Value Based Incentive Programs

Glycemic Status Assessment for Patients with Diabetes <8% (GSD)

Qualifying Membership: SoonerSelect

Bonus Amounts

50^th Percentile: $10

75^th Percentile: $20

90^th Percentile: $30

Measure Description

The percentage of members 18–75 years of age as of December 31 in the measurement year with diabetes (types 1 and 2) whose most recent glycemic status hemoglobin A1c [HbA1c] or glucose management indicator [GMI] was at the following levels during the measurement year: Glycemic Status Control (<8.0%) or Glycemic Status Poor Control (>9.0%).

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

Ensure HbA1c and other labs are ordered prior to patient appointments.

Offer lab testing on-site or support lab scheduling at accessible in-network facility during patient visit and have referrals easily accessible or standing orders.

Consider referral to diabetic educator or nutritionist.

Evaluate and document HbA1c every three to six months.

Outreach to patients with sub-optimal HbA1c.

Remind patients to bring logbooks or glucose monitors to their appointment.

Care coordination with other providers caring for the patient.

Ensure patient understands education materials with new onset diabetes.

For patients taking diabetes medication, encourage adherence by providing 90-day prescriptions. Your patient may be eligible for prescription delivery by mail through Express Scripts

Set up a tracking mechanism within your healthcare system to identify gaps in care. Utilize EHR flags and reporting to assist in tracking patients in need of follow-up visits and those who cancel or do not show up for appointments so appropriate outreach can be made.

Did you know?

The HbA1C test measures the average glucose level over the past three months. Numerous studies conclude that keeping HbA1C in the desired range can help reduce complications of diabetes. The higher the levels, the greater your risk of developing diabetes complications. HbA1c is an important tool for managing diabetes, but it doesn’t replace regular blood sugar testing at home. Blood sugar goes up and down throughout the day and night, which isn’t captured by your HbA1c. Two people can have the same HbA1c, one with steady blood sugar levels and the other with high and low swings. The American Diabetes Associations’ (ADA) recommendation for measuring HbA1C is at least two times a year for those currently meeting goals. HbA1C should be checked quarterly if >8%.

Controlling Blood Pressure (CBP)

Qualifying Membership: SoonerSelect

Bonus Amounts

50^th Percentile: $10

75^th Percentile: $20

90^th Percentile: $30

Measure Description

The percentage of members 18 to 85 years of age who had at least two visits on different dates of service with a diagnosis of hypertension during the measurement year, and whose BP was adequately controlled (<140/90 mm during the measurement year). The most recent BP reading during the measurement year must occur on or after the second date of diagnosis of hypertension.

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

When taking blood pressure:

·    Assure cuff fits properly on bare arm.

·    Have patient sit with feet flat on floor and legs uncrossed.

·    Support elbow at heart level during BP reading.

·    Repeat later in visit and/or different arm if blood pressure is elevated.

·    Record lowest systolic and lowest diastolic blood pressure.

·    Do not round-up blood pressure.

Schedule follow-up visit for blood pressure monitoring or medication adjustments.

Educate patient about medication adherence and lifestyle changes.

Did you know?

Hypertension, otherwise known as high blood pressure, affects nearly half of the adults in the United States. It is known as the "silent killer" because it has no warning signs or symptoms. It also increases the risk of heart disease, stroke, kidney disease and a number of other serious conditions. Controlling blood pressure through medications, diet and lifestyle changes reduces these risks. While a normal blood pressure (BP) is 120/80 or less for most adults, maintaining a blood pressure of less than 140/90 is considered controlled, with the help of the above modifications.

Weight Assessment and Counseling for Nutrition and Physical Activity for Children-Adolescents (WCC)

Qualifying Membership: SoonerSelect and Children’s Specialty Program

Bonus Amounts

50^th Percentile: $10

75^th Percentile: $20

90^th Percentile: $30

Measure Description

The percentage of members 3–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year: BMI percentile (can be BMI percentile or plotted on age-growth chart) & Height & Weight, Counseling for physical activity, and Counseling for nutrition.

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

This measure couples well with well-child visits. Both measures will benefit from one visit. Please ensure correct coding when billing for both measures.

Utilize sick visits and sports physicals to also complete this measure. Include and document all three measure components during a sick visit for a compliant WCC record.

