OPTIMUM PHYSICIAN ALLIANCE CONTACT

PO Box 90 MERI NOTARO Buffalo, New York opawny.com 14240 1-844-769-5879 OPA 2017 NETWORK + INCENTIVE GUIDE

Prepared For:

Date Issued: A GUIDE FOR 10.31.2016 PRIMARY CARE PHYSICIANS Valid To: 12.31.2017 OPA PHYSICIAN PARTNERS Table of Contents CONTENTS 1 2 3

Take a look at what you'll find inside this guide. INTRODUCTION TIERING PROGRAM STANDARD INCENTIVE

OPA Overview 3 OPA Primary Care 12 Standard Incentive Overview 17 Physician Tiering Overview 2017 Network Standards 5 Primary Care Metrics 19 2017 PCP 13 OPA Resources 7 Tiering Structure Pediatric Care Metrics 22

Network Incentive and 9 Standard Incentive Metrics 23 PCP Tiering Overview

4 5 6

CENTERS OF EXCELLENCE PRACTICE OPTIMIZATION APPENDICES PROGRAM (POP)

Centers of Excellence 25 Practice Optimization 31 Standard Incentive 45 Overview Program (POP) Guidelines Code Lists

Activity Based 27 Sample POP Application 39 Performance Measures

Utilization Based 28 Performance Measures

Centers of Excellence Metrics 29

1 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 2 [ the platform that simplifies the practice of medicine ]

Optimum Physician Alliance (OPA), formed in 2012, is the platform that simplifies the practice of medicine. It consists of approximately 600 physicians in the areas of primary and specialty care, Organization located mainly in Erie and Niagara counties. OPA is committed to promoting prac- meaningful engagement among healthcare tice transformation, with a patient-centered partners. OPA provides key resources to reduce Overview approach, and understands the importance administrative burdens and offers incentive pro- of leveraging healthcare data to support high grams designed to promote the type of practice quality outcomes for patients. This systematic transformation necessary for success in this OPA is an organization committed to excellence. Learn a little bit approach to healthcare is anchored by the pri- evolving industry. more about us. mary care physician and driven by collaboration This handbook is for you, our physician between primary and specialty care physicians, partner, to navigate and explore the benefits of hospitals, a health plan and most importantly, being an OPA physician, and provide you with patients. an understanding of OPA's Network Standards, This collaborative relationship sets OPA Resources, Incentive Programs and more! apart as a unique organization which facilitates

We accelerate smart, patient-centered and value based care. Take a look at the values that help us achieve our vision and define our culture.

WHY CHOOSE US?

PATIENT FOCUSED INTEGRITY

COMMITMENT RESPECT

FORWARD-THINKING

3 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 4 [ 2017 network standards ]

As an Optimum Physician Alliance (OPA) provider you have agreed to actively participate in, and * The Network Standards are reviewed on an to adhere to, the Network Standards.* intermittent basis, and revised if warranted

Standard No. 4

Each OPA practice must identify and commit a physician champion (solo physicians are champion by default), and an administrative champion.

Standard No. 1 Standard No. 5

Physicians must be credentialed through BlueCross BlueShield of Western New York Each OPA physician and administrative champion must have a unique functioning (BCBSWNY) in order to participate in OPA. email address.

Standard No. 2 Standard No. 6

Participating OPA providers must have privileges at Kaleida Health or an agreement in place All champions (as stated in #5) must meet with their OPA Physician Advisor on a regular basis with a hospital group that has privileges at Kaleida. throughout the year.

