Pacific Partners Management Services Inc.

Integrated Healthcare Association (IHA) & National Committee of Quality Assurance (NCQA)

Valid CPT Codes for Pay for Performance Measures

Childhood Immunizations Status

The percentage of enrolled children two years of age who were identified as having completed the following antigen series by their second birth day.

* 4 DTaP/DT * 3 H Influenza type B * 1 chicken pox vaccine

* 3 IVP * 3 Hepatitis B * 4 pneumococcal conjugate vaccines

* 1 MMR

Codes to Identify Childhood immunizations

Immunization / CPT / ICD 9 CM Diagnosis
DTaP / 90698,90700,90721,90723
Diphtheria and tetanus / 90702
Diphtheria / 90719 / 032,v02.4
Tetanus / 90703 / 037
IPV / 90698, 90713, 90723 / 045, 138, v12.02
MMR / 90707, 90710
Measles & Rubella / 90708
Mumps & Rubella / 90709
Measles / 90705 / 055
Mumps / 90704 / 072
Rubella / 90706 / 056
HiB / 90645-90648, 90698, 90721, 90748 / 038.41, 041.5, 320.0, 482.2
Hep B / 90723, 90740, 90744, 90747, 90748 / 070.2, 070.3, v02.61
VZV / 90710, 90716 / 052, 053
Pneumococcal Conjugate / 90669

Codes to Identify Exclusions

Immunization / Description / ICD 9 CM Diagnosis
DTaP / Encephalopathy / 323.5 with E948.4 E98.5 or E98.6
IPV / Anaphylactic reaction to streptomycin, polymyxin B or neomycin / 999.4
MMR and VZV / Immunodeficiency including genetic (congenital) immunodeficiency syndromes / 279
MMR and VZV / HIV Disease; asymptomatic HIV / 042, v08
MMR and VZV / Cancer of lymphoreticular or histolic tissue / 200-202
MMR and VZV / Multiple myeloma / 203
MMR and VZV / Leukemia / 204-208
MMR and VZV / Anaphylactic reaction to neomycin / 999.4
HiB / None
Hep B / Anaphylactic reaction to common bakers yeast / 999.4
Pneumococcal Conjugate / None

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 within three days after the episode date.

Codes to Identify URI

Description / ICD -9- CM Diagnosis
Acute nasopharyngitis ( common cold) / 460
URI / 465

Breast Cancer Screening (BCS)

The percentage of women 40- 69 years of age who had a mammogram to screen for breast cancer during the measurement year or year prior to the measurement year.

Codes to identify Breast Cancer Screening

CPT / ICD-9- Procedure
76083, 76090-76092 / 87.36, 87.37, V76.11, V76.12

Codes to Identify Exclusions

Description / CPT / ICD 9 CM Procedure
Bilateral Mastectomy / 191.80 or 191.80 with modifier code 0099508
19200.50 or 19200 with modifier code 009958
19220.50 19220 with modifier code 09950
19240.50 or 19240 with modifier code 09950 / 85.42, 85.44, 85.46, 85.48
Unilateral mastectomy (members must have 2 separate occurrences on 2 different dates of service) / 19180, 19200, 19220, 19240 / 85.41, 85.43, 85.45, 85.47

Cervical Cancer Screening (CCS)

The percentage of women 18-64 years of age who received one or more Pap test to screen for cervical cancer during the measurement year or the two years prior to the measurement year.

Codes to identify Cervical Cancer Screening

CPT / ICD-9- Procedure
88141-88145, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175 / 91.46, V72.32, V76.2

Codes to Identify Exclusions

Description / CPT / ICD 9 CM Procedure / ICD 9 CM Diagnosis
Hysterectomy / 51925, 56308, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58550-58554, 58951, 58953, 58954, 58956, 59135 / 68.4- 68.8, V67.01, V76.47 / 618.5

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.

Codes to identify Chlamydia Screening

CPT
87110, 87270, 87320, 87490, 87491, 87492, 87810

Codes to identify Exclusions in Chlamydia Screening

Description / CPT
Pregnancy test / 81025, 84702, 84703,
WITH
Diagnostic radiology / 70010-76499
Prescription for Acutance

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 1- November 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)

Codes to identify LDL-C Screening

CPT CODE / CPT Category ll
80061, 83700, 83701, 83704, 83715, 83716, 83721 / 3048F, 3049F, 3050F

Diabetes Care CDC

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

Codes to identify HbA1c Screening

CPT CODE / CPT Category ll
83036, 83037 / 3046F, 3047F

Codes to identify LDL-C Screening

CPT CODE / CPT Category ll
80061, 83700, 83701, 83704, 83715, 83716, 83721 / 3048F, 3049F, 3050F

Codes to identify Nephropathy Screening

Description / CPT
Nephropathy Screening Test / 82042, 82943, 82044, 84156

Use of Appropriate Medications for People with Asthma

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.

Codes to identify Asthma

Description / ICD -9- CM Diagnosis
Asthma / 493

Asthma Medications

Description / Prescriptions
Preferred Therapy / Cromolyn sodium Nedocromil
Inhaled corticosteroids Methylxanthines
Leukotriene modifiers
Add-on therapy / Long acting inhaled beta 2 agonists
Short acting inhaled beta 2 agonists