Download Coding for Pediatric Health HEDIS® Measures

PATH Quick Reference Guide: Coding for Pediatric Health HEDIS® Measures
This guide is designed to be a quick reference tool to help with medical coding of select HEDIS measures that close care opportunities.
If you’d like additional information about these measures and more, please see the Pediatric Reference Guide for Health at
UnitedHealthcareOnline.com > Tools & Resources > Medicare > PATH.
Information contained in this guide is based on National Committee for Quality Assurance (NCQA) HEDIS technical specifications.
For more details, please visit ncqa.org.
Adolescent Well-Care Visits (AWC)
Percentage of members ages 12–21 who had at least one comprehensive well-care
visit with a primary care provider or an OB/GYN during the measurement year*
Well-Child Visits in the First 15 Months of Life (W15)
Percentage of members who turned 15 months old during the measurement year
and had six or more well-child visits with a primary care provider during their first
15 months of life
Well-Child Visits in the Third, Fourth, Fifth and Sixth
Years of Life (W34)
Percentage of members ages 3–6 who had one or more well-child visits with a
primary care provider during the measurement year
Well-Care / Well-Child Visits
CPT/CPT II
HCPCS
ICD-10 Diagnosis
99381-85, 99391-95, 99461
G0438, G0439
Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5,
Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6,
Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9
Weight Assessment and Counseling for Nutrition and
Physical Activity for Children/Adolescents (WCC)
Percentage of members ages 3–17 who had an outpatient visit with a primary care
provider or OB/GYN and had evidence of the following during the measurement year:
•• Body mass index (BMI) percentile
documentation
•• Counseling for nutrition
•• Counseling for physical activity
BMI Percentile
ICD-10 Diagnosis
Z68.51, Z68.52, Z68.53, Z68.54
Counseling for Nutrition
CPT/CPT II
HCPCS
ICD-10 Diagnosis
97802-04
G0270, G0271, G0447, S9449, S9452, S9470
Z71.3
Counseling for Physical Activity
HCPCS
G0447, S9451
ICD-10 Diagnosis
Z02.5
* In most cases, the measurement year is the 12-month timeframe in which a service was rendered. Generally, this is Jan. 1 through Dec. 31. Data
collected for measurement year 2016 would be reported in 2017.
Disclaimer: UnitedHealthcare will make the final determination regarding reimbursement upon receipt of a claim. Submitting a claim with a code
included in this document is not a guarantee of payment. Payment of covered services is contingent upon coverage within an individual member’s
benefit plan, your eligibility for payment, any claim processing requirements, and your participation agreement with UnitedHealthcare.
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PATH Quick Reference Guide: Coding for Pediatric Health HEDIS® Measures
Childhood Immunization Status (CIS)
Influenza
Percentage of children age 2 who had the following vaccines on or before their
2nd birthday:
•• Four doses of diphtheria, tetanus
•• Three doses of polio (IPV)
and acellular pertussis (DTaP)
•• One measles, mumps and rubella
•• One hepatitis A (Hep A)
(MMR)
•• Three doses of hepatitis B (Hep B)
•• Four doses of pneumococcal
•• Three doses of haemophilus
conjugate (PCV)
influenza type B (HiB)
•• Two or three doses of rotavirus (RV)
•• Two doses of influenza (flu)
•• One chicken pox (VZV)
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
HPCS
DTaP
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
4
Do not count dose administered from birth through 42 days.
90698, 90700, 90721, 90723
20, 50, 106, 110, 120
Hep A
Number of Doses
CPT/CPT II
CVX Codes
1
90633
83
Hep B
Number of Doses
CPT/CPT II
CVX Codes
HCPS
3
90723, 90740, 90744, 90747-48
08, 44, 51, 110
G0010
90655, 90657, 90661-62, 90673, 90685, 90687
135, 140, 141, 153, 155, 161, 166
G0008
IPV
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
3
Do not count dose administered from birth through 42 days.
90698, 90713, 90723
10, 110, 120
MMR
Number of Doses
CPT/CPT II
CVX Codes
1
90705-08, 90710
03, 04, 05, 06, 94
PCV
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
HPCS
4
Do not count dose administered from birth through 42 days.
90669-70
100, 133
G0009
Rotavirus
HIB
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
2
Do not count dose administered prior to age 6 months.
3
Do not count dose administered from birth through 42 days.
90645-48, 90698, 90721, 90748
46-51, 120, 148
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
2 or 3
Do not count dose administered from birth through 42 days.
