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Connection supplemental articles and policies - September 2007

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Connection - September 2007 (pdf, 140 KB)

supplemental articles

policies and forms

new fchp masshealth benefits in effect

We’d like to make you aware of three new FCHP MassHealth member benefits that went into effect on July 1, 2007: (1) medical nutritional therapy, (2) diabetes self-management training and (3) transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border). These benefits have been added to the MassHealth Standard, Family Assistance and Basic plans. 

The first two benefits, medical nutritional therapy and diabetes self-management training, are FCHP-covered benefits (the procedure codes are listed below); the transportation benefit is covered by MassHealth. The lists for FCHP MassHealth-covered services will be updated to reflect these benefit changes.

benefit descriptions

  • medical nutritional therapy - nutritional, diagnostic, therapy and counseling services for the purpose of disease management that are furnished by a physician, registered dietitian, licensed dietitian/nutritionist, or other health-care provider with specific training in the provision of nutritional counseling. The following codes are covered for medical nutritional therapy for dates of service on or after July 1, 2007:
    • 97802 
      Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the
      patient, each 15 minutes.
    • 97803 
      Reassessment and intervention, individual, face-to-face with the patient, each 15 minutes.
    • 97804 
      Group (two or more individuals), each 30 minutes
    • G0270 
      Medical nutrition therapy; reassessment and subsequent intervention(s) following second
      referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes.
    • G0271 
      Medical nutrition therapy, reassessment and subsequent intervention(s) following second
      referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes.
  • diabetes self-management training - educational and training services furnished to an individual with diabetes by a physician or certain accredited mid-level providers (registered nurses, physician assistants, nurse practitioners and registered dietitians). The following codes are covered for members with a diagnosis of diabetes for DSMT for dates of service on or after July 1, 2007:
    • G0108 
      Diabetes self-management training services, individual, per 30 minutes
    • G0109 
      Diabetes self-management training services, group session (two or more individuals), per 30
      minutes
  • transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border) - non-emergent ambulance (land) services or nonemergent chair car services, that generally are prearranged to transport an enrollee to a covered service that is located in-state or within a 50-mile radius of the Massachusetts border. This is a non-MCO covered service and is an additional benefit being provided by MassHealth for MassHealth Basic and MassHealth Family Assistance products.


new tool for senior “phit”-ness

Fallon Senior Plan™ members now have access to SeniorPHIT, a Web-based health program that complements the SilverSneakers® Fitness Program, available to them at no additional cost beyond their monthly plan premium. “PHIT” stands for Personal Health Improvement Tracking, and that’s just what they get with this tool.

The Web site offers participants help to set goals in the areas of fitness, nutrition/healthy eating and life management, and provides resources to help meet them. Additional tools at SeniorPHIT include Personal Coaching (interacting with health and wellness professionals) and a Virtual Trainer (visual demonstrations of exercises).

Encourage your Fallon Senior Plan members to go to the SilverSneakers Web site at www.silversneakers.com and click on the “Members” section, where they’ll be asked to register as a new user. They’ll receive an e-mail confirmation and directions for logging on to SeniorPHIT.

SilverSneakers® is a registered trademark of Healthways.


fchp in the community

Summit ElderCaresm was recognized last June as “top health care organization” in the Worcester Business Journal’s second annual Health Care Heroes Awards program. Summit ElderCare, sponsored by Fallon Community Health Plan, helps frail elders live independently in the comfort of home. For more information about Summit ElderCare, go to www.summiteldercare.org.

On September 24, FCHP will host its second annual Golf FORE a Goal tournament at Worcester Country Club. Last year, we raised $115,000 to benefit Boys & Girls Clubs throughout Massachusetts. This year’s event will benefit food pantries and hunger relief programs in the state.

FCHP this year began a new philanthropic initiative, the FCHP Mini-Grants Program. Unlike our annual Community Benefits grants, we’ll award two mini-grants of up to $1,000 each every month. For information about applying for a mini-grant, organizations can download an application from the FCHP Web site at www.fchp.org.