When counseling for nutrition, discuss appropriate food intake, healthy eating habits, issues including body image and eating disorders, etc.

When counseling for physical activity, discuss organized sports, activities, and document age-appropriate activity such as “rides bike for 30 minutes a day”.

Documenting “Handouts given” or “age-appropriate anticipatory guidance” alone, without mention of the specific elements listed, are not acceptable compliance.

Incorporate educational handouts and document their use in the EMR during the encounter. Materials can be obtained at brightfutures.aap.org, agesandstages.com, and CDC.gov.

Acceptable documentation examples:

o   Documented Referral to WIC meets criteria for counseling for nutrition.

o   Discussion of current nutrition (e.g., eating habits, dieting behaviors, “Patient has an adequate or well-balanced diet”, A Checklist indicating nutrition or physical activity was addressed.

o   Counseling or referral for nutrition or physical activity.

o   Discussion of current physical activity behaviors (e.g., discuss exercise routine, participation in sports activities, exam for sports participation, “Patient gets an adequate amount of exercise.”, “No physical activity” (if not related to acute or chronic condition)).

o   Note Member received educational materials for nutrition and physical activity during a face-to-face visit. 

o   Weight or obesity counseling (eating disorders). Services rendered for obesity or eating disorders meets criteria for both nutrition and physical activity counseling.

 Not Acceptable documentation examples:

o   BMI percentile ranges, No BMI percentile documented in medical record or plotted on age-growth chart, notation of BMI value only, or notation of height and weight only.

o   Physical exam findings or observations or developmental milestones alone (e.g., well-nourished, does not throw a ball, can jump).

o   Notation of discussion without specific mention of nutrition or physical activity (e.g., appetite, healthy lifestyle habits, limits TV, computer time, cleared for gym class).

o   Assessment of an acute or chronic condition (e.g., presents with chronic foot pain—unable to run, presents with diarrhea—instructed to do BRAT diet).

Did you know?

Over the last three decades, childhood obesity has more than doubled in children and tripled in adolescents, causing both immediate and long-term effects on health and well-being. Healthy lifestyle habits, including healthy eating and physical activity, can lower the risk of becoming obese and developing related diseases. Obesity can become a lifelong health issue; therefore, it is important to monitor weight problems in children and adolescents and provide guidance for maintaining a healthy weight and lifestyle.

Childhood Immunization Status (CIS)

Qualifying Membership: SoonerSelect and Children’s Specialty Program

Bonus Amounts

50^th Percentile: $10

75^th Percentile: $20

90^th Percentile: $30

Measure description

The percentage of children who have had the completed all of the following vaccines on or before their 2nd birthday:

• 4 diphtheria, tetanus, and acellular pertussis (DTaP)
• 2 influenza (Flu)
• 2 or 3 rotavirus (RV)
• 4 pneumococcal conjugate (PCV)
• 1 hepatitis A (HepA)
• 3 haemophilus influenza type B (HIB)
• 1 measles, mumps, and rubella (MMR)
• 3 hepatitis B (HepB)
• 1 varicella zoster (VZV)
• 3 polio (IPV)

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

Preventative and Health maintenance summaries are acceptable for abstraction only if there is evidence that validates administration of the immunizations and not just when they are due.

Schedule the next appointment while the patient is in the office. Call members and remind them about upcoming appointments.

If newborn Hep B vaccination is administered, ensure it is coded in the child’s record.

Parent/caregiver reported vaccines are acceptable if documented in chart with vaccine name and administered date.

A note, such as “up to date with all immunizations”, that does not list the dates of all immunizations and the names of the immunization agents does not constitute sufficient evidence of immunization for HEDIS® reporting.

Did you know?

Immunizations are essential for disease prevention and are a critical aspect of preventable care for children. Vaccination coverage must be maintained to prevent a resurgence of vaccine-preventable diseases. Physician recommendation is critical in promoting vaccine coverage.

Immunizations for Adolescents (IMA)

Qualifying Membership: SoonerSelect and Children’s Specialty Program

Bonus Amounts

50^th Percentile: $10

75^th Percentile: $20

90^th Percentile: $30

Measure Description

The percentage of adolescents who had one dose of meningococcal (MCV) vaccine (between 11^th and 13^th birthdays), one tetanus, diphtheria, pertussis (Tdap) vaccine (between 10^th and 13^th birthdays), and the complete human papillomavirus (HPV) vaccine series (between 9^th and 13^th birthdays).