Standard No. 3 Standard No. 7

Participating OPA practice must have an operational EMR. Each OPA provider practice must be compliant with the HEALTHeLINK Consent Process AND have an effective workflow in place to obtain HEALTHeLINK consents from patients

5 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 6 [ resources that we provide ]

The way you practice medicine has changed drastically in the last few years. On top of your clinical responsibilities there are greater administrative burdens placed on your practice. OPA understands the need to focus on healthcare, and not just administration. As a member of Integrated Care EMR Support Specialist Variation Analysis OPA, you can receive comprehensive support through the following services: for Kids (Inc/K)

Review and analysis of care OPA physicians, within the Behavioral Health (BH) support management platforms, same specialty type, are for children and their families, predictive modeling tools, brought together to examine therapy and psychiatry services EMR systems and network unwarranted variations in conveniently provided at the connectivity to illustrate the care and develop common patient's PCP office, assistance value of care coordination and standards that improve quality with medication management, outcomes achieved in care and access to care and help linking families to management initiatives other BH support services

PCMH/PCSP Consulting Nutrition Education Health Coach Pharmacist Patient Centered Medical Home Outreach Associate Patient Centered Specialty Practice

One-on-one nutrition Support for weight manage- Pharmacy support services Supports practices in achieving Communication assistance to education for adults and ment, physical activity, stress include high level practice PCMH or PCSP recognition keep patients up-to-date on children, nutrition education management, smoking cessa- analysis to improve both the appointments and necessary for those with chronic diseases, tion, disease prevention and quality and efficiency of care milestones, training for staff to follow-ups by phone or in free wellness education classes as well as patient specific improve efficiency and better office, electronic medical record education with a focus on meet the needs of patients, (EMR) documentation for each best practice and therapeutic and assistance streamlining one-on-one visit with BlueCross efficacy organizational workflows BlueShield of Western New York (BCBSWNY) members

7 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 8 [ 2017 PCP incentive program overview ]

Standard Incentive

The standard incentive is broken down into two (2) components - the Network Incentive and the At-Risk Incentive. These NETWORK INCENTIVES incentives will be evaluated based on the performance of the overall OPA network. • It is a well-known fact that early detection is key to preventing and/or lessening the impact of chronic conditions and illnesses, however screening rates for common diseases have not changed much year after year. TheNetwork AND OPA TIERING Incentives were designed to engage our OPA partners in developing population management techniques, which will be critical to future success in healthcare. • The At-Risk Incentive is designed to facilitate coordination and cooperation among physicians to improve the quality PROGRAM OVERVIEW of care for patients and reduce unnecessary costs. Additional information will be available about this incentive in the coming weeks.

OPA is excited to offer several incentive programs for 2017, giving practices the opportunity to earn additional revenue through quality focused initiatives, network Centers of Excellence engagement and improvements in the quality and coordination of patient care. The objectives, structure, and reimbursement methodologies vary across incentive This incentive focuses on engagement and encourages physicians to attend local events, network with peers in the programs, but are all tied to OPA’s goal to be the platform that simplifies the practice community, and allows for the opportunity to share and receive information on both local and national healthcare trends. of medicine. To qualify for each incentive, physicians must be active OPA The specific benchmarks are described in more detail within the Centers of Excellence section of this guide. Payment of this incentive is distributed quarterly and will be based on practice performance. providers and practice a minimum of twelve (12) clinical hours per week.

In addition, starting January 1, 2017, OPA will be launching a new PCP Tiering Program. The Tiering Program is an initiative aimed at improving the quality, Practice Optimization Program efficiency, and overall engagement of the OPA primary care physician network and will impact eligibility for OPA’s incentive program. For more information on the The Practice Optimization Program (POP) is designed to provide the necessary support and resources to prepare physicians Tiering Program, please see the Tiering section of this guide. and their practices for the next decade of healthcare evolution. It is an incentive opportunity designed to empower OPA practices to determine how they would like their incentive dollars applied within their practice. In order to receive incentive dollars, practices must submit the POP application within the designated time-frames and identify a project that will help transform their practice. Payment of this incentive is distributed quarterly.