90680-81
Rotavirus two dose: 119, Rotavirus three dose: 116
VZV
Disclaimer: UnitedHealthcare will make the final determination regarding reimbursement upon
receipt of a claim. Submitting a claim with a code included in this document is not a guarantee
of payment. Payment of covered services is contingent upon coverage within an individual
member’s benefit plan, your eligibility for payment, any claim processing requirements, and your
participation agreement with UnitedHealthcare.
Number of Doses
CPT/CPT II
CVX Codes
1
90710, 90716
21, 94
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Immunizations for Adolescents (IMA)
Chlamydia Screening in Women (CHL)
Percentage of adolescents age 13 who had the following vaccines on or before their
13th birthday:
Percentage of female members ages 16–24 who were identified as sexually active
and who had at least one test for chlamydia during the measurement year
•• Three doses of human
papillomavirus (HPV)
•• One dose of meningococcal
•• One tetanus, diphtheria toxoids and
acellular pertussis (Tdap)
Chlamydia Screening Test
CPT/CPT II
LOINC
HPV*
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
3
Dose must be administered on or between the 9th and
13th birthdays.
90649-51
62, 118, 165
Meningococcal Conjugate
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
1
Dose must be administered on or between the 11th and
13th birthdays.
90644, 90734
136, 148
Tdap
Number of Doses
Special
Circumstances
CPT/CPT II
CVX Codes
1
Dose must be administered on or between the 10th and
13th birthdays.
90715
115
87110, 87270, 87320, 87490-92, 87810
14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1,
14509‑4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6,
21190‑4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772‑7,
31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304‑5,
43404-3, 43406-8, 44806-8, 44807-6, 45067-6, 45068-4,
45069-2, 45070-0, 45074-2, 45076-7, 45078-3, 45080-9,
45084‑1, 45091-6, 45095-7, 45098-1, 45100-5, 47211‑8,
47212‑6, 49096-1, 4993-2, 50387-0, 53925-4, 53926‑2, 557-9,
560-3, 6349-5, 6354-5, 6355-2, 6356-0, 6357‑8, 80360-1,
80361-9, 80362-7, 80363-5, 80364-3, 80365‑0, 80367-6
Lead Screening in Children (LSC)
Percentage of children age 2 who had one or more capillary or venous lead blood
test for lead poisoning on or by their 2nd birthday
Lead Test
CPT/CPT II
LOINC
83655
10368-9, 10912-4, 14807-2, 17052-2, 25459-9, 27129-6,
32325-3, 5671-3, 5674-7, 77307-7
*The Centers for Disease Control and Prevention (CDC) issued a new recommendation for the HPV vaccine in December 2016, which says that only
two HPV vaccines are required in the series. NCQA HEDIS technical specifications will reflect this change in reporting year 2018.
Disclaimer: UnitedHealthcare will make the final determination regarding reimbursement upon receipt of a claim. Submitting a claim with a code
included in this document is not a guarantee of payment. Payment of covered services is contingent upon coverage within an individual member’s
benefit plan, your eligibility for payment, any claim processing requirements, and your participation agreement with UnitedHealthcare.
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PATH Quick Reference Guide: Coding for Pediatric Health HEDIS® Measures
Appropriate Testing for Children with Pharyngitis (CWP)
Percentage of children ages 3–18 who were diagnosed with pharyngitis, dispensed
an antibiotic and received a group A streptococcus (strep) test for the episode
Group A Strep Test
CPT/CPT II
LOINC
87070-71, 87081, 87430, 87650-52, 87880
11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 5036-9, 60489‑2,
626-2, 6556-5, 6557-3, 6558-1, 6559-9, 68954-7, 78012-2
Appropriate Treatment for Children with Upper
Respiratory Infection (URI)
Percentage of children ages 3 months–18 years who were given a diagnosis of
upper respiratory infection (URI) and were not dispensed an antibiotic prescription
Upper Respiratory Infection Codes that Do Not Need Antibiotics
ICD-10 Diagnosis
J00, J06.0, J06.9
This document is provided by UnitedHealthcare as part of the
PATH program. For more information about how our programs can help
support your patients who are UnitedHealthcare members, please contact
your UnitedHealthcare representative.
path
Disclaimer: UnitedHealthcare will make the final determination regarding reimbursement upon receipt of a claim. Submitting a claim with a code
included in this document is not a guarantee of payment. Payment of covered services is contingent upon coverage within an individual member’s
benefit plan, your eligibility for payment, any claim processing requirements, and your participation agreement with UnitedHealthcare.
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