Product Lines:
Advantage MD.

Eligible Population:
Members 18 years and older as of December 31 of the measurement year.

Definition:
The percentage of emergency department (ED) visits for members 18 years of age and older who have multiple high-risk chronic conditions who had a follow-up service within 7 days of the ED visit.

Report two age stratifications and a total rate:

• 18–64 years. 
• 65 years and older.
• Total.

Continuous Enrollment:

• 365 days prior to the ED visit through 7 days after the ED visit.

Best Practice and Measure Tips

• The denominator is based on ED visits, not members.
• ED visits count between January 1 and December 24 of the measurement year where member was 18 years of age or older on the date of the visit.
• ED visits that result in an inpatient stay, either acute or non-acute, within 7 days after the inpatient stay are excluded.
• The following are eligible chronic condition diagnoses. Each bullet indicates an eligible chronic condition (for example, COPD and asthma are considered the same chronic condition):
  • COPD, asthma, unspecified bronchitis 
  • Alzheimer’s disease and related disorders 
  • Chronic kidney disease 
  • Depression 
  • Heart failure (Chronic Heart Failure; Heart Failure Diagnosis).
  • Acute myocardial infarction (MI Value Set; Old Myocardial Infarction).
  • Atrial fibrillation 
  • Stroke and transient ischemic attack (visit with a principal diagnosis of encounter for other specified aftercare not included). 
• ED visits are counted for members with two or more different chronic conditions prior to the ED visit 
• Eligible chronic condition diagnoses are identified on the discharge claim, on different dates of service, during the measurement year or year prior. (Visit type need not be the same for the two visits, but the visits must be for the same eligible chronic condition.)
  • At least two outpatient visits ED visits, telephone visits, e-visits or virtual check-ins, nonacute inpatient encounters or nonacute inpatient discharges.
• Visits are identified chronologically.  Only one visit per 8-day period. If a member has more than one ED visit in an 8-day period, only the first eligible ED visit is included.
• Ensure member has follow-up services within 7 days after the ED visit. Eight days totals to include visits that occurred on the day of the ED visit.

Measure Exclusions

Required Exclusions:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.

Measure Codes

• Outpatient visit, telephone visit, e-visit or virtual check-in 
  • CPT: 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99421, 99422, 99423, 99429, 99441, 99442, 99443, 99455, 99456, 99457, 99458, 99483 
  • HCPCS: G0071, G0402, G0438, G0439, G0463, G2010, G2012, G2250, G2251, G2252, T1015**
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
  • UBREV: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0982, 0983
• Transitional Care Management Services CPT: 99495, 99496
• Case Management Encounter
  • CPT: 99366
  • HCPCS: T1016, T1017, T2022, T2023
• Complex Care Management Services 
  • CPT: 99439, 99487, 99489, 99490, 99491
  • HCPCS: G0506
• Visit Setting Unspecified 
  • CPT: 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
  • An outpatient or telehealth behavioral health visit (Visit Setting Unspecified CPT) with Outpatient Place of Service (POS):

• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified CPT) with Partial Hospitalization Place of Service (POS):

• A community mental health center visit (Visit Setting Unspecified CPT) with Community Mental Health Center Place of Service (POS): 

• A telehealth visit (Visit Setting Unspecified CPT with Telehealth Place of Service (POS): 

• An outpatient or telehealth behavioral health visit: BH Outpatient
  • CPT: 98960, 98961, 98962, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
  • HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, T1015
  • UBREV: 0510, 0513, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0900, 0902, 0903, 0904, 0911, 0914, 0915, 0916, 0917, 0919, 0982, 0983
• Partial Hospitalization or Intensive Outpatient
  • HCPS: G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485
  • UBREV: 0905, 0907, 0912, 0913
• Electroconvulsive Therapy
  • CPT: 90870
  • ICD-10-PCS: GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ
  • Electroconvulsive Therapy with any of the following Place of Service (POS):
    • Ambulatory Surgical Center POS: 24
    • Community Mental Health Center POS: 53
    • Partial Hospitalization POS: 52  
    • Outpatient POS:

• Substance Abuse Counseling and Surveillance
  • ICD-10-CM: Z71.41, Z71.51
• Substance Use Disorder Services 
  • CPT:  99408, 99409
  • HCPCS: G0396, G0397, G0443, H0001, H0005, H0007, H0015, H0016, H0022, H0047, H0050, H2035, H2036, T1006, T1012
  • UBREV: 0906, 0944, 0945