FCHP awarded $5,000 to Worcester Latino Dollars for Scholars, a non-profit organization that provides education assistance for post-secondary study to Latino students from Worcester public schools.

formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Please note the following changes to our commercial plan formulary.

commercial plan formulary

additions
amlodipine/benazepril cap Tier 1
AzaSite™ (azithromycin ophthalmic solution)   Tier 3
Clarifoam™ EF Tier 3
dexmethylphenidate tab Tier 1
Divige® (estradiol) gel Tier 3
Elestrin™ (estradiol) gel Tier 3, 2 copayments per container
Fosamax Plus D® (70 mg alendronate/5600 IU vit.D3) Tier 2, QLL 4 per 30 days

changes
Clobex® (clobetasol) spray  New to market to 3PA
Desonate™ (desonide) gel New to market to 3PA
Invega™ (paliperidone) New to market to 3PA
Lialda™ (mesalamine DR) New to market to 3PA
Olux-E™ (clobetasol) foam New to market to 3PA

new to market policy*

Letairis™ (ambrisentan)
Lybrel® (levonorgestrel/ethinyl estradiol, continuous)
Vyvanse™ (lisdexamfetamine)

* FCHP’s New to Market Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for noncovered pharmaceuticals. •

code updates

Please note that effective November 1, 2007, the following codes will no longer be separately reimbursed by FCHP. 

code

description

0001F

Heart failure assessed (includes assessment of all the following components)(CAD, HF)1: Blood pressure measured (2000F)1 Level of activity assessed (1003F)1 Clinical symptoms of volume overload (excess) assessed (1004F)1 Weight, recorded (2001F)1 Clinical signs of volume overload (excess) assessed (2002F)1

0005F

Osteoarthritis assessed (OA)1 Includes assessment of all the following components: Osteoarthritis symptoms and functional status assessed (1006F)1 Use of anti-inflammatory or over-the-counter (OTC) analgesic medications assessed (1007F)1 Initial examination of the involved joint(s) (includes visual inspection, palpation, range of motion) (2004F)1

0012F

Community-acquired bacterial pneumonia assessment (includes all of the following components) (CAP)1: Co-morbid conditions assessed (1026F)1 Vital signs recorded (2010F)1 Mental status assessed (2014F)1 Hydration status assessed (2018F)1

0016T

Destruction of localized lesion of choroid (eg, choroidal neovascularization), transpupillary thermotherapy

0017T

Destruction of macular drusen, photocoagulation

0018T

Delivery of high power, focal magnetic pulses for direct stimulation to cortical neurons

0019T

Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy

0026T

Lipoprotein, direct measurement, intermediate density lipoproteins (IDL) (remnant lipoproteins)

0027T

Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (eg, spinal endoscopic catheter system) or solution injection (eg, normal saline) including radiologic localization and epidurography

0028T

Dual energy x-ray absorptiometry (DEXA) body composition study, one or more sites

0029T

Treatment(s) for incontinence, pulsed magnetic neuromodulation, per day

0030T

Antiprothrombin (phospholipid cofactor) antibody, each IG class

0031T

Speculoscopy

0032T

Speculoscopy; with directed sampling

0041T

Urinalysis infectious agent detection, semi-quantitative analysis of volatile compounds

0042T

Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

0043T

Carbon monoxide, expired gas analysis (e.g., etcoc/hemolysis breath test)

0046T

Catheter lavage of a mammary duct(s) for collection of cytology specimen(s), in high risk individuals (GAIL risk scoring or prior personal history of breast cancer), each breast; single duct

0047T

Catheter lavage of a mammary duct(s) for collection of cytology specimen(s), in high risk individuals (GAIL risk scoring or prior personal history of breast cancer), each breast; each additional duct

0048T

Implantation of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation

0049T

Prolonged extracorporeal percutaneous transseptal ventricular assist device, greater than 24 hours, each subsequent 24 hour period (List separately in addition to code for primary procedure)

0050T

Removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation

0051T

Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy

0052T

Replacement or repair of thoracic unit of a total replacement heart system (artificial heart)

0053T

Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit

0054T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)

0055T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)

