood samples by finger stick.

Clinical Laboratory Improvement Amendments, so it's CLIA certified.

Point-of-care testing reimbursable by Horizon NJ Health for $10.

Free MedTox kits can be obtained from LabCorp.

The MedTox contact is Joe Huffer, and that number is 1-877-725-7241.

MedTox testing kits can be ordered online.

Best practices for Lead Screening in Children.

Educate guardians on the importance of lead screening and the dangerous effects of lead poisoning.

Set EMR alerts and standard orders.

Order the test at the appropriate ages.

Follow up on open lab orders for lead screening.

Be sure chart documentation includes the date the test was performed and the result or finding.

Utilize the HEDIS recommended codes to ensure these gaps are closed. Consider providing in-office testing.

Please note, if a member has not had a lead test by 24 to 72 months of age, testing should be done, but will not be compliant.

Weight Assessment and Counseling for Nutrition and Physical Activity, WCC.

This measure evaluates the percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OBGYN, and had evidence of the following during the measurement year; BMI percentile documentation, counseling for nutrition, and counseling for physical activity.

The eligible population are members 3 to 17 years of age as of December 31st of the measurement year.

The member will need to have had an outpatient visit with a PCP or OBGYN during the measurement year to be eligible.

The line of business, Medicaid and Commercial.

A possible exclusion is if there was a diagnosis of pregnancy during the measurement year.

Here are some examples of compliant documentation, starting with BMI percentile.

The BMI percentile plotted on an age-growth chart is acceptable.

The documentation of a distinct BMI percentile.

Documentation of greater than 99% or less than 1%, meets criteria.

Member reported height, weight, and BMI percentiles must be documented in the medical record by the PCP.

Moving on to nutrition. Some acceptable documentation is discussion of a current nutrition behavior, such as eating habits, dieting behaviors.

A checklist indicating nutrition was addressed.

Counseling or referral for nutrition education.

Educational materials distributed during an in-person visit on nutrition.

Anticipatory guidance for nutrition.

A referral to WIC may be used.

Physical activity. Discussion of current physical activity behaviors, such as exercise routine, participation in sports activities, or an exam for sport participation.

Completed checklist indicating physical activity was addressed.

Counseling or referral for physical activity.

Educational materials distributed during an in-person visit on physical activity.

And anticipatory guidance for physical activity or exercise.

Here are some examples of non-compliant documentation.

For BMI, documentation of height, weight and BMI percentile ranges and thresholds. Remember the only range is greater than 99%, which is 100%, or less than 1, which is 0%.

Another non-compliant documentation is notation of BMI value alone.

Notation of height and weight only.

For nutrition and physical activity, some items that are noncompliant is notation of health education or anticipatory guidance, without specific mention of nutrition or physical activity.

Documentation related to an acute or chronic illness.

For nutrition, a physical exam finding or observation alone, such as well-nourished or well-developed, will not be compliance. Documentation related to our members appetite, such as appetite fear, or poor or picky eater.

Notation that the member with diarrhea is following the banana, rice, applesauce and toast diet, the BRAT diet.

For physical activity, non-compliant documentation, notation for cleared for gym class alone without documentation of a discussion.

Notation of anticipatory guidance related solely to safety.

Notation related to screen time, without specific mention of physical activity.

Notation that the member with chronic knee pain is able to run without limping.

Notation that the member has exercise-induced asthma will not meet compliance.

Here are some best practices for WCC.

Take advantage of every visit, including sick and telehealth visits, to capture BMI percentile, nutrition and physical activity assessments and anticipatory guidance.

Document member reported biometric values such as height, weight and BMI percentile.

Document services rendered for obesity or eating disorders, if applicable, to comply for both nutrition and physical activities sub-measures.

Use standardized templates in charts and EMRs that allowed checkboxes for standard counseling activities.

Educate patients on the importance of having at least one ambulatory or preventive care visit during the measurement year.

Utilize the HEDIS recommended codes to ensure these gaps are closed.

Well-Child Visits in the First 30 Months of Life, W30.

The measure evaluates the percentage of children who turned 30 months old during the measurement year and who had at least six well visits with a PCP by 15 months of age and who had at least two well visits with a PCP between the child's 15 month birthday +1 day.

So, with this measure, there are two rates.

The first rate are children turning 15 months of age during the measurement year.

The second rate are children turning 30 months of age during the measurement year.

The line of business, Medicaid and Commercial.

So, what meets the measure?

For rate one, the member had to have at least six well visits with a PCP within the first 15 months of age. All dates of service for well visits must be 14 days apart.

For rate two, the member needs to have at least two well visits with a PCP between the ages of 15 months +1 day through 30 months of age. All dates of service for well visits must be 14 days apart.

Visits must contain documentation of all the following;

A health history, a physical developmental history, a mental developmental history, a physical exam, and health education or anticipatory guidance.

W30 components. Now, what will make the visit compliant?

Before we review this information, it has to be noted that they do not have to be on the same dates of service. It can be taken from sick visits, as long as it does not apply to an acute or chronic illness.

So, for health history, this includes past medical history, surgical history, birth history, such as a C-section or family history.

For physical developmental history, it can include gross or fine motor skills.

