PPO Reporting Possibilities and Issues
Office of Health Care Statistics
Summary:
· State of PPO Reporting
o Maryland
o California
· Implementing PPO Reporting
o Consumer Comparisons
§ Provide individuals with information on PPOs and HMOs
o Statewide Comparisons
§ Currently, only HMO data available
o Decline of HMO membership
§ Reached peak in the mid to late 90s
· PPO Reporting Issues
o Voluntary Submissions
§ Should data be required?
o Health Plan Inclusion
§ Should all health plans be included, or a reasonable percentage?
o Measures
§ 30 measures (22 quality, and 8 customer satisfaction)
o Data Collection
§ Administrative or Hybrid? Both?
o Costs to Health Plans
§ Costs outlined for data submissions
o Categorizing Health Plans
§ PPO, HMO, HMO with POS
o One Report or Two Reports
§ An HMO report and a PPO report, or combined report?
The State of PPO Reporting
In 2005, NCQA (National Committee for Quality Assurance) asked for voluntary submissions from health plans around the country to report PPO (Preferred Provider Organization) data. At that time, 80 health plans provided HEDIS (Healthcare Effectiveness Data and Information Set) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) data to NCQA. In 2007, NCQA once again asked for voluntary submissions from health plans around the country. In 2007, 141 PPOs reported audited HEDIS data to NCQA. There were 83 commercial plans and 58 Medicaid health plans that voluntarily submitted data to NCQA. There were 22 quality measures that were derived from HEDIS and 8 consumer satisfaction measures derived from CAHPS.
Following NCQA’s initiation of PPO reporting, two states in the nation are producing, or are planning to produce a PPO report. The first of which is Maryland. Maryland plans to produce a PPO report in 2008. The data is gathered strictly on a voluntary basis, since there are no state regulations regarding data submissions. That being the case, not all PPOs will be covered in the report, only those that choose to do so. The health plans that are cooperating are Aetna, CareFirst BlueCross BlueShield, CIGNA, and United Healthcare.
The second state to conduct PPO reporting is California, but their report is not planned until 2009. California is also utilizing voluntary submissions, without any state regulations in place. Not all PPOs will be participating in the data submission process. The health plans that are cooperating are Aetna, Blue Shield of California, Cigna, Health Net Inc., WellPoint Inc. and UnitedHealth Group.
California and Maryland are relying on voluntary data submissions. In the related press reports, both states are relying on health plans not wanting to “look bad” by not reporting data. The states believe that the health plans will want to be included, so that the health plans will not look like they have something to hide. Two of the health plans that are contributing voluntary submissions to California and Maryland also have NCQA accredited PPOs in Utah: Aetna and Cigna.
NCQA looked at how comparable the data was between HMOs (Health Maintenance Organization) and PPOs. The found that HMOs and PPOs were comparable. One interesting note is that the data collected was only done administratively. NCQA is not accepting hybrid (administrative and chart review) data from PPOs until 2010, until then only administratively collected data is being accepted by NCQA.
Implementing PPO Reporting
The current HMO Performance Report covers about 40% of insured Utahns. This includes enrollees in Commercial and Medicaid HMOs, as well as CHIP plans. This leaves a large portion of Utahns not being provided with quality and consumer satisfaction information regarding their health plans.
A PPO report would be beneficial to those who are trying to decide on which health plan will meet their needs, as well as their family’s needs. Currently, there is no way in which a consumer can compare the differences between an HMO and a PPO that is available to them. With a PPO report, consumers would be able to compare the health plans available to them. Many times employees have a choice between a HMO and PPO when choosing insurance plans through their employment. Consumers would be able to compare benefits, quality of care, and consumer satisfaction. This, in turn, would allow consumers to make informed decisions regarding their health care choices.
Another important benefit of PPO reporting would be a comparison of health plans at a state level. Currently only HMOs can be compared with one another, this comparison can also be made utilizing national benchmarks. As a whole, statewide averages are not available, so comparisons can only be made regarding the 40% of Utahns with an HMO. Statewide comparisons cannot be done, since much of the data for Utah’s insured is currently missing.
It should also be noted that HMOs reached their peak enrollment in the mid 1990s, and while Medicaid is relying heavily on HMOs, commercial health plans are providing more PPOs to their members. In January of 2008, the Health Data Committee granted an exemption to Cigna so that they would not have to report data for the 2008 HMO Performance Report. This decision was based on Cigna’s enrollment numbers being too low to provide meaningful data. There is another HMO with very similar enrollment numbers, which may follow the same suit and file an exemption in 2009. That being the case, both insurance companies have a substantial PPO population in Utah.