0056T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, image-less (List separately in addition to code for primary procedure)

0058T

Cryopreservation; reproductive tissue, ovarian

0059T

Cryopreservation; oocyte(s)

0060T

Electrical impedance scan of the breast, bilateral (risk assessment device for breast cancer)

0061T

Destruction/reduction of malignant breast tumor including breast carcinoma cells in the margins, microwave phased array thermotherapy, disposable catheter with combined temperature monitoring probe and microwave sensor, externally applied microwave energy, including interstitial placement of sensor

0062T

Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level

0063T

Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to 0062T for primary procedure)

0064T

Spectroscopy, expired gas analysis (e.g., nitric oxide/carbon dioxide test)

0065T

Ocular photoscreening, with interpretation and report, bilateral

0068T

Acoustic heart sound recording and computer analysis; with interpretation and report

0069T

Acoustic heart sound recording and computer analysis; acoustic heart sound recording and computer analysis only

0070T

Acoustic heart sound recording and computer analysis; interpretation and report only

0071T

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue

0072T

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue

0073T

Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session

0074T

Online evaluation and management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient's request, established patient

0077T

Implanting and securing cerebral thermal perfusion probe, including twist drill or burr hole, to measure absolute cerebral tissue perfusion

0088T

Submucosal radiofrequency tissue volume reduction of tongue base, one or more sites, per session (ie, for treatment of obstructive sleep apnea syndrome)

0089T

Actigraphy testing, recording, analysis and interpretation (minimum of three-day recording)

0090T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression) cervical; single interspace

0092T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression) cervical; each additional interspace (List separately in addition to code for primary procedure)

0093T

Removal of total disc arthroplasty, anterior approach cervical; single interspace

0095T

Removal of total disc arthroplasty, anterior approach cervical; each additional interspace (List separately in addition to code for primary procedure)

0096T

Revision of total disc arthroplasty, anterior approach cervical; single interspace

0098T

Revision of total disc arthroplasty, anterior approach cervical; each additional interspace (List separately in addition to code for primary procedure)

0099T

Implantation of intrastromal corneal ring segments

0100T

Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy

0101T

Extracorporeal shock wave involving musculoskeletal system, not otherwise specified

0102T

Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle

0103T

Holotranscobalamin quantitative

0104T

Inert gas rebreathing for cardiac output measurement; during rest

0105T

Inert gas rebreathing for cardiac output measurement; during exercise

0106T

Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation

0107T

Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation

0108T

Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia

0109T

Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia

0110T

Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation

0111T

Long-chain (c20-22) omega-3 fatty acids in red blood cell (RBC) membranes

0115T

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter

0116T

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; subsequent encounter

0117T

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service)

0123T

Fistulization of sclera for glaucoma, through ciliary body

0124T

Conjunctival incision with posterior juxtascleral placement of pharmacological agent (does not include supply of medication)

0126T

Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment

0130T

Validated, statistically reliable, randomized, controlled, single-patient clinical investigation of FDA approved chronic care drugs, provided by a pharmacist, interpretation and report to the prescribing health care professional

0133T

Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with injection of implant material into and along the muscle of the lower esophageal sphincter (eg, for treatment of gastroesophageal reflux disease)

0135T

Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

0137T

Biopsy, prostate, needle, saturation sampling for prostate mapping

0140T

Exhaled breath condensate Ph

0141T

Pancreatic islet cell transplantation through portal vein, percutaneous

0142T

Pancreatic islet cell transplantation through portal vein, open

0143T

Laparoscopy, surgical, pancreatic islet cell transplantation through portal vein

0144T

Computed tomography, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium

0153T

Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation and instrument calibration (List separately in addition to code for primary procedure)

0154T

Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report

0155T

Laparoscopy, surgical; implantation or replacement of gastric stimulation electrodes, lesser curvature (ie, morbid obesity)

0156T

Laparoscopy, surgical; revision or removal of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)

0157T

Laparotomy, implantation or replacement of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)

0158T

Laparotomy, revision or removal of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)

0159T

Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure)

