Provider Alert! Attention: NCQA HEDIS Measure Changes

Provider Alert!

Provider Alert! Attention: NCQA HEDIS Measure Changes

Attention: PCP, OB/GYN and Endocrinologist Providers
Effective Date: January 1, 2020

Call to action: Texas Children’s Health Plan (TCHP) would like to inform you of changes to the National Committee for Quality Assurance (NCQA) HEDIS Technical Specifications released on July 1st, 2020.

How this impacts providers: These changes are effective as of January 1, 2020.

Please submit all claims timely, as soon as services are rendered, and use appropriate codes to reflect the services provided particularly for Well-Care Visits and THSteps.

REVISED MEASURES

  • Well-Child Visits in the First 30 Months of Life (W30)
    • Revised the measure name and replaces the former W15 measure
    • Added Age 15 Months – 30 Months
    • Two rates will be reported:
      1. Well-Child Visits in the First 15 Months: Six or more well-child visits
      2. Well-Child Visits for Age 15 Months – 30 Months: Two or more well-child visits
    • Removed the Medical Record Review as a data collection method and is now an administrative only rate – compliance will be calculated directly from claims or encounters submission
    • Included telehealth as acceptable code[1] (see THSteps guidance on appropriate billing below)

Please make sure to submit claims timely using the appropriate codes to get credit for the visits.hedis-pa-chart1

                   NOTE: Both CPT and appropriate ICD-10 codes must be present for claim to be paid. Claims should be billed using only the child’s Medicaid number.

  • Child and Adolescent Well-Care Visits (WCV)
    • Combination measure that replaces the former W34 and AWC measures
    • Added members 7-11 years old; measure now encompasses 3-21 years old
    • Removed the Medical Record Review as a data collection method and is now an administrative only rate – compliance will be calculated directly from claims or encounters submission
    • Included telehealth as acceptable code (see THSteps guidance on appropriate billing below)Please make sure to submit claims timely using the appropriate codes to get credit for the visits.hedis-pa-chart2

 

Guidance for Texas Health Steps (THSteps):

Due to the ongoing pandemic, HHSC is allowing Telehealth visits for THSteps for children over 24 months of age beginning with the 30-month checkup.

 

Providers must use the appropriate Place of Service (POS) Code with Telehealth Modifier 95 to ensure timely and accurate claims processing.

     

Place of Service Code Modifier
02, 11, 50, 72 95

 

Additionally, the Texas Medical Association has provided a Quick Reference Guide for appropriate telehealth billing.

 

Some of the requirements for THSteps, such as immunizations and physical exams, require an in-person visit. The physical portions of the visit must be performed within 6 months from the initial visit.

 

When the patient is brought into the office within the 6-month timeframe to complete the outstanding components of the visit, providers should bill the Texas Health Steps follow-up visit code, 99211. TCHP provider communication on THSteps including both telemedicine and in-person visits are available here: http://www.thecheckup.org/provider-alerts/.

 

  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
    • Allowed member-reported biometric values (body mass index, height and weight)
    • Telephone visit, e-visit or virtual check-in meet criteria

 

  • Comprehensive Diabetes Care (CDC)
    • Allowed BP readings reported or taken by the member
    • Allowed BPs taken by any digital device
      • Non-digital device such as with a manual blood pressure cuff and a stethoscope do not meet criteria if taken by member
    • CDC Medical Attention for Nephropathy has been retired
      • Replaced with Kidney Health Evaluation for Patients With Diabetes (KED)

 

  • Prenatal and Postpartum Care (PPC)
    • Allowed telephone visit, e-visit or virtual check-in

 

  • Follow-Up After Hospitalization for Mental Illness (FUH)
    • Added “Local Mental Health Authority” and “Physician Assistant (Psychiatry)” to acceptable provider types

 

RETIRED MEASURES – these specific measures have completely gone away

  • Adult BMI Assessment (ABA)
  • Medication Management for People with Asthma (MMA)

Next steps for providers:

Providers should become familiar with the changes to the HEDIS measures and implement protocols to improve the compliance rate if needed.

We have developed HEDIS Toolkits that contain helpful information regarding the measure requirements, standards and codes to use that are acceptable for HEDIS reporting. The toolkit will be posted to the TCHP provider portal on the Provider Education menu and on the TCHP website on the Provider Resources menu:

https://www.texaschildrenshealthplan.org/for-providers/provider-resources/hedis-toolkit

TCHP uses Inovalon, a HEDIS certified software, to calculate HEDIS rates. Included are historic claims from TMHP files, as well as information from ImmTrac, the State’s immunization registry. Providers should report their completed patient’s immunization with correct vaccine codes regularly so records are up to date and accurate.
IMMTrac: The Texas Immunization Registry;
https://www.dshs.texas.gov/immunize/ImmTrac/provider-resources/

 

Resources:

Texas Health Steps Quick Reference Guide; http://www.tmhp.com/TMHP_File_Library/Provider_Manuals/THStepsQRG/THSteps_QRG.pdf

Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents;
https://www.dshs.texas.gov/uploadedFiles/Content/Family_and_Community_Health/thsteps/pdfdocs/PS_large_2018.pdf

Texas Medical Association Telemedicine Guide;

Click here

TCHP THSteps Alert;
http://www.thecheckup.org/2020/07/31/provider-alert-texas-health-steps-thsteps-and-chip-medical-checkups-via-remote-delivery/

 

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

[1] For HHSC THSteps, telehealth checkups are allowed for children over 24 months of age beginning with the 30-month checkup

Share this post

Leave a Reply

Your email address will not be published. Required fields are marked *