Currently, there are no other states planning PPO reporting, at least on a state level. When looking at the health plans providing voluntary submissions to both states, there are similarities in the health plans that are participating. Through discussions with health plans in the state of Utah, many are prepared to report PPO data, since many are already collecting it for internal purposes.
PPO Reporting Issues
Voluntary data submissions:
The first issue to be discussed is whether to allow voluntary submissions of data. The other two states in the nation have decided that voluntary submissions are adequate for their PPO reporting. While this allows for PPO reporting, it does have limitations. The largest limitation is that the report will only cover a portion of the PPO population. If a health plan chooses not to provide data, their Utah members will not be able to access information regarding their health plan. This would make statewide comparisons impossible, and could leave many Utahns in the dark regarding their health care choices. Voluntary submissions are beneficial to the health plans, since they would be able to choose if they are going to submit data or not. This decision may be based on financial reasons, complexity of providing data, or simply not wanting to provide data.
Health plan inclusion:
While the goal of the report is to cover the largest portion of insured Utahns, a balance will need to be determined for health plan inclusion. The number of members served by a health plan can determine their inclusion. If there are too many health plans in the report, the readability of the report may suffer; if there are too few health plans in the report, the information provided by the report will suffer. For this reason a balance should be sought to determine which health plans will be included in the report. NCQA currently uses the following guidelines for data submissions, HEDIS requires 15,000 members and CAHPS requires 5,000 members. These numbers are used so that that data obtained from health plans can be reproduced effectively. Any lower than the provided numbers and the data may not be useful or statistically relevant. For reference, according to the Department of Insurance, there are 53 health plans that utilize some form of managed care (7 HMOs, 3 HMOs with POS, and 43 PPOs). The Department of Insurance claims approximately 88% of Utah’s health insurance market belongs to some form of managed care.
Measures to be included in report:
Currently, the measures to be used will come directly from the HEDIS and CAHPS surveys, there are 30 measures used (22 quality and 8 experience). HEDIS measures were developed by NCQA, and were originally designed so that consumers could compare the performance of one health plan with another. There are eight different categories for HEDIS measures focusing on the quality of care health plan enrollees are receiving. NCQA updates the measures yearly depending upon the growing need of consumers.
CAHPS is funded by AHRQ (Agency for Health Care Research and Quality), and was developed as a standardized survey to explore what the enrollees’ experiences are with their health plans. The focus is not the quality of care an enrollee receives, but rather it attempts to capture the enrollees’ thoughts and beliefs regarding the health plan. It uses a variety of rating scales to determine the attitudes of the enrollees.
The report can also contain information regarding each PPO. This can be comprised of the health plan’s contact information, enrollment figures, benefits, and percentage of certified physicians. This is all dependent on the data provided by the health plans.
Data collection:
NCQA is utilizing both CAHPS and HEDIS to report on PPOs. HEDIS is gathered from health plan records and focuses on the quality of care, while CAHPS is a survey is typically administered by an outside vendor and focuses on consumer satisfaction.
Presently there are eight CAHPS measures being utilized for PPOs to obtain the levels of enrollee satisfaction regarding the health plan. For our HMO report, the data are gathered by a certified vendor and submitted to OHCS for analysis and reporting. The survey cost is shared between the state and the health plans, with current costs to the plans ranging from $1,700 to $11,000.
HEDIS is collected using health plans’ administrative records and medical chart reviews. The data can be collected using two different methods, and is an important aspect to keep in mind. The first is administratively collected data. This method is the cheaper of the two methods. Each health plan utilizes codes for billing purposes. These codes are specific for medical procedures. With administrative data, the health plan simply looks at the number of codes that are present in their database for a specific procedure and that number is reported. This method is the cheapest and fastest method of providing data. It does have disadvantages. It relies solely on the ability of the health plan to accurately report data based on their coding system. Many times codes are missing for procedures done in an office, or are coded incorrectly. Another issue is that some measures cannot be collected administratively, particularly measures that are designed to measure an individual’s adherence to medications or procedures (diabetes control, etc…). These measures require charts to be accessed and administrative data collection makes this impossible. Administrative rates are also typically lower than the rates obtained from hybrid data collection.
