Download Breast Cancer Screening Valid Exclusions

Pay for Performance (aka: Quality Measures) Overview
In January of 2002, The Integrated Health Association (IHA) launched the Pay For Performance (P4P) initiative, a California
statewide effort to use standard measures to evaluate the performance of contracted physician organizations. The goals of the
program is to develop a common set of measures and publicly report scores for those measures for California Physician
organizations and to provider health plans with the information they need for rewarding physician organizations financially based
on performance.
Reminder: The Measurement Year is from January 1 to December 31
Clinical Measures:
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Childhood Immunizations Status (CIS) 24- Month Continuous Enrolment
The percentage of enrolled children two years of age that were identified as having completed the
following antigen series by their second birthday.
4 DTaP/DT
3 Hepatitis B
3 H Influenza type B
1 MMR
1 Chicken pox vaccine
3 IPV
4 pneumococcal conjugate vaccines
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
The percentage of children 3 months- 18 years of age who were given a diagnosis of upper respiratory
infection (URI) and were NOT dispensed an antibiotic prescription on or 3 days after the episode date.
Breast Cancer Screening (BCS)
The percentage of Women 42-69 years of age who had a mammogram to screen for breast cancer during
the measurement year or year prior to the measurement year.
Cervical Cancer Screening (CVS)
The percentage of Women 18-64 years of age who received one or more Pap during the measurement year
or the two years prior to the measurement year
Chlamydia Screening in Women (CHL)
The percentage of women 16-25 years of age who were identified as sexually active and who had at least
one test for Chlamydia during the measurement year.
Cholesterol Management for Patients with Cardiovascular conditions (CMC)
The percentage of members 18-75 years of age who, from January 1 through November1 of the year prior
to the measurement year, were discharged alive for acute myocardial infarction (AMI), coronary artery
bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular
disease (IVD) during the measurement year (January 1 to deceber31) and the year prior to the
measurement year.
LDL-C Screening Performed
LDL _C Control (<100 mg/dl)
LDL-C Controlled (<130 mg/dl)
Diabetes Care (CDC) – HbA1c Testing and Poor Control
LDL Screening and Control, Nephropathy Monitoring
The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the
following:
A Hemoglobin A1C (HbA1c) test
HbA1c Poor Control (> 9.0%)
LDL-C Screening test
LDL-C Control (<130mg/dl)
LDL-C Control (<100mg/dl)
Nephropathy Monitoring
Use of Appropriate Medications for People with Asthma (ASM)
The percentage of members 5-56 years of age during the measurement year who were identified as having
persistent asthma and who were appropriately prescribed medication during the measurement year.
Colon rectal Cancer Screening (COL) (Medicare Population Only)
The percentage of adults 50- 80 years of age that had an appropriate screening for colon rectal cancer (CRC)
Medicare product line will be collected but will not be publicly reported of paid for measurement year 2006.
Helpful Hints to Increase your Pay for Performance Score
A key element to consider a PCP goes through their list of patients in need of quality measures is “to not forget to work
the exclusions”. While we all must work aggressively to ensure that all pay for performance eligible members fulfill the
measures, often times the exclusion that remove eligible patients from the denominator are overlooked.
All quality measures have “valid’ excuses that by employing them correctly will remove the patient form the
denominator that counts toward their overall P4P score.
Chlamydia Test Valid Exclusions
 Patient is a male
 Pregnancy Test & Diagnostic Radiology
 Pregnancy Test & On Accutane
Breast Cancer Screening Valid Exclusions
 Patients has had a bilateral mastectomy CPT Code 19180.50
 Patients is male
Cervical Cancer screening Valid Exclusions
 Patients has had a total Hysterectomy 58150
 Patient is a male
Diabetes Care Valid Exclusions
 Patient does not have diabetes (for example gestational diabetes)
Cardio Care Valid Exclusions
 Patient did not have a heart episode
Childhood Immunizations Status (CIS)
Administrative Specifications Guide
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DTaP/DT: An initial DTaP vaccination followed by at least three (3) DTaP, DT or individual diphtheria and tetanus
shots, with different dates of service on or before the child’s second birthday. Any vaccination administered prior to
42 days after birth cannot be counted.
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IPV: At least three (3) polio vaccinations (IPV), with different dates of service on or before the child’s second
birthday. IPV administered prior to 42 days after birth cannot be counted.
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MMR: At least one measles, mumps and rubella (MMR) vaccination, with the date of service falling on or before the
child’s second birthday.
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HIB: Three H influenza type B (HIB) vaccinations, with different dates of service on or before the child’s second
birthday. HIB administered prior to 42 days after birth cannot be counted.
Note: Because one type of HIB vaccine only requires three doses, The HEDIS measure requires that organizations
meet the minimum possible standard of three doses, rather than the recommended four doses.
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Hepatitis B: Three hepatitis B vaccinations, with different dates of service on or before the child’s second birthday.
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VZV: At least one chicken pox vaccination (VZV), with the date of service falling on or before the child’s second
birthday.
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Pneumococcal Conjugate: At least four pneumococcal conjugate vaccinations on or before the child’s second
birthday.