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Pediatric Measures

Review of the Pediatric HEDIS Measures that includes suggested best practices and appropriate documentation for compliance and review of the importance of Lead Screening.

Pediatric Measures


Hello and welcome to Pediatric Measures Webinar.

Here are the objectives. We will review the pediatric measures in the R&R program 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.

So there are some exclusions that may apply to certain measures, and some that may apply to every measure. The only required exclusion for every measure pertains to hospice.

Now, if a member is to be excluded from the 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, WCC which is weight assessment and counseling for nutrition and physical activity for children and adolescents.

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

As we review the measures, we will talk about the eligible population for each measure, what specifically meets the measure for compliance and if any of the possible exclusions that may apply.

Now, 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, evaluating the percentage of children, 2 years of age who had all immunizations on or before their 2nd birthday.

The eligible population are members who turn 2 years of age during the measurement year. 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, 1 of those can be a newborn vaccine during the 8 day period from the date of birth to 7 days after. This is where documentation is very important to capture this.

The 10 immunizations are 4 DTaps, 3 IPVs, 3 HIBs or H.I.B, 4 PCVs and either a 2 or 3 dose of Rotavirus series. The child has to be at least 42 days of age before receiving any of these.

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 forward, 2 flu vaccines between 6 months of age, and the 2nd birthday. Now if 1 of the 2 flu vaccinations is the L. A. I. V. 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 forward, 1 MMR, 1 Varicella, & 1 Hep A between the 1st and 2nd birthday. 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 that parental refusal is not an exclusion that would actually be considered noncompliant.

Immunization for Adolescents (IMA).

For the IMA measure, it is the percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one Tdap vaccine and have completed the human papilloma virus, HPV series by his or her 13th birthday.

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 the 13th birthday, now, just to be clear, Dtap does not count towards Tdap they are two 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 vaccines.

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 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 date and types of immunization administered.

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

Rotavirus vaccine administration must indicate if it is a 2 or 3 dose series. Now, notation that member is up to date with all immunizations does not meet compliance.

Here are some best practices for CIS and IMA, schedule appointments to coincide with required timeframe for immunization administration, use your electronic medical record system to set reminder flags.

During talks, talk to parents about the importance of having their child immunized.

Be sure that your medical record includes immunization history from all sources, utilize the HEDIS recommended codes to ensure these gaps are closed and update the New Jersey immunization information system registry.

Chlamydial Screening in Women (CHL).

Chlamydia screening in women, the eligible population are women 16 to 24 years of age as of December 31st in the measurement year, and who have been determined to be sexually active by either pharmacy data dispensing event for contraceptives, or a claim for pregnancy tests.

Now, to be compliant, the member must have at least 1 chlamydia test during the measurement year, the testing can be done either by urine or swab.

Now, if done at another office, such as an OB/GYN, you can submit to get the credit. 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.

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 test.

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 tests, as we know some X rays require a member to get a pregnancy test prior to getting an X ray.

In both examples, pregnancy tests were ordered for reasons other than sexual activity.

Here are some best practices for CHL, many offices have already adopted a process of universal screening for all girls and boys in this age range through a basic urine test, especially in the pediatric offices, starting at their well visits at 16 years.

So, that's something to consider doing. This screening should occur with or without symptoms as long as it is done, screening should also occur at any visit where oral contraceptive pills, STD 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 OB/GYN providers participating in the members care.

Lead screening in children. LSC.

Lead screening in children, NCQA requirements.

The percentage of children, 2 years of age during the measurement year who had one or more capillary or venous blood tests for lead poisoning on or before their 2nd birthday.

If the lab claim is not received to close the care gap, we require a note from a lab report from the medical record, indicating the date the test was reported or collected and the result. For the collection and reported dates, it cannot be more than 7 days apart.

For instance, if a child had a lead screening sample collected on December 28 of the measurement year and a lead screening result on January 2nd of the following year, the dates are within 7 days and can be considered the same test.

Result may be documented as a numerical value or quantitative value, such as within normal limits, negative or none detected.

The Lead screening questionnaire, which is not part of the R&R incentives, should be completed starting at 6 months and continue through 6 years of age at every well visit.

Keep in mind, this does not count towards this measure, so be mindful of that. It must be the actual blood lead level tests.

So, let's review the state requirements for lead.

The state contract states that providers will have a compliance rate of greater than 80% for 2 consecutive 6 months, period for lead level test, children, 9 months to 19 months of age are eligible in the measurement year.