0160T

Therapeutic repetitive transcranial magnetic stimulation treatment planning

0161T

Therapeutic repetitive transcranial magnetic stimulation treatment delivery and management, per session

0162T

Electronic analysis and programming, reprogramming of gastric neurostimulator (ie, morbid obesity)

0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace

0164T

Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace

0165T

Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace

0166T

Transmyocardial transcatheter closure of ventricular septal defect, with implant; without cardiopulmonary bypass

0167T

Transmyocardial transcatheter closure of ventricular septal defect, with implant; with cardiopulmonary bypass

0168T

Rhinophototherapy, intranasal application of ultraviolet and visible light, bilateral

0169T

Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s)

0170T

Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [sis1]

0171T

Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level

0172T

Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure)

0173T

Monitoring of intraocular pressure during vitrectomy surgery (List separately in addition to code for primary procedure)

0174T

Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure)

0175T

Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation

0176T

Transluminal dilation of aqueous outflow canal; without retention of device or stent

0177T

Transluminal dilation of aqueous outflow canal; with retention of device or stent

0500F

Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit and, in a separate field, the date of the last menstrual period-LMP) (Prenatal)2

0501F

Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period - LMP (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)1

0502F

Subsequent prenatal care visit (Prenatal)2

0503F

Postpartum care visit (Prenatal)2

0505F

Hemodialysis plan of care documented (ESRD)1

0507F

Peritoneal dialysis plan of care documented (ESRD)1

1000F

Tobacco use assessed (CAD1, CAP1, COPD1, DM4, PV1)

1002F

Anginal symptoms and level of activity, assessed (CAD)1

1003F

Level of activity assessed (HF)1

1004F

Clinical symptoms of volume overload (excess) assessed (HF)1

1005F

Asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/survey/questionnaire) (Asthma)1

1006F

Osteoarthritis symptoms and functional status assessed (may include the use of a standardized scale or the completion of an assessment questionnaire, such as the SF-36, AAOS Hip & Knee Questionnaire) (OA)1

1007F

Use of anti-inflammatory or analgesic over-the-counter (OTC) medications for symptom relief assessed (OA) 1

1008F

Gastrointestinal and renal risk factors assessed for patients on prescribed or OTC non-steroidal anti-inflammatory drug (NSAID) (OA)1

1015F

Chronic obstructive pulmonary disease (COPD) symptoms assessed (Includes assessment of at least one of the following: dyspnea, cough/sputum, wheezing), or respiratory symptom assessment tool completed (COPD)1

1018F

Dyspnea assessed, not present (COPD1)

1019F

Dyspnea assessed, present (COPD1)

1022F

Pneumococcus immunization status assessed (CAP1, COPD1)

1026F

Co-morbid conditions assessed (eg, includes assessment for presence or absence of: malignancy, liver disease, congestive heart failure, cerebrovascular disease, renal disease, chronic obstructive pulmonary disease, asthma, diabetes, other co-morbid conditions) (CAP)1

1030F

Influenza immunization status assessed (CAP1)

1034F

Current tobacco smoker (CAD1, CAP1, COPD1, DM4, PV1)

1035F

Current smokeless tobacco user (e.g., chew, snuff) (PV1)

1036F

Current tobacco non-user (CAD1, CAP1, COPD1, DM4, PV1)

1038F

Persistent asthma (mild, moderate or severe)

1039F

Intermittent asthma

1040F

DSM-IV™ criteria for major depressive disorder documented (MDD)1

1050F

History obtained regarding new or changing moles (ML)

1055F

Visual functional status assessed (EC)

2000F

Blood pressure, measured 1

2001F

Weight recorded (CHF, PAG)

2002F

Clinical signs of volume overload (excess) assessed

2004F

Initial examination of the involved joint(s) (includes visual inspection, palpation, range of motion) (OA)1

2010F

Vital signs documented and reviewed (includes at minimum: temperature, pulse, respiration, and blood pressure)(CAP)2 (EM)5

2014F

Mental status assessed (CAP)1(EM) 5

2018F

Hydration status assessed (normal/mildly dehydrated/severely dehydrated)(CAP1)

