Pacific Partners Management Services Inc



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|279 |

| |syndromes | |

|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 |85.42, 85.44, 85.46, 85.48 |

| |19200.50 or 19200 with modifier code 009958 | |

| |19220.50 19220 with modifier code 09950 | |

| |19240.50 or 19240 with modifier code 09950 | |

|Unilateral mastectomy (members must have 2 separate occurrences|19180, 19200, 19220, 19240 |85.41, 85.43, 85.45, 85.47 |

|on 2 different dates of service) | | |

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, |91.46, V72.32, V76.2 |

|88174-88175 | |

Codes to Identify Exclusions

|Description |CPT |ICD 9 CM Procedure |ICD 9 CM Diagnosis |

|Hysterectomy |51925, 56308, 58150, 58152, 58200, 58210, 58240,|68.4- 68.8, V67.01, V76.47 |618.5 |

| |58260, 58262, 58263, 58267, 58270, 58275, 58280,| | |

| |58285, 58290-58294, 58550-58554, 58951, 58953, | | |

| |58954, 58956, 59135 | | |

| | | | |

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 ( ................
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