For it to meet requirement it is required by the state of New Jersey that a child has two lead tests either by capillary or venous blood test.

A capillary or venous blood tests can be documented through administrative data or medical record review.

A verbal risk assessment shall be performed for lead toxicity at every periodic visit between the ages of 6 and 72 months.

Now, just to drill this point, NCQA requires one lead testing on or before the 2nd birthday the state requires two lead tests on or before

12 months, and the second test on or before 24 months.

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 obtained. If the answer 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.

So here are some examples of the questions; does your child live in or regularly visits a house with peeling or chipping paint before 1978?

Another one is, does your child frequently come in contact with an adult whose job or hobby involves exposure to lead?

The new reference value for what is considered high risk equals more than 3.5 microgram per DL.

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 between the ages of 6 months to 6 years of age.

This is the MedTox testing kits. It's an in-office collection of blood samples by finger stick. It is CLIA certified, which is the Clinical Laboratory Improvement Amendments, point of care testing reimbursable by Horizon NJ health for 10 dollars.

Free MedTox kits can be obtained from LapCorp. The MedTox contact is Joe Huffer and the number is 1-877-725-7241.

Also MedTox kits can be ordered online.

Here are some 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 tests at the appropriate ages. Follow up on open lab orders for lead screening. Be sure to document 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. Provide in-office testing.

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.

Here we are measuring the percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OB/GYN and have documentation of a body mass index percentile.

Counseling for nutrition and counseling for physical activity. The eligible population are members who are 3 to 17 years of age by December 31st of the measurement year.

Now, before I move forward, there's something called a delayed schedule. If a child is 2 years of age, comes in for a visit, but the child will turn 3 in that measurement year, that visit will still count towards this measure. So just please be mindful of that.

The 3 sub measures are independent of the other for compliancy and incentives earned.

So BMI percentile is for the members to be compliant, a BMI percentile or evidence of a BMI percentile plotted on a growth chart specific for BMI percentile during the measurement year.

Now, counseling for nutrition for the member to be compliant, there has to be documentation of nutrition counseling done during the measurement year. Counseling for physical activity again, there has to be documentation of physical activity counseling done during the measurement year.

So, we are going to review each of these sub measures in more detail to review what is compliant and what is not compliant.

Also, please note, the exclusion of diagnosis of pregnancy, it must be occurring in the measurement year.

Here are some examples of compliant documentation for a BMI.

BMI percentile plotted on an age growth chart, documentation of a distinct BMI percentile, documentation of greater than 99% or less than 1% meets criteria.

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

For nutrition, discussion of current nutrition behaviors, such as eating habits or dieting behaviors, 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. Referral to WIC may be used.

So, physical activity, discussion of current physical activity behaviors, such as exercise routine, participation in sport activities, exam for sports 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.

Anticipatory guidance for physical activity or exercise.

Now, here are examples of non-compliant documentation.

For BMI, documentation of height, weight, BMI percentile ranges, and thresholds. Notation of BMI value alone, notation of height and weight alone.

For nutrition and physical activity, 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 findings, or observation alone, such as well-nourished or well-developed. Documentation related to a member's appetite such as appetite fair or poor, or picky eater or little eater,

appetite rather. Notation that member with diarrhea is following the banana, rice, apple sauce and toast diet, which is the BRAT diet.

Physical activity, 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 member with chronic knee pain is able to run without limping. Notation that member has exercise induced asthma. Once again everything here is an example of a non-compliant documentation.

So, let's take a look at some best practices. Take advantage at every visit, including sick visits to capture the BMI percentile, nutrition and physical activity assessments and anticipatory guidance.

Remember, as long as it is not specifically related to an acute reason they're being seen, it can be used. Document weight and obesity counseling if applicable to comply for both nutrition and physical activity sub-measures. Use standardized templates in charts and EMRs that allow check boxes for counseling activities.

Please remember the standardized templates with check boxes must be specific for nutrition and physical activity, simply stating anticipatory guidance given will not make the member compliant.

Utilize the HEDIS recommended codes to ensure these gaps are closed. A couple of things to note here, services rendered for eating disorders may be used to meet criteria for counseling for nutrition and counseling for physical activity if the documentation is specified and present.

Again, referral to WIC, the special supplemental nutrition program for woman, infants and children may meet the criteria for counseling for nutrition and members who report biometric values during a telehealth visit and are documented in the medical record by the provider at the time of the visit are acceptable.

