How To Close HEDIS Gaps In Care (GIC) For 2021

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How to Close HEDIS Gaps in Care (GIC) for 2021HEDIS GIC MeasureDocumentation to Submitfor a “Pass”Documentation to Submit forExclusion from MeasureBCSA mammogram completed on or betweenOctober 2018 through December 31 of themeasure year.Mastectomy—both breasts removed any time inthe member’s history through December 31, 2020.This may take place during the same or separateoperations.Breast Cancer ScreeningWomen age 50–74   Send test report(only Film, Digital, or 3D mammos).   DO NOT SEND biopsies, US, or MRIs of thebreasts.CCSCervical Cancer ScreeningWomen age 21–64   Send an office note showing the date and nameof the procedure(s). OR the Report(s) of Operation.   OR send an office note showing the name ofscreening and date completed.Note: Members who received Palliative Careservices in 2020 are exluded.Women age 21–64 who had Pap smear in2018, 2019 or 2020; OREvidence of a hysterectomy with no residual cervix:Women 30–64 years of age as of December 31,2020 who had cervical high-risk humanpapillomavirus (hrHPV) testing from2016-2020 and who were 30 years or older asof the date of testing. The HPV test alone orPap/HPV co-testing may be accepted.   Cervical biopsies cannot be substituted(they are not primary cervical cancerscreening).   Send results of the Pap (cervical cytology),the Pap/HPV co-testing or the hrHPV testalone.   Do not count lab results that explicitlystate the sample was inadequate or that"no cervical cells were present"; this is notconsidered appropriate screening.Note: Lab results that indicate the samplecontained "no endocervical cells" may beused if a valid result was reported for the test.   OR send an office note showing the date,name of procedure AND the result.   History of “complete”, “radical”, “total”hysterectomy, vaginal hysterectomy, TAH, or TVH.   “Hysterectomy” alone does not meet criteria as itdoes not indicate absence of cervix.   Send an office note showing the date of thesurgery   OR a Report of Operation for the hysterectomyprocedure   OR a GU physical exam notation to indicatecervix is not present.   Cervical agenesis, or acquired absence of cervixare also exclusions; send an office note showingthis historyIf the type of hysterectomy is unknown:   documentation of “hysterectomy” and “vaginalpap smear” together will be accepted OR   documentation of both “hysterectomy” and astatement to indicate “the pt. no longer requirescervical cancer screening.”These exclusions may occur any time in themember’s history through December 31, 2020.Note: Members who received Palliative Careservices in 2020 are excluded.CHLChlamydia Screeningin WomenWomen age 16–24MVPPR0035 (03/2021) 2021 MVP Health CareSexually active females must be tested atleast annually.   Send lab report AND the result from 2020.   OR send an office note showing the name oftest and date completed.   A pregnancy test during 2020 and aprescription for Accutane (Isotretinoin) on thedate of the pregnancy test or the six days afterthe pregnancy test.   A pregnancy test during 2020 and an x-ray onthe date of the pregnancy test or the six daysafter the pregnancy test.

How to Close HEDIS Gaps in Care (GIC) HEDIS GIC MeasureCOLColorectal CancerScreeningMembers age 50–75Page 2Documentation to Submitfor a “Pass”Documentation to Submit forExclusion from Measure   The record must indicate the name of the testand date the screening was performed. Thiscan include visit notes, procedure notes orpathology reports that indicate the name ofthe procedure. If the name of the procedureis not documented on the pathologyreport, it can be accepted if it indicates theanatomical location of the specimen to bebeyond the splenic flexure, meeting criteriafor a completed colonoscopy; an incompletecolonoscopy meets criteria for a flexiblesigmoidoscopy if the scope was advanced atleast to the sigmoid colon.   A note indicating a diagnosis of colorectal cancerany time through December 31, 2020   A result is not required if the proceduredocumentation is clearly part of the MedicalHistory, Preventive Maintenance, or HealthCare Maintenance section of the recordshowing the name of the test and date ofcompletion.Any one of these tests, within the specifiedtimeframe will close a COL gap:   FOBT in 2020—Guaiac stool cards or FITimmunochemical test (iFOBT)—Do notcount digital rectal exams (DRE), FOBT testsperformed in an office setting or performedon a sample collected via DRE (the testmay be analyzed in an office lab, but notcollected in the office setting)   Colonoscopy from 2011-2020   Flexible sigmoidoscopy from 2016-2020; anincomplete colonoscopy can be considereda flexible sigmoidoscopy if the scope waspassed at least to the sigmoid colon.   FIT-DNA (Cologuard) from 2018-2020; thereport must state "DNA" or "Cologuard"   CT Colonography (virtual colonoscopy)from 2016-2020   Submit procedure reports, path reports oroffice notes that show the name and dateof the completed procedure. If the nameof the procedure is not documented onthe pathology report, it can be acceptedif it indicates the anatomical location ofthe specimen to be beyond the splenicflexure, meeting criteria for a completedcolonoscopy; an incomplete colonoscopymeets criteria for a flexible sigmoidoscopyif the scope was advanced at least to thesigmoid colon.   An office note showing documentation of a totalcolectomy any time through December 31, 2020 OR a Report of Operation. OR Palliative Care services in 2020