Hybrid data collection is the second method of collecting the data and it is a combination of administrative data collection, as well as chart reviews. Since many of the codes may be missing or coded improperly, charts can be reviewed to determine if the medical procedure was in fact completed. This data collection method provides rates that are typically higher than data collected administratively. However, there are costs to this as well. Hybrid data costs health plans much more money to collect than administrative data. This cost stems from resources needed to track down charts for patients. HMOs have the advantage of utilizing Primary Care Physicians. These physicians are gatekeepers for procedures and tracking down charts for HMO enrollees is much simpler than that of PPOs. PPO enrollees can go to any doctor they would like, which in turn makes locating their charts much more difficult. Utah does have the advantage of having most of the population living in a small area, but it would be more expensive for hybrid data to be collected.
Regardless of the data collection method, one aspect to keep in mind is the comparison that can be made between the health plans. Previously it was mentioned that administrative data collection rates are typically lower than hybrid data collection, this makes comparing the two methods very difficult. In any given measure, if two different types of data collection methods are utilized, the rates can vary simply based on the data collection method and not on the health plan’s performance. Previous discussions have been held concerning mandating a single method of data collection. This would allow for more valid comparisons between health plans, as well as put the health plans on a level playing field.
Another complexity regarding data collection concerns how the data will be submitted to the State of Utah. Regarding CAHPS, one single vendor is currently used for the HMO Performance Report. This vendor works with the State and health plans to ensure the survey is done correctly. The cost is shared between the State of Utah and the health plans. This procedure has worked well in the past and continues to be a success.
Regarding HEDIS, health plans may choose to use their own vendor, or one vendor can be selected to manage and clean all of the HEDIS data for all health plans. A single vendor can be utilized and cost sharing can be utilized so the cost to the health plan will be based upon the health plan’s market share. Those with more members pay more of the costs. This has many benefits, including less time spent making sure all the health plans have provided the necessary materials, less time cleaning data, and it helps ensure that the data was collected and cleaned in a similar manner. While one vendor has advantages, health plans may already have procedures in place for their data submissions.
Costs to health plans:
There will be costs associated with PPO reporting that health plans will incur. How much exactly depends on a number of factors, especially the number of members that utilize the health plan. NCQA has provided some figures based on enrollment between 50,000 and 100,000 members. It is important to note that most of the costs stem from being accredited by NCQA, which does not have to be a requirement for the PPO reporting.
A plan seeking NCQA accreditation must first be surveyed by NCQA to determine the quality of the health plan. This typically costs between $44,550 and $53,550 depending upon the number of members. It then costs the health plans $1,650 for NCQA to process the data submissions. NCQA requires the HEDIS data to be audited, which costs between $15,000 and $20,000. Additionally, a CAHPS survey costs between $12,000 to $18,000. If the health plan does not seek accreditation, and the data is collected administratively, the cost to the health plan would be less. This is especially true if cost sharing is utilized and health plans only pay for the portion of the population they serve. According to NCQA, a moderately sized health plan would be charged less than $50,000 (direct costs) to submit HEDIS and CAHPS data. Health plans may incur other internal expenses to obtain the data, but it should be minimal. This portion of the cost may be offset by cost sharing with the State.
Categorizing health plans:
Health plans evolve over time, and change their benefits and costs of their membership. This adds complexity when it comes time to categorize a health plan as a PPO or HMO. The dividing line between the types of coverage is diminishing. Some HMOs are very strict, demanding that enrollees see their primary care physician, while others have opt-out procedures, in which an enrollee can go to any doctor, while still receiving limited benefits. The following are NCQA’s definitions of HMOs, HMOs with POS, and PPOs.
HMO (Health maintenance organization). An organized health care system that is accountable for both the financing and delivery of a broad range of comprehensive health services to an enrolled population.
An HMO is accountable for assessing access and ensuring quality and appropriate care. Practitioners affiliated with the health care system render health care services. In this type of organization, members must obtain all services from affiliated practitioners and must usually comply with a predefined authorization system to receive reimbursement. A practitioner is a professional who provides health care services and is usually required to be licensed as defined by law.
POS (Point of service). An HMO with an opt-out option. In this type of organization, members may choose to receive services either within the organization’s health care system (e.g., an in-network practitioner) or outside the organization’s health care delivery system (e.g., an out-of-network practitioner).