2019F

Dilated macular exam performed, including documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity (EC)5

2020F

Dilated fundus evaluation performed within six months prior to cataract surgery (EC)5

2021F

Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy (EC)5

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (DM)4

2024F

Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (DM)4

2026F

Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed (DM)4

2027F

Optic nerve head evaluation performed (EC)5

2028F

Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam - report when any of the three components are completed) (DM)4

2029F

Complete physical skin exam performed (ML)

2030F

Hydration status documented, normally hydrated (PAG)1

2031F

Hydration status documented, dehydrated (PAG)1

3006F

Chest X-ray results documented and reviewed(CAP1)

3011F

Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C) (CAD)1

3014F

Screening mammography results documented and reviewed (PV1)

3017F

Colorectal cancer screening results documented and reviewed (PV1) 

3020F

Left ventricular function (LVF) assessment (eg, echocardiography, nuclear test, or ventriculography) documented in the medical record (includes: quantitative or qualitative assessment results) (HF)1

3021F

Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function (CAD, HF)1

3022F

Left ventricular ejection fraction (LVEF) >= 40% or documentation as normal or mildly depressed left ventricular systolic function (CAD, HF)1)

3023F

Spirometry results documented and reviewed (COPD1)

3025F

Spirometry test results demonstrate FEV1/FVC < 70% with COPD symptoms (eg, dyspnea, cough/sputum, wheezing) (CAP, COPD)1)

3027F

Spirometry test results demonstrate FEV1/FVC >= 70% or patient does not have COPD symptoms (COPD)1

3028F

Oxygen saturation results documented and reviewed (Includes assessment through pulse oximetry or arterial blood gas measurement) (COPD, CAP)1, (EM)5

3035F

Oxygen saturation <= 88 % or a PA02 <= 55 mm hg (COPD1)

3037F

Oxygen saturation greater than 88% or PAO2 greater than 55 mmhg (COPD1)

3040F

Functional expiratory volume (FEV1) < 40% of predicted value (COPD)1

3042F

Functional expiratory volume (FEV1) >= 40% of predicted value (COPD)1

3044F

Most recent hemoglobin A1c level (HbA1c) level < 7.0% (DM)2,4

3045F

Most recent hemoglobin A1c (HbA1c) level 7.0 - 9.0 % (DM)2,4

3046F

Most recent hemoglobin A1c level > 9.0% (DM)4

3048F

Most recent LDL-C < 100 mg/dL (DM)4

3049F

Most recent LDL-C 100-129 mg/dL (DM)4

3050F

Most recent LDL-C >= 130 mg/dL (DM)4

3060F

Positive microalbuminuria test result documented and reviewed (DM)4

3061F

Negative microalbuminuria test result documented and reviewed (DM)4

3062F

Positive macroalbuminuria test result documented and reviewed (DM)4

3066F

Documentation of treatment for nephropathy (eg, patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist) (DM)4

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year) (DM)4

3073F

Pre-surgical (cataract) axial length, corneal power measurement and method of intraocular lens power calculation documented within six months prior to surgery (EC)5

3074F

Most recent systolic blood pressure < 130 mm Hg (DM)2,4, (HTN)1

3075F

Most recent systolic blood pressure 130 - 139mm Hg (DM)2,4, (HTN)1

3076F

Most recent systolic blood pressure < 140 mm Hg (DM4 HTN1)

3077F

Most recent systolic blood pressure >= 140 mm Hg (HTN)1 (DM)4

3078F

Most recent diastolic blood pressure < 80 mm Hg (HTN)1 (DM)4

3079F

Most recent diastolic blood pressure 80-89 mm Hg (HTN)1 (DM)4

3080F

Most recent diastolic blood pressure >= 90 mm Hg (HTN)1 (DM)4

3082F

Kt/V <1.2 (Clearance of urea (Kt)/volume (V)) (ESRD)1

3083F

Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea (Kt)/volume (V)) (ESRD)1

3084F

Kt/V >= 1.7 (Clearance of urea Kt)/volume (V)) (ESRD)1

3085F

Suicide risk assessed (MDD)1

3088F

Major depressive disorder, mild (MDD)1

3089F

Major depressive disorder, moderate (MDD)1

3090F

Major depressive disorder, severe without psychotic features (MDD)1

3091F

Major depressive disorder, severe with psychotic features (MDD)1

3092F

Major depressive disorder, in remission (MDD)1

3093F

Documentation of new diagnosis of initial or recurrent episode of major depressive disorder (MDD)1