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

- Use a well visit at age 11 to review the status of immunizations.

- Parent refusal does not count as a closure of care gap.

- Educate parents on the importance of obtaining timely vaccines.

- Advise that the HPV vaccination is preventive.  Although their child may not currently be sexually active, it is important to receive the HPV vaccination now to prevent their child from getting HPV in the future.

- Encourage the parent or guardian to attend all scheduled visits.

- Submit claims and/or encounter data for each service rendered.

- Enter administered immunizations in the Oklahoma State Immunization Information System (OSIIS).

- Parent/caregiver reported vaccines are acceptable if documented in the chart with vaccine name and administered date.

- Document both the name of the vaccine and the date it was administered.

- Ensure the patient’s medical record includes immunization history from all sources (e.g., hospital, local health department, previous provider(s).

- A note that the “patient is up to date” with all immunizations does not close the gap in care.

- Document any anaphylactic reactions. There must be a note indicating the date of the event occurring by the member’s 13th birthday.

- Visit the Center for Disease Control (CDC) for additional information on recommended immunization by age:  https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html

Did you know?

Vaccines are a safe and effective way to protect adolescents against potentially deadly and preventable diseases. including meningococcal meningitis, and human papillomavirus. Physician recommendation is critical in promoting vaccine coverage.

Well-Child Visits in First 30 Months of Life (W30)

Qualifying Membership: SoonerSelect and Children’s Specialty Program

Bonus Amounts to be paid out for members 0-15 months, and again when they are 15-30 months.

Bonus Amounts to be paid out for members 0-15 months

50th Percentile: $10

75th Percentile: $20

90th Percentile: $30

Bonus Amounts to be paid out for members 15-30 months

50th Percentile: $10

75th Percentile: $20

90th Percentile: $30

Measure Description

The Percentage of members who had the following number of well-child visits with a PCP during their first 30 months of life.

·       Children who turned 15 months old during the measurement year: Six or more well-child visits.

·       Children who turned 30 months old during the measurement year: Two or more well-child visits.

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

- When a child is in your office for a sick visit, also conduct a well-child visit if appropriate.

- Please ensure correct coding when billing for both measures.

- Well-care visits can be completed via telehealth.

- Assessment or treatment of an acute or chronic condition does not count towards the measure.

- While a patient is in your office for a well-child visit, administer required vaccinations and testing.

- Schedule next appointment at close of visit and offer flexible appointment availability including evening, weekends, telehealth, and family appointments.

- Educate caregivers and patients on the importance of preventative care visits.

- Educate staff to schedule member well-care visits.

- Be sure to use appropriate coding to get credit for closing the gap.

Did you know?

Access to primary care and assessments of physical, emotional, and social development are important for the health and well-being of young children. Consistent screening, appropriate treatment and preventive services can reduce non-urgent emergency room visits for children. Well-child visits are opportunities for providers to influence health and development.

Annual Preventive Visit (APV)

Qualifying Membership: SoonerSelect and Children’s Specialty Program

Bonus Amount

One Time Payment $20 per member per year

Measure Description

The percentage of adults 18-75 years of age, as of December 31 of the measurement year who had an ambulatory or preventive care visit. Synchronous telehealth visits do count.

What do you need to do?

Submit claims (CPT, CPT II codes, etc.) and encounter data in a timely manner, including diagnosis codes.

Key tips

- Medicaid requires yearly visits for preventive health maintenance.

- Ambulatory care visits are appointments where providers see the individual for an acute problem or a chronic condition.

- Preventive care visits are appointments set up for completing screenings and performing wellness checks.

- Include the type of visit within the documentation note of the medical record.

- Report all services by utilizing the correct billing codes to capture all services provided during a visit.

Did you know?

This health care visit is an opportunity for individuals to receive preventive services and counseling by providers. Adult access to health service visits are a set time to manage chronic conditions, address acute issues, and look at preventive screening needs. Important topics to discuss during an annual preventive visit include cervical cancer screening, prostate cancer screening, flu vaccine administration, medication reconciliation, pain & functional assessments, checking routine measurements & vital signs, and creating a preventive screening schedule.