PPO (Preferred provider organization). PPOs take responsibility for providing health benefits-related services to covered individuals and for managing a practitioner network. They may administer health benefits programs for employers, either by assuming insurance risk or by providing only administrative services.
The above definitions may be sufficient to categorize health plans into various categories, but other methods can be employed as well. For example, health plans can be categorized by the necessity of a primary care provider, the costs to the enrollee (deductibles, co-payments, etc…), or how the care is managed by the health plan, if at all. Other methods may be necessary to categorize health plans due to the diminishing differences between types of health plans. Another option is to not separate HMOs from PPOs since they serve the same population of individuals. In addition, NCQA compared the PPOs and HMOs and found the results to be comparable.
One report vs. two:
Currently the HMO Performance Report is made up of different sections based on enrollment in commercial HMOs, or Medicaid HMOs. Adding PPO reporting can be done in two different methods. The first would be to simply add a section to the existing report in which PPOs would reside. The second method would be to create a second report dedicated to PPO reporting.
One report comprises of HMOs and PPOs would have a few important advantages. The first advantage would allow enrollees could easily compare all health plans that they have access to in one single report. In this manner, PPOs and HMOs could be compared side by side. Utilizing a web-based report, this is feasible. Another advantage is that less time and resources would be required to create a single report, rather than complete two different reports.
A disadvantage to utilizing one single report is the length of the report. This disadvantage is mitigated using a web-based report. On the web, enrollees can click and choose the information that is the most important for them to make their decisions. They would not have to flip through page after page to find the information. The information in the report will be quite comprehensive and may be difficult to navigate, however with proper planning and usability issues resolved in advance this may not be difficult to overcome. Another disadvantage may be that the number of PPOs in the report may be overwhelming, but this can also be solved by only including PPOs that would maximize the information for enrollees without being intimidating.
If one report were utilized, it would consist of all commercial HMOs and PPOs, Medicaid, CHIP, PCN, and self-funded health plans. This would substantially raise the percentage of insured Utahns covered by the report. NCQA claims PPOs insure 6 out of 10 individuals. With the additions of PPOs, a reasonable goal would be for the report to cover 70% – 80% of insured Utahns.
Health Plans
Many health plans were contacted to determine what type of expenses they would incur with PPO reporting. Regence, Altius, and UntiedHealthcare expressed that the expenses will be minimal since they are collecting the data by corporate mandate. This is especially true if the data is collected administratively. The primary concern of the health plans is that the data is comparable with one another, meaning one method of data collection (administrative or hybrid) is utilized. At this time only Aetna and CIGNA are the only NCQA accredited PPOs in Utah.
Existing HMO Reporting Rules
R428. Health, Center for Health Data, Health Care Statistics.
R428-2. Health Data Authority Standards for Health Data.
R428-2-1. Legal Authority.
This rule is promulgated under authority granted by Title 26, Chapter 33a.
R428-2-2. Purpose.
This rule establishes the reporting standards which apply to data suppliers, and the classification, control, use, and release of data received by the committee pursuant to Title 26, Chapter 33a.
R428-2-3. Definitions.
The following definitions apply to all of R428.
A. "Office" means the Office of Health Care Statistics within the Utah Department of Health, which serves as staff to the Utah Health Data Committee.
B. "Committee" means the Utah Health Data Committee created by Section 26-1-7.
C. "Data element" means the specific information collected and recorded for the purpose of health care and health service delivery. Data elements include information to identify the individual, the health care provider, the data supplier, the service provided, the charge for service, payer source, medical diagnosis, and medical treatment.
D. "Data release, disclosure, or disclose" means the disclosure or the communication of health care data to any individual or organization outside the committee, its staff, and contracting agencies.
E. "Data supplier" means a health care facility, health care provider, self-funded employer, third-party payer, health maintenance organization, or government department required to provide health data under rules adopted by the committee.
F. "Health Data Plan" means the plan developed and adopted by the Health Data Committee under Chapter 33a, Title 26, Section 104.
G. "Health care provider" means any person, partnership, association, corporation, or other facility or institution that renders or causes to be rendered health care or professional services as a physician, registered nurse, licensed practical nurse, nurse-midwife, dentist, dental hygienist, optometrist, clinical laboratory technologist, pharmacist, physical therapist, podiatrist, psychologist, chiropractic physician, naturopathic physician, osteopathic physician, osteopathic physician and surgeon, audiologist, speech pathologist, certified social worker, social service worker, social service aide, marriage and family counselor, or practitioner of obstetrics, and others rendering similar care and services relating to or arising out of the health needs of persons or groups of persons, and officers, employees, or agents of any of the above acting in the course and scope of their employment.