Some examples are walking ability, physical milestones.

For the mental developmental history, it can include cognitive development such as cooing, reasoning, or getting along with their peers.

For the physical exam, assesses body systems and must be a hands-on exam and must assess at least five bodily systems.

And for the health education or anticipatory guidance, any advice or counseling.

Here are some examples of a non-compliant documentation.

For the health history, notation of allergies, or medications, or immunization status alone, you need all three components to be compliant.

For the physical developmental history, notation of Tanner stage or scale. Tanner, sexual maturity rating, starts at age 8.

This measure focuses on well visits during the first 30 months of life.

Notation of appropriate for age, without specific mention of development.

Notation of well-developed, nourished or appearing, will not meet compliance.

Moving on to mental developmental history, notation of appropriately responsive for age, or notation of a neurological exam, will not meet compliance.

For the physical exam, vital signs alone will not meet compliance.

And lastly, for health education or anticipatory guidance, information regarding medication or immunizations, or their side effects, will not meet compliance.

Here are some reminders for W30.

Services may be rendered during a visit other than a well-child visit.

Services rendered in an emergency department, or during an impatient visit, do not count.

Services specific to the assessment, or treatment of an acute or chronic condition, do not count.

Services rendered during a consultation or with a specialist, do not count.

The well-child visit must occur with a PCP, but that PCP does not have to be the practitioner assigned to the child.

Child and Adolescent Well-Care Visits, WCV.

This measure is based on the American Academy of Pediatrics, Bright Futures guidelines for a healthy supervision of infants, children and adolescents.

This measure evaluates the percentage of members 3 to 21 years of age who had at least one well visit in the measurement year with a PCP or OBGYN.

The line of business, Medicaid and Commercial.

The eligible population are members 3 to 21 years of age as of December 31st of the measurement year.

Now, if a member comes in at 2 years of age, but will turn 3 years old during the measurement year, we can still accept that visit.

For the member to be compliant they need to have one well visit in the measurement year.

Here's some best practices for WCV and W30.

Take advantage of every visit, including sick visits to capture the components of this measure.

Schedule visits within the recommended time frames.

Now, for the W30 measure, based on the well-visit schedule by the American Academy of Pediatrics, there are 7 opportunities to capture these visits.

Such as newborn, the first, second, 4th month, 6th, 9 and so on.

Outreach calls or send letters to advise members of the need for a visit.

Consider offering extended practice hours to increase care access.

Use standardized templates and charts and EMRs that allow checkboxes for standard counseling activities.

Encourage parents and patients to maintain the relationship with the PCP to promote consistent and coordinated of care.

Asthma Medication Ratio, AMR.

This is the last measure we have in the pediatric Results and Recognition program.

The measure evaluates members 5 to 64 years of age who are identified as having persistent asthma and had a ratio of controller medication to total asthma medications of 0.50 or greater during the measurement year.

Eligibility are members 5 to 64 years of age who had persistent asthma and met at least one of the following criteria during both the measurement year and the year prior to the measurement year, so they need just one.

At least one ED visit with the principal diagnosis of asthma.

At least one acute inpatient encounter with the principal diagnosis of asthma without telehealth.

At least one acute inpatient discharge with the principal diagnosis of asthma on the discharge claim.

At least four outpatient visits, observation visits, telephone visits, or online assessments, on different dates of service, with any diagnosis of asthma, and at least two asthma medication dispensing events for any controller or reliever meds, or four asthma medication dispensing events for any controller or reliever medication.

The line of business, Medicaid and Commercial.

So, what meets the measure?

The number of members who have a medication ratio of 0.50 or greater during the measurement year.

There's no math being done on your end, but basically this measure is looking to make sure that the member is taking their controller medication more than their reliever medication.

Here are some possible exclusions; Emphysema, COPD, acute respiratory failure, and it's also important to note that members who had no asthma controller or reliever medication dispensed during the measurement year can be excluded.

Best practices for AMR.

Develop an asthma action plan.

Educate members on the importance of adhering to medication and reducing asthma triggers.

Advise members to incorporate inhalers into their daily routine.

Reach out to members to schedule follow up visits for the condition.

Bright Futures. This is a national health promotion and prevention initiative led by the American Academy of Pediatrics, AAP.

It provides theory and evidence based guidance for all preventative care screenings and well child visits.

Now, we have many different tools and resources available and this is just one that contains a lot of information pertaining to the pediatric population.

Please reach out to your Clinical Quality Improvement Liaison for additional tools and resources.

Suggestions for success with closing gaps.

EMR is updated to reflect member's current specialists for patient care team.

Incorporate templates and ticklers into your EMR system as a reminder of HEDIS recommended screenings.

Develop electronic health record, standing order sets capturing applicable coding requirements.

Submit accurate claims or encounter data for each and every service rendered and ensure medical record documentation reflects all services billed.

Use gap lists to identify open care gaps and manage your total population.

Determine reasons for open care gaps and identify barriers and provide solutions such as transportation, extended clinical hours and immunization clinics.

Use reminder notifications advising members of the need for a visit.

Access the Quality Resource Center for strategies and tools to provide quality service to your patients.

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