How to Close HEDIS Gaps in Care (GIC) HEDIS GIC MeasureCDCComprehensiveDiabetes Care—Retinal Eye ExamMembers age 18–75 withType I or Type II DiabetesPage 3Documentation to Submitfor a “Pass”Documentation to Submit forExclusion from Measure   Submit a report of retinal exam by anophthalmologist or optometrist in 2020.All eye exam reports must include thecredential of the eye care professional.   Members who did not have a diagnosisof diabetes during 2019 or 2020 and whohad a diagnosis of gestational diabetes,steroid‑induced diabetes, or PolycysticOvarian Syndrome (PCOS) in any settingduring 2019 or 2020.   OR submit a report of retinal exam by anophthalmologist or optometrist in 2019ONLY IF THE RESULT IS NEGATIVE for diabeticretinopathy or hypertensive retinopathy.Documentation does not specifically haveto state “no diabetic retinopathy” to beconsidered negative for retinopathy; however,it must be clear that the patient had a dilatedor retinal exam and that retinopathy was notpresent.   OR submit an office note stating the dateand result of the retinal exam AND the nameand credentials of the eye care professional.   Documentation of “normal findings” for adilated or retinal exam meets criteria andcan be used.   Blindness is not an exclusion for a diabeticeye exam.At a minimum, documentation in the medicalrecord must include one of the following:   A note or letter prepared by an ophthalmologist,optometrist, PCP or other health careprofessional indicating that an ophthalmoscopicexam was completed by an eye care professional(optometrist or ophthalmologist), the date whenthe procedure was performed and the results.   A chart or photograph indicating the date whenthe fundus photography was performed.* Palliative Care services during 2020   Notations limited to a statement thatindicates “diabetes without complications”cannot be submitted.   OR submit proof of bilateral eye enucleation(removal of both eyes) or acquired absenceof both eyes any time during the member’shistory through December 31, 2020—sendoffice note or Report of Operation(s).ComprehensiveDiabetes Care—Hemoglobin A1c TestingSubmit the latest HbA1c test in 2020 (the mostrecent)* ranges (ie.A1c between 7-8) andthresholds (ie.A1c) do not meet criteria. Adistinct numeric result is required.**  At a minimum, documentation in themedical record must include a noteindicating the date when the HbA1c testwas performed and the result. A laboratoryreport is preferable.   Members who did not have a diagnosisof diabetes during 2019 or 2020 and whohad a diagnosis of gestational diabetes,steroid‑induced diabetes, or PolycysticOvarian Syndrome (PCOS) in any settingduring 2019 or 2020.   Blindness is not an exclusion for a diabeticeye exam.At a minimum, documentation in the medicalrecord must include one of the following:   A note or letter prepared by an ophthalmologist,optometrist, PCP or other health careprofessional indicating that an ophthalmoscopicexam was completed by an eye care professional(optometrist or ophthalmologist), the date whenthe procedure was performed and the results.   A chart or photograph indicating the date whenthe fundus photography was performed.* Palliative Care services during 2020