I. "Health data" means information relating to the health status of individuals, health services delivered, the availability of health manpower and facilities, and the use and costs of resources and services to the consumer.
H. "Identifiable health data" means any item, collection, or grouping of health data that makes the individual supplying or described in the health data identifiable.
J. "Individual" means a natural person.
K. "Order" means a committee action that determines the legal rights, duties, privileges, immunities, or other interests of one or more specific persons, but not a class of persons.
L. "Report" means a compilation, study or data release developed from resource documents to display information in a simplified manner and designed to meet the needs of specific audiences or nontechnical users.
M. "Resource document" means contemplated tabulation formats defined in the Health Data Plan to display information, documents, or records containing measures relating to health care. These documents are classified as standard, special, and electronic.
R428-2-4. Technical Assistance.
The Office may provide technical consultation to a data supplier upon request and resource availability. The consultation shall be to enable a data supplier to submit health data according to R428.
R428-2-5. Data Classification and Access Requirements.
A. The Utah Health Data Authority Act, Section 108, specifically classifies all information, reports, statements, memoranda, or other data received by the committee as "strictly confidential." All data received under rules of the Utah Health Data Authority Act are strictly confidential. This strict classification means the committee's data are not public, and as such are exempt from the Classification and Release Requirements specified in the Government Records Access And Management Act, Chapter 2, Title 63, Utah Code Annotated. The committee shall establish guidelines for the protection, use and release of the data.
B. Persons having access to data under control of the committee shall not:
1. take any action that might provide information to any unauthorized individual or agency;
2. scan, copy, remove, or review any information to which specific authorization has not been granted;
3. discuss information with unauthorized persons which could lead to identification of individuals;
4. give access to any information by sharing passwords or file access codes.
C. Any person having access to data under control of the committee shall:
1. maintain the data in a safe manner which restricts unauthorized access;
2. limit use of the data to the purposes for which access is authorized;
3. report immediately any unauthorized access.
D. A failure to report known violations by others of responsibilities specified in 3 and 4 above is subject to the same punishment as a personal violation.
E. The Office shall deny a person access to the facilities, services and data as a consequence of any violation of the responsibilities specified in R428-2-5(C) and R428-2-5(D) above.
F. The committee may, pursuant to Chapter 33a, Title 26, Section 110, subject the person to legal prosecution for any unauthorized use, disclosure, or publication of its data.
R428-2-6. Security.
The Office shall implement procedures protecting data confidentiality. These procedures shall ensure the committee's health data against unauthorized access.
R428-2-7. Editing and Validation.
A. The data supplier shall review each health data record prior to submission. The review shall consist of checks for accuracy, consistency, completeness, and conformity.
B. The Office may subject health data to edit checks. The Office may require the data supplier to correct health data failing an edit check. The data supplier may perform data validation before public disclosure.
1. The Office may, by first class U.S. mail, return to the submitting data supplier all health data failing an edit check. The submitting data supplier shall correct all returned health data and resubmit all corrected health data to the Office within 35 calendar days of the date the Office mails the records.
2. Data validation gives the data supplier the right to review, comment, and provide support for corrections of any information relating to its activities prior to public release. The data supplier shall return the validation document to the Office with comments and support for corrections within 35 calendar days of the date the Office mails the validation document. If the data supplier fails to return the information within the 35 day period, the committee may conclude that the information is correct and suitable for release.
3. The committee may note in its resource documents, reports, and publications that accurate appraisal of a certain category or entity cannot be presented because of a failure to comply with the committee's request for data, edit corrections, or data validation.
R428-2-8. Error Rates.
The committee may establish and order reporting quality standards based on non-reporting or edit failure rates.
R428-2-9. Data Disclosure.
A. The committee may release information, compilations, reports, statements, memoranda, or other data received or derived from its health data as specified in Chapter 33a, Title 26, Sections 107, 108, and 109. The Office may disclose the submitted data as resource documents or reports in either standard, special, or electronic format. The Office may prepare data for disclosure annually as standard or special resource documents specified in the health data plan. If the disclosure identifies a health care provider, the Office must adhere to the procedures specified in R428-2-9(B).
