Product Lines:
Advantage MD.

Measurement Period: January 1 - December 31

Description:
The percentage of emergency department (ED) visits for persons 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.

Stratifications: 
Age as of the ED visit.

• 18–64 years.
• 65 years and older.

Measure Reporting:
CMS Start Rating Measure. 

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• Administrative.
• Hybrid.
• Supplemental.

Initial Population:

• Measure Item Count: Episode.
• Age: 18 years of age or older as of the ED visit.
• Benefits: Medical.
• Continuous Enrollment: 365 days prior to the ED visit through 7 days after the ED visit.
• Allowable Gap: No more than one gap of ≤45 days during the 365 days prior to the ED visit. No gaps on the date of the ED visit through the 7 days following the visit.

Denominator:
ED visits for persons who have multiple high-risk chronic conditions.
ED visits on or between January 1 and December 24 of the measurement period where the person had a chronic condition prior to the ED visit.

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 or unspecified bronchitis (Asthma, COPD and Unspecified Bronchitis Value Set).
• Alzheimer’s disease and related disorders (Dementia Value Set; Frontotemporal Dementia Value Set).
• Chronic kidney disease (Chronic Kidney Disease Value Set).
• Depression (Major Depression Value Set; Dysthymic Disorder Value Set).
• Heart failure (Heart Failure and Cardiomyopathy Value Set).
• Acute myocardial infarction (MI Value Set; Old Myocardial Infarction Value Set).
• Atrial fibrillation (Atrial Fibrillation Value Set).
• Stroke and transient ischemic attack (Stroke Value Set).

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerator:
7-day follow-up. 
Include visits that occur on the date of the ED visit through 7 days after the ED visit (8 total days).
Any of the following meet criteria for a follow-up service.

• An outpatient visit, telephone visit, e-visit or virtual check-in.
• Transitional care management services.
• Case management visits. 
• Complex Care Management Services.
• An outpatient or telehealth behavioral health visit.
• An intensive outpatient encounter or partial hospitalization.
• A community mental health center visit.
• Electroconvulsive therapy.
• A telehealth visit.
• A substance use disorder service.
• Substance use disorder counseling and surveillance.

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

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.
• Exclude ED visits that result in an inpatient stay.
• Any visit with any diagnosis of concussion with loss of consciousness or fracture of vault of skull, initial encounter (Other Stroke Exclusions Value Set).
• Any visit with a principal diagnosis of encounter for other specified aftercare (ICD-10-CM code Z51.89).

Exclusion Codes

Other Stroke Exclusions 

• ICD-10-CM: S02.0XXA, S02.0XXB, S06.0X1A, S06.0X1D, S06.0X1S, S06.0X9A, S06.0X9D, S06.0X9S, S06.0XAA, S06.0XAD, S06.0XAS
• SNOMED CT US Edition: 22383006, 25424007, 48466003, 62564004, 83385002, 95850008, 111593004, 111597003, 111611005, 111615001, 207687004, 207705002, 207707005, 209827006, 444867009, 445159008, 445493000, 446195009, 446597007, 447396006, 698616008, 698617004, 698618009, 698619001, 698621006, 448331000124101

Measure Codes

Outpatient visit, telephone visit, telehealth visit (e-visit or virtual check-in)      

• CPT: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 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)
• SNOMED CT US Edition: 50357006, 77406008, 84251009, 86013001, 90526000, 185317003, 185463005, 185464004, 185465003, 209099002, 281036007, 314849005, 386472008, 386473003, 401267002, 439740005, 866149003, 3391000175108, 444971000124105, 456201000124103
• UBREV: 0510, 0511, 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
• SNOMED CT US Edition: 386230005, 416341003, 425604002

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):
  • 03 School
  • 05 Indian Health Service Free-standing Facility
  • 07 Tribal 638 Free-standing Facility
  • 09 Prison/Correctional Facility
  • 11 Office
  • 12 Home
  • 13 Assisted Living Facility
  • 14 Group Home
  • 15 Mobile Unit
  • 16 Temporary Lodging
  • 17 Walk-in Retail Health Clinic
  • 18 Place of Employment-Worksite
  • 19 Off Campus-Outpatient Hospital
  • 20 Urgent Care Facility
  • 22 On Campus-Outpatient Hospital
  • 33 Custodial Care Facility
  • 49 Independent Clinic
  • 50 Federally Qualified Health Center
  • 71 Public Health Clinic
  • 72 Rural Health Clinic
• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified CPT) with Partial Hospitalization Place of Service (POS):
  • 52 Psychiatric Facility-Partial Hospitalization
• A community mental health center visit (Visit Setting Unspecified CPT) with Community Mental Health Center Place of Service (POS):
  • 53 Community Mental Health Center
• A telehealth visit (Visit Setting Unspecified CPT with Telehealth Place of Service (POS):
  • 02 Telehealth Provided Other than in Patient’s Home
  • 10 Telehealth Provided in Patient’s Home

An outpatient or telehealth behavioral health visit: BH Outpatient

• CPT: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 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, G0560, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, T1015**
• NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
• SNOMED CT US Edition: 50357006, 77406008, 84251009, 86013001, 90526000, 185463005, 185464004, 185465003, 209099002, 281036007, 391223001, 391224007, 391225008, 391233009, 391237005, 391239008, 391242002, 391257009, 391260002, 391261003, 439740005, 866149003, 3391000175108, 444971000124105, 456201000124103
• 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
• SNOMED CT US Edition: 7133001, 305345009, 305346005, 305347001, 391038005, 391042008, 391043003, 391046006, 391047002, 391048007, 391054008, 391055009, 391056005, 391133003, 391150001, 391151002, 391152009, 391153004, 391170007, 391185001, 391186000, 391187009, 391188004, 391191004, 391192006, 391194007, 391195008, 391207001, 391208006, 391209003, 391210008, 391211007, 391228005, 391229002, 391232004, 391252003, 391254002, 391255001, 391256000
• UBREV: 0905, 0907, 0912, 0913

Electroconvulsive Therapy

• CPT: 90870
• ICD-10-PCS: GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ
• SNOMED CT US Edition: 10470002, 11075005, 23835007, 231079005, 231080008, 284468008, 313019002, 313020008, 1010696002, 1010697006
• 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 (Listed above)

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
• SNOMED CT US Edition: 20093000, 23915005, 56876005, 61480009, 64297001, 67516001, 87106005, 182969009, 266707007, 310653000, 370776007, 370854007, 385989002, 386449006, 386450006, 386451005, 414054004, 414056002, 414283008, 414501008, 415662004, 445628007, 445662007, 450760003, 704182008, 707166002, 711008001, 713106006, 713107002, 713127001, 720174008, 720175009, 720176005, 720177001, 763104007, 763233002, 763302001, 772813001, 774090004, 774091000, 792901003, 792902005, 827094004, 865964007, 428211000124100 
• UBREV: 0906, 0944, 0945