How to Close HEDIS Gaps in Care (GIC) HEDIS GIC MeasureCDCComprehensiveDiabetes CareMedical Attention forNephropathy*EFFECTIVE 2020: This submeasure applies to MedicareMembers only.Page 4Documentation to Submitfor a “Pass”Documentation to Submit forExclusion from Measure   Submit a urine test for albumin or proteindone in 2020. Any of the following meetthe criteria:   “Microalbumin”, “macroalbumin”, or“micral” Spoturine (urine dipstick or test strip) for albumin or protein   24-hour urine for albumin or protein   Timed urine for albumin or protein   Urine for albumin/creatinine ratio   Random urine for protein/creatinine ratio   Members who do not have a diagnosis ofdiabetes during 2019 or 2020 and who hada diagnosis of gestational diabetes, steroidinduced diabetes or PCOS in any settingduring 2019 or 2020.   OR submit an office note showing medicalattention for any of the following in 2020:   Diabetic nephropathy   End stage renal disease (ESRD)   Chronic renal failure (CRF)   Chronic kidney disease (CKD)   Renal insufficiency   Proteinuria   Albuminuria   Renal dysfunction   Acute renal failure (ARF)   Dialysis (any method)   OR submit an office note showing a visit to anephrologist in 2020.   OR submit an office note or Report ofOperation showing a history of renaltransplant or nephrectomy on or beforeDecember 31, 2020.   OR submit an office note or medicationlist showing an ACEI or ARB drug wasprescribed in 2020.(See page 5 for related drug list)

How to Close HEDIS Gaps in Care (GIC) HEDIS 2020ACE/ARBListAngiotensin convertingenzyme inhibitors (ACE) andAngiotensin-receptor blockers(ARB). Acceptable ACE/ARBdrugs are shown in the table tothe right.Submit an office note ormedication list showing an ACEor ARB drug was prescribedin 2020 to close the CDCnephropathy gap.Use of drugs listed here willscore the sub-measure ascompliant. Refer to the MVPFormulary to learn whichof these medications arecovered by the member’s plan;visit mvphealthcare.comand select Providers, thenPharmacy, then MVPFormularies.Page 5Acceptable ACE Inhibitor/ARB Medication Therapies (not rilCapozideLotensinTarka

How to Close HEDIS Gaps in Care (GIC) Page 6HEDIS GIC MeasureDocumentation to Submitfor a “Pass”Documentation to Submit forExclusion from MeasureIMA   Submit a note indicating the name ofthe specific vaccine and the dates ofadministration.Exclude members who had a contraindication,such as an anaphylactic reaction to the HPVvaccine or its components.   OR submit an Immunization Record withcompleted HPV series.Submit evidence in the form of an office note,allergy list or immunization record with notation ofthe contraindication.Immunizations forAdolescents—HumanPapillomavirus Vaccine(HPV) series onlyFemale and male adolescentswho completed an HPVvaccine series by the 13thbirthday. (Two-or three-doseseries as ordered by provider)Two-dose HPVVaccination Series:   At least two HPV vaccines,with different dates ofservice, on or between themember’s 9th and 13thbirthdays.   OR submit a certificate of immunizationprepared by an authorized health careprovider or agency including the specificdates and names of immunizationsadministered.* Members in hospice during 2020   OR submit an immunization recordobtained from a state vaccine registry orfrom a local RHIO (ie HIXNY)   HPV brand names:Gardasil, Gardasil 9, CervarixThere must be at least 146days (5 months, 4 days)between the first and seconddose of the HPV vaccine.Three-dose HPVVaccination Series:   At least three HPV vaccines,with different dates ofservice, on or between themember’s 9th and 13thbirthdays.LSCLead Screening in ChildrenChildren two years old in 2020who had at least one leadblood test by their secondbirthday.Lab test can either be capillaryor venous lead blood testing.   Submit a note indicating the datethe lead test was performed and theresult. A result may be documented asa numeric value, or stated as “WNL” or“negative” for this measure.   OR submit the lab report(s) showingthe result.A lead risk screening is not accepted inplace of the lab blood test.   There are no exclusions for this measure.

How to Close HEDIS Gaps in Care (GIC) Page 5 HEDIS 2020 ACE/ARB List Angiotensin converting enzyme inhibitors (ACE) and Angiotensin-receptor blockers (ARB). Acceptable ACE/ARB drugs are shown in the table to the right. Submit an office note or medication list showing an ACE or ARB drug

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