B. Prior to any release of a compilation, report, or resource document in which a health care provider is identified, the Office shall notify the data supplier and the health care provider by first class mail using the last known address. The data supplier and health care provider have the right to:
1. review the information to be disclosed and verify the accuracy of the information contained therein;
2. submit to the Office evidence of errors in the disclosure document;
3. develop written comments or alternate interpretations to the information reported for inclusion with the disclosure;
4. return the disclosure notice, evidence of errors, and comments within 35 calendar days of the date the Office mails the notice. The committee may interpret the failure to return the notice of disclosure within the designated time period as agreement that the reports are acceptable for release in any format outlined in the Health Data Plan.
5. the Office shall correct data it finds to be in error and provide data suppliers and health care providers notification of the corrections subject to the rights specified in R428-2-9(B).
C. The committee may allow exemptions to the notification procedures specified in R428-2-9(B):
1. The Office may release to the data supplier its data elements used to create compilations, reports, or resource documents without notification when a data supplier requests the data it supplied.
2. The Office may make additional disclosures to other requesters of compilations, reports, or resource documents previously reviewed under the procedures specified in R428-2-9(B).
D. The Office may, by its initiative, prepare and disclose special compilations, reports, studies or analyses relating to health care cost, quality, access, health promotion programs, or public health. These actions may be to meet legislative intent or upon request from individuals, government agencies, or private organizations.
E. The committee may make data available for disclosure in computer readable formats.
1. The public data set provides general health care data. The Director of the Office may approve written requests for the public data set without approval of the committee. Written requests must include the following:
a. the name, address, and telephone number of the requester;
b. a statement of the purpose for which the data will be used; and
c. the starting and ending dates for which data are requested.
2. The design of the research oriented data set is for bona fide research of health care cost, quality, access, health promotion programs, or public health issues. A research oriented data set is available by request to the committee. Requests for a research oriented data set must be accompanied by a completed request form as established by the committee. Request forms are included in Technical Manuals that are available from the Office. The committee requires documentation of the requester's:
a. need for the research oriented data set to conduct bona fide research;
b. intent to use the data to study, promote, or improve accessibility, quality, or cost-effective health care;
c. integrity and ability to safeguard the data from any breach of confidentiality;
d. competency to effectively use the data in the manner proposed;
e. affiliation with an institutional review board; and
f. guarantee that no further disclosure will occur without prior approval of the Office.
R428-2-10. Penalties.
Pursuant to Section 26-23-6, any person that violates any provision of this rule may be assessed an administrative civil money penalty not to exceed $3,000 upon an administrative finding of a first violation and up to $5,000 for a subsequent similar violation within two years. A person may also be subject to penalties imposed by a civil or criminal court, which may not exceed $5,000 or a class B misdemeanor for the first violation and a class A misdemeanor for any subsequent similar violation within two years.
HEDIS Rule Example
· Moved ICD-9-CM Procedure code 45.42 from Flexible sigmoidoscopy description to Colonoscopy description in Table COL-A.
· Added CPT codes 44157, 44158 to Table COL-B.
Description
The percentage of members 50–80 years of age who had appropriate screening for colorectal cancer.
Eligible Population
|
Product lines |
Commercial, Medicare (report each product line separately). |
|
Ages |
51–80 years as of December 31 of the measurement year. |
|
Continuous enrollment |
The measurement year and the year prior to the measurement year. |
|
Allowable gap |
No more than one gap in continuous enrollment of up to 45 days during each year of continuous enrollment. |
|
Anchor date |
December 31 of the measurement year. |
|
Benefit |
Medical. |
|
Event/diagnosis |
None. |
Administrative Specification
|
Denominator |
The eligible population. |
|
Numerator |
One or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria. · Fecal occult blood test (FOBT) during the measurement year · Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year · Double contrast barium enema (DCBE) or air contrast barium enema during the measurement year or the four years prior to the measurement year · Colonoscopy during the measurement year or the nine years prior to the measurement year A member had an appropriate screening if a submitted claim/encounter contains any code in Table COL-A. |
_________________
Current Procedure Terminology © 2005 American Medical Association. All rights reserved.
