Product Lines:
EHP, Priority Partners and USFHP.

Eligible Population:
Members 3 to 21 years of age as of December 31 of the measurement year.

Definition:
The percentage of members 3–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

Report three age stratifications and a total rate:

• 3–11 years.
• 12–17 years.
• 18–21 years.
• Total- The total is the sum of the age stratifications for each product line.

Report Stratification by race and ethnicity.

Provider Specialty: PCP, OB/GYN

Measure is through Administrative Data. Medical record review is not performed.

Continuous Enrollment:

• The measurement year.

Best Practice and Measure Tips

• Visits must be with a PCP. The PCP does not have to be the practitioner assigned to the child.
• Assessment or treatment of an acute or chronic condition does not count towards the measure.
• Well-care visits can be performed anytime in the measurement/calendar year.
• This measure is based on the American Academy of Pediatrics Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (published by the National Center for Education in Maternal and Child Health). Visit the Bright Futures website for more information about well-child visits (https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/).

To meet administrative measure requirements, JHHC reminds all LOB well-care visits can be done in conjunction with sick visits, as long as they are billed appropriately.

How can a provider turn a sick visit into a well visit?

• If provider is seeing a patient for Evaluation and Management (E/M) services and all well-care visits components are completed: Attach modifier 25 or 59 to the well-child procedure code so it’s reviewed as a significant, separately identifiable procedure.
• Modifier 25 is used to indicate a significant and separately identifiable evaluation and management (E/M) service by the same physician on the same day another procedure or service was performed.
• Modifier 59 is used to indicate that 2 or more procedures were performed at the same visit, but to different sites on the body.
• Be sure to give addition guidance that is not related to the sick visit.
• Examples:
  • Is the child wearing their seatbelt?
  • Discussion of oral health.
  • Document home or school life.
  • Are they participating in a team sport?
  • Are they adjusting to a new school?
  • Visit the Bright Futures website for more information about well-child visits (https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/).

Measure Exclusions

Required Exclusion:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.

Measure Codes

• Be sure to use age-appropriate codes.
• Well-Care
  • CPT: 99382-99385, 99392- 99395
  • HCPCS: G0438, G0439, S0302, S0610, S0612, S0613
  • ICD-10-CM: Z00.00, Z00.01,  Z00.121, Z00.129, Z00.2, Z00.3, Z01.411, Z01.419, Z02.5, Z76.1, Z76.2