Well Child Visits in the first 30 months of life. W30.

The percentage of children who turned 30 months of age during the measurement year, who had 6 or more well visits by 15 months of age and 2 well visits between 15 months 1 day and 30 months of age.

The eligible population for this measure is broken down into 2 rates.

Rate 1 are members turning 15 months of age during the measurement year.

Rate 2 are members turning 30 months of age during the measurement year.

To meet compliance for rate 1 the member must have at least 6 well visits on or before 15 months of life.

Based on the well visit schedule, there are 7 opportunities to capture these visits. Newborn, as long as it is not just for weight check, 1 month, 2 month, 4, 6, 9, 12 and 15 months of life.

To meet compliance, for rate 2, the member must have 2 well visits that have to occur at 15 months 1 day and on, or before, 30 months of life.

The visits must contain documentation of a health history, physical and mental developmental history, a physical exam, and health education, and we will look at these components a bit more in the following slides.

Now, visits to school based clinics with practitioners in the organization would consider a PCP, may be counted as a well child visit, if all the components are present and documented in the medical record.

W30 components. What will make a visit compliant.

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

For health history, we're looking for past medical history, surgical history, birth history, such as C section and or family history. If the note contains medication, allergies and immunization, this is compliant, but please remember the note must contain all 3 components to be completed for health history.

Physical developmental history to include growth and fine motor skills, such as walking ability, physical milestones.

Mental developmental history, cognitive development, to include cooing, reasoning, getting along with peers.

Physical exam assesses body systems and must be hands on exam, must assess at least 5 bodily systems.

Health education, anticipatory guidance, such as advice and counseling.

Here are some examples of noncompliant documentation.

Health history, notation of allergies, or medications, or immunization status alone.

Again, all 3 components must be present. Physical developmental history, notation of Tanner stage or scale.

This is not compliant because Tanner addresses sexual maturity rating and this starts typically at age 8 and 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.

Mental developmental history, notation appropriately responsive for age. Notation of neurological exam. Physical exam vital signs alone.

Health Education, anticipatory guidance information regarding medication or immunizations, or their side effects.

Again, all of these are examples of noncompliant documentation.

A few important reminders for the past 3 measures we just reviewed.

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

Services rendered in an emergency department or during an inpatient 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 will not count for the W30 measure.

Visits must be at these 14 days apart. However, the 14 day threshold does not apply when capturing different components from well and sick visits.

The well child visit must occur with the PCP or OB/GYN for the well child visits. And the 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 Pediatric Bright Futures.

Child and adolescent well care visit measures the percentage of members each 3 to 21 years old who had at least one well visit in the measurement year with the PCP or OB/GYN.

Once again, the delayed schedule applies here if a child has a visit when they're 2 years old, but they will turn 3 in the measurement year that visit will still count and for the member to be compliant, they need to have one well visit in the measurement year.

Here are 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 timeframe.

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

Make outreach calls and or send letters to advise members of the needs for a visit. Consider offering extended practice hours to increase care access. Use standardized templates in charts and EMRs that allow check boxes for standard counseling activity.

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

Asthma Medication Ratio, this is the last measure we have in the pediatric R&R program.

Here we're measuring the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medication to total asthma medication of 0.50 or greater during the measurement year.

The eligible population are members who have persistent asthma, a true diagnosis of being asthmatic and not seasonal or allergic asthma.

In addition to this, they must meet at least one of the following criteria during both the measurement year and the year prior such as, at least one ED visit with the principal diagnosis of asthma, at least one,

acute impatient 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 medication. And then, at least four asthma medication dispensing events for any controller, or reliever medication.

I want to repeat they only need to have one of these criteria.

Now, there are some exclusions, and some of these exclusions can be COPD, chronic respiratory conditions due to fumes or vapes and these are just a few.

Members who had no asthma controller or reliever medication dispensed during the measurement year may also be excluded.

Here are some best practices for AMR.

Develop an asthma action plan. Educate members on the importance of adhering to medications and reducing asthma triggers. Advise members to incorporate inhalers in their daily routine. Reach out to members to schedule follow up visits for the condition.

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

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

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

Please reach out to your Clinical Quality Improvement Liaison for additional tools and resources, suggestions for success with closing gaps.

EMR is up to date to reflect members’ current specialists for patient care team, incorporate templates and ticklers into your EMR systems 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 hours, immunization clinics. Use reminder notifications advising members of the need for a visit.

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

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