1. HEDIS® OVERVIEW AND TIPS

2. Peach State Health Plan – At A Glance
400 local employees
Serving 400,000 Georgia families
Care Management Organization (CMO) since 2006
Subsidiary of
Centene covers:
29 states
11.4M
managed care members
2 international markets

3. We Are Local and Our Focus Is…
Member Concierge Services
Our Providers
Simplified Administrative Procedures
Web Portal and Auth Tools
Supportive Provider Relations Field Teams
Rapid Response Team
Member Connections — Locate Your Patients
Community Based Physician, Rx, & Nurse Teams
Innovative Clinical Programs for Your Patients
Member Portal
Member
Education
Member Rewards Program
Enrollment
& Eligibility Processing
Member
Member Connections-Find a Member
Community Events/Health Fairs
THINC Appointment Assistance

4. HEDIS®
What are HEDIS® Scores Used For? As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s ability to demonstrate an improvement in preventive health outreach to its members. Physician-specific scores are being used as evidence of preventive care from primary care practices.

5. *Well Child Visits in the First 15 Months of Life (W15)
Eight (8) visits should occur by 15 months for EPSDT (HEDIS requires at least 6 visits).
To Improve HEDIS Scores: Take advantage of sick visits and sports physicals to perform a well-child visit. **Visits must be 14 days apart (this includes catch-up visits).**
Billing Codes for HEDIS:
Diagnosis Codes: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9
Procedure Codes for: 99381, 99382, 99391, 99392
Contact Peach State Health Plan Provider Services at if you would like to schedule a Peach State Day to increase well visits compliance.
*Follow the current Bright Futures Schedule for the Periodicity and Age Specific Components of Well Visits Ages 0 to 21.
Updated as of February 2017 American Academy of Pediatrics (AAP) Bright Futures Recommendations for Pediatric Health Care” Periodicity Schedule (copyright 2017) is used for the periodicity schedule for EPSDT visits and services.

6. *Adolescent Well-Care Visits (AWC) & Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
HEDIS requires annual visits to be completed before December 31st of each calendar year.
To Improve HEDIS Scores: Take advantage of sick visits and sports physicals to perform a comprehensive well-child visit. **Peach State Health Plan pays for well-care/well-child visits at each age.**
Billing Codes for HEDIS:
Diagnosis Codes: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9
Procedure Codes for: 99382, 99383, 99384, 99385, 99392, 99393, 99394, 99395
Contact Peach State Health Plan Provider Services at if you would like to schedule a Peach State Day to increase well visits compliance.
*Follow the current Bright Futures Schedule for the Periodicity and Age Specific Components of Well Visits Ages 0 to 21.
Updated as of February 2017 American Academy of Pediatrics (AAP) Bright Futures Recommendations for Pediatric Health Care” Periodicity Schedule (copyright 2017) is used for the periodicity schedule for EPSDT visits and services.

7. Childhood Immunization Status: sub measure – Combination 10 (CIS-10)
Children must be fully immunized on or before the 2nd birthday.
Note: If the child is 2 years and 1 day old, service(s) will not count towards HEDIS.
To Improve HEDIS Scores: Check compliance with immunizations at each well AND sick visit, and administer due/overdue immunizations medically appropriate. Encourage and offer flu shots during the months of September through May.
Enter immunizations in GRITS registry as required – and enter lead screenings at
Combination
DTaP
IPV
MMR
HiB
Hep B
VZV
PCV
Hep A RV
Influenza
Combination 2 
Combination 3
Combination 4
Combination 5
Combination 6
Combination 7
Combination 8
Combination 9
Combination 10

8. *Developmental Screening in the First Three Years of Life
A Developmental Screening using a STANDARIZED DEVELOPMENTAL SCREENING TOOL must be performed at age appropriate well-child visits:
9 month visit (1st year)
18 month visit (2nd year)
30 month visit (3rd year)
To Improve Scores: Ensure a standardized tool is used. **When records are requested, ensure you include the standardized tool used and documented evidence of the screening result or screening score.**
Billing Codes:
Providers must bill code with the EP modifier and the appropriate ICD-10 diagnosis code in order to receive reimbursement for this screening.
*The Developmental Screening measure is a Core Set measure, not a HEDIS measure.
ICD-10 Diagnosis Code
Z or Z00.129
Z02 – Z02.89