|
Description |
CPT |
HCPCS |
ICD-9-CM Diagnosis |
ICD-9-CM Procedure |
LOINC |
|
FOBT |
82270, 82274 |
G0107, G0328 |
V76.51 |
|
2335-8, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3 |
|
Flexible sigmoidoscopy |
45330-45335, 45337-45342, 45345 |
G0104 |
|
45.24 |
|
|
DCBE |
74280 |
|
|
|
|
|
Colonoscopy |
44388-44394, 44397, 45355, 45378-45387, 45391, 45392 |
G0105, G0121 |
|
45.22, 45.23, 45.25, 45.42, 45.43 |
|
Exclusion (optional)
Organizations may exclude members with a diagnosis of colorectal cancer or total colectomy. Organizations should look for evidence of colorectal cancer or total colectomy as far back as possible in the member’s history. The codes in Table COL-B identify exclusions.
|
Description |
CPT |
HCPCS |
ICD-9-CM Diagnosis |
ICD-9-CM Procedure |
|
Colorectal cancer |
|
G0213-G0215, G0231 |
153, 154.0, 154.1, 197.5, V10.05 |
|
|
Total colectomy |
44150-44153, 44155-44158, 44210-44212 |
|
|
45.8 |
Hybrid Specification
|
Denominator |
A systematic sample drawn from the eligible population for each product line. The organization may reduce the sample size using the current year’s administrative rate or the prior year’s audited, product line-specific rate. For information on reducing the sample size, refer to the Guidelines for Calculations and Sampling. |
Numerator |
One or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria. · FOBT during the measurement year · Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year · DCBE or air contrast barium enema during the measurement year or the four years prior to the measurement · Colonoscopy during the measurement year or the nine years prior to the measurement year |
|
Administrative |
Refer to the Administrative Specification above to identify positive numerator hits from the administrative data. |
_________________
|
Current Procedure Terminology © 2005 American Medical Association. All rights reserved.Medical record |
Documentation in the medical record must include the following. · A note indicating the date the colorectal cancer screening was performed · For a notation in the progress notes, the result or finding must also be present (this ensures that the screening was performed and not merely ordered) A result is not required for a notation in the medical history because it pertains to screenings that occurred in the past and it is assumed that the result was negative (a positive result would have been noted as such). A notation in the medical history must include a date reference that meets the timeline outlined in the specifications. |
Exclusion (optional)
Refer to the Administrative Specification above for exclusion criteria. Exclusionary evidence in the medical record must include a note indicating a diagnosis of colorectal cancer or total colectomy. The diagnosis must have occurred by December 31 of the measurement year. Use the codes in Table COL-B as synonyms for a diagnosis of colorectal cancer or total colectomy.
Note
· Do not count digital rectal exam toward this measure because it is not specific or comprehensive enough to screen for colorectal cancer.
· Do not count single contrast barium enema or a notation of barium enema toward this measure because they are not as specific or as comprehensive as the double contrast or air contrast barium enema.
· There are two types of FOBT tests: guaiac (gFOBT) and immunochemical (iFOBT). Immunochemical FOBT tests may require fewer than three samples. Regardless of test type, for administrative data assume that the required number of samples was returned; if the medical record data does not indicate how many samples were returned, assume that the required number of samples was returned.
· If the medical record indicates that fewer than three samples were returned and does not indicate the type of test (guaiac or immunochemical), the member does not meet the screening criteria for inclusion in the numerator. If the medical record indicates that fewer than three samples were returned and an iFOBT was done, the member meets the screening criteria for inclusion in the numerator.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
|
|
Administrative |
Hybrid |
|
Measurement year |
ü |
ü |
|
Data collection methodology (Administrative or Hybrid) |
ü |
ü |
|
Eligible population |
ü |
ü |
|
Number of numerator events by administrative data in eligible population (before exclusions) |
|
ü |
|
Current year’s administrative rate (before exclusions) |
|
ü |
|
Minimum required sample size (MRSS) or other sample size |
|
ü |
|
Oversampling rate |
|
ü |
|
Final sample size (FSS) |
|
ü |
|
Number of numerator events by administrative data in FSS |
|
ü |
|
Administrative rate on FSS |
|
ü |
|
Number of original sample records excluded because of valid data errors |
|
ü |
|
Number of administrative data records excluded |
|
ü |
|
Number of medical record data records excluded |
|
ü |
|
Number of employee/dependent medical records excluded |
|
ü |
|
Records added from the oversample list |
|
ü |
|
Denominator |
|
ü |
|
Numerator events by administrative data |
ü |
ü |
|
Numerator events by medical records |
|
ü |
|
Reported rate |
ü |
ü |
|
Lower 95% confidence interval |
ü |
ü |
|
Upper 95% confidence interval |
ü |
ü |