3095F

Central Dual-energy X-Ray Absorptiometry (DXA) results documented (OP)5

3096F

Central Dual-energy X-Ray Absorptiometry (DXA) ordered (OP)5

4000F

Tobacco use cessation intervention, counseling (COPD, CAP, CAD)1

4001F

Tobacco use cessation intervention, pharmacologic therapy (COPD, CAD, CAP, PV)1 (DM)4

4002F

Statin therapy, prescribed (CAD)1

4003F

Patient education, written/oral, appropriate for patients with heart failure, performed (HF)1

4005F

Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed (OP)5

4006F

Beta-blocker therapy, prescribed (CAD, HF)1

4007F

Age-Related Eye Disease Study (AREDS) formulation prescribed or recommended (EC) (EC)5

4009F

Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, prescribed (HF, CAD)1

4011F

Oral antiplatelet therapy prescribed (e.g., aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox) (CAD)1

4012F

Warfarin therapy prescribed (CHF)1

4014F

Written discharge instructions provided to heart failure patients discharged home. (Instructions include all of the following components: activity level, diet, discharge medications, follow-up appointment, weight monitoring, what to do if symptoms worsen)3

4015F

Persistent asthma, preferred long term control medication or an acceptable alternative treatment, prescribed (Asthma)1

4016F

Anti-inflammatory/analgesic agent prescribed

4017F

Gastrointestinal porphylaxis for NSAID use prescribed

4018F

Therapeutic exercise for the involved joint(s) instructed or physical or occupational therapy prescribed (OA)1

4019F

Documentation of receipt of counseling on exercise AND either both calcium and vitamin D use or counseling regarding both calcium and vitamin D use (OP)5

4025F

Inhaled bronchodilator prescribed (COPD1)

4030F

Long-term oxygen therapy prescribed (more than 15 hours per day) (COPD1)

4033F

Pulmonary rehabilitation exercise training recommended (COPD1)

4035F

Influenza immunization recommended (COPD1)

4037F

Influenza immunization ordered or administered (COPD1, PV1)

4040F

Pneumococcal immunization ordered or administered (COPD1)

4045F

Appropriate empiric antibiotic prescribed (CAP)1, (EM)5

4050F

Hypertension plan of care documented as appropriate (HTN1)

4051F

Referred for an arterio-venous (AV) fistula (ESRD)1

4052F

Hemodialysis via functioning arterio-venous (AV) fistula (ESRD)1

4053F

Hemodialysis via functioning arterio-venous (AV) graft (ESRD)1

4054F

Hemodialysis via catheter (ESRD)1

4055F

Patient receiving peritoneal dialysis (ESRD)1

4056F

Appropriate oral rehydration solution recommended (PAG)1

4058F

Pediatric gastroenteritis education provided to caregiver (PAG)1

4060F

Psychotherapy services provided (MDD)1

4062F

Patient referral for psychotherapy documented (MDD)1

4064F

Antidepressant pharmacotherapy prescribed (MDD)1

4065F

Antipsychotic pharmacotherapy prescribed (MDD)1

4066F

Electroconvulsive therapy (ECT) provided (MDD)1

4067F

Patient referral for electroconvulsive therapy (ECT) documented (MDD)1

5005F

Patient counseled on self-examination for new or changing moles (ML)5

5010F

Findings of dilated macular or fundus exam communicated to the physician managing the diabetes care (EC)5

5015F

Documentation of communication that a fracture occurred and that the patient was or should be tested or treated for osteoporosis (OP)5

6005F

Rationale (e.g., severity of illness and safety) for level of care (e.g., home, hospital) documented (CAP)1