9. Weight Assessment/Counseling for Nutritional and Physical Activity for Children/Adolescents (WCC)
ALL Children years old must have documentation of a BMI Percentile, Nutritional Counseling, and Physical Activity Counseling in the Medical Record at least annually.
To Improve HEDIS Scores: BMI Percentile, Nutritional Counseling and Physical Activity Counseling should be performed on every child, not just those with high/low BMI values. ** If a child has any visit during the year (sick and/or well), calculation of a BMI percentile and conducting nutritional and physical activity counseling is expected.**
Billing Codes for HEDIS:
BMI Percentile:
Less than 5th percentile for age: Z68.51
5th to less than 85th percentile for age: Z68.52
85th to less than 95th percentile for age: Z68.53
Greater than or equal to 95th percentile for age: Z68.54
Nutritional Counseling
Physical Activity Counseling
Z71.3
ICD-10CM: Z02.5
HCPCS: G0447, S9451

10. Weight Assessment/Counseling for Nutritional and Physical Activity for Children/Adolescents (WCC) CONTINUED
What DOES NOT COUNT for Medical Record Documentation:
BMI Percentile:
Notation of BMI value only
Notation of height and weight only
Nutritional Counseling
Examples such as "eating a wide variety of foods", or "eats 3 balanced meals per day" do meet criteria as they indicate nutrition behaviors (nutritional value of what the child eats) were discussed.
Examples such as "good appetite" or "the child is eating well/not eating well" do not meet criteria because they are an assessment of appetite.
Physical Activity Counseling
Notation of "Cleared for gym class” alone without documentation of a discussion
Health education” or “anticipatory guidance” without specific mention of physical activity
Developmental milestones as discussion of physical activity, such as “can ride a bike”, “child can crawl, child can jump on one foot"
Anticipatory guidance related solely to safety (e.g., wears helmet or water safety) or to screen time (computer or television) without specific mention of physical activity recommendations

11. *Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Children ages 6–12 who are newly prescribed an ADHD medication must have at least three follow-up care visits:
One within 30 calendar days of when the first ADHD medication was dispensed (initiation phase)
Two additional visits 9 months after the initiation phase ends
To Improve HEDIS® Scores
Schedule a two week follow-up to check member and ensure return by 30 days. Schedule 6 weeks, 3 months and 6 months to ensure child has 2 visits in 9 months. Explain the importance of taking medication as prescribed everyday and including weekends.
*The intent of the measure is to assess medication impact and side effects and therefore, visits with a counselor does not count. The visit should be with a practitioner with prescribing authority.

12. Medication Management for People with Asthma – 75% (MMA)
Members years of age who were identified as having persistent asthma and were dispensed appropriate (controller) medication which they remained on for least 75% of the treatment period.
To Improve HEDIS® Scores
Ensure members who are referred to a specialist for Asthma are keeping appointments. Coordinate with the referred provider on receiving a list of current medications prescribed. Create and maintain an asthma action plan. Stress the importance and positive effects of taking controller medications.
Note: This is a measure that tracks the number or prescription fills; not provider appointments.

13. Comprehensive Diabetes Care (CDC)
Members age >18 years old with diabetes (types 1 & 2) must receive:
HbA1c testing (results should show good control < 9%)
Diabetic eye (retinal) exam
Medical Attention for Nephropathy annually
Blood Pressure (results should show control < 140/90)
To Improve HEDIS® Scores
Ensure members who are referred to a specialist for Diabetes are keeping appointments. Coordinate with the referred provider on receiving a list of current medications and services. Ensure members are aware of the need to receive diabetic eye exams (Peach State Health Plan covers the exam).

14. Comprehensive Diabetes Care (CDC) (Continued)
Billing Codes for HEDIS HbA1c Testing and Results:
Rapid (in office) HbA1c
83036
83037
*Results of HbA1c Testing (CPT-CAT-II)
3044F: <7.0%
3045F: between 7.0% -9.0%%
3045F: >9.0%
Billing Codes for HEDIS Blood Pressure Results:
*SYSTOLIC Blood Pressure (CPT-CAT-II)
3074F: <130
3075F: 130 to 139
3077F: ≥140
*DIASTOLIC Blood Pressure (CPT-CAT-II)
3078F: <80
3079F:
3080F: ≥90
*ONLY THE MOST RECENT SCREENING RESULTS DURING THE YEAR COUNTS TOWARDS COMPLIANCE