9 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 10 11 Program Program Physician Tiering Care OPA Primary OPTIMUM PHYSICIAN ALLIANCE PHYSICIAN OPTIMUM OPTIMUM PHYSICIAN ALLIANCE PHYSICIAN OPTIMUM community integration. mitted to providing highqualitypatient care and tices dedicated to practice transformation, com- will ultimately shiftincentive dollars to theprac pact eligibilityfor OPA’s incentive program, which careplicable physiciansandwillim- to primary OPA physicians.TheTiering Program willbeap the quality, efficiency, and cooperation among menting aTieringProgram designedto improve [ 2017 PCP tiering program overview ] Effective, January 1,2017,OPAEffective, January willbeimple - - - collaboration andreduce duplication ofservices. continuum ofpatient-centered care, improve more opportunities OPA hasto buildaseamless a cohesive network ofhealthcare providers, the engagement withinOPA. Themore OPA alignsas Standards, to whichwere encourage developed The program isalsolinked to OPA’s Network

12 TIERING [ 2017 tiering structure ]

The Tiering Program is comprised of three (3) tiers – the amount of incentive dollars practices can earn will be dependent upon which tier they belong.

Tiering Criteria Tier 1 Tier 2 Tier 3

MEET AND APPLY OPA 100% COMPLIANCE 100% COMPLIANCE 1 NETWORK STANDARDS PATIENT CENTERED MEDICAL 100% COMPLIANCE PURSUING RECOGNITION 2 HOME (PCMH) RECOGNIZED IN 2017 CORTEXT ALL PHYSICIANS MET 100% COMPLIANCE FAILURE TO ACHIEVE 3 COMPLIANCE IN 2016 3 OUT OF 4 QUARTERS TIER I OR II STATUS

WORKGROUP ALL PHYSICIANS MET 100% COMPLIANCE 4 PARTICIPATION IN 2016 3 OUT OF 4 QUARTERS

TIERING CRITERIA 1-4 TIERING CRITERIA 1-4 TIER DETERMINATIONS MUST BE MET MUST BE MET

INCENTIVE ELIGIBILITY ELIGIBLE $ + + ELIGIBLE $ + INELIGIBLE

TIERING Determination Tiering levels will be determined by December Practices in Tier II or III will have an opportunity & Timelines 31, 2016 and will be based on a practice’s to move up a tier on a quarterly basis if they completion of the criteria above. Please be meet the Tiering criteria by the last day of advised that in order to be eligible for Tier I or II, the quarter. Practices will receive retroactive all criteria must be met for that Tier group payment.

Physicians who are no longer on a practice’s To retain Tier status, practices must continue to In order to be eligible, all physicians and all roster as of January 1, will have no impact to the meet the criteria for that Tier group throughout locations must be compliant. It’s important to Tiering position for that coming year. Please note 2017. understand that an unengaged physician can - no exceptions will be made after this time. jeopardize the incentive payout for the whole practice.

13 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 14 [ tiering criteria ] 01 02 03 04 Network Standards Patient Centered Medical Cortext PCP Workgroups Home Recognition

Practices who have met the 2016 Network Standards Practices will be eligible for Tier I if they are fully In order to be eligible for Tier I status, all physicians In order to be eligible for Tier 1, all physicians in by December 31, 2016 will be eligible for Tier I or II. PCMH recognized (all physicians and at all locations) in a practice must have utilized Cortext a minimum a practice must have attended a PCP workgroup Practices must continue to adhere to the Network or if they have submitted their applications to the of three (3) times per month throughout 2016. meeting, once per quarter, during 2016. Practices National Committee for Quality Assurance (NCQA) Standards during 2017 to remain eligible for Tier I or II. Practices who met this criterion for only three (3) who met this criterion for only three (3) quarters of by December 31, 2016. quarters of 2016 will qualify for Tier II or III.* 2016 will qualify for Tier II or III.* Providers who are not recognized or who have not submitted their application by December 31, 2016, still have an opportunity to meet this criterion if they purchase the 2014 NCQA PCMH Tool by March 31, 2017 and submit their application to NCQA by September 30, 2017.

Tiering placement will be retroactive to the date of PCMH submission, but will be contingent upon NCQA recognition. If the PCMH application is denied, the practice will be placed in the appropriate tier.

Practices that acquire a new location, which is not PCMH recognized, will have a twelve (12) month During the first two (2) quarters of 2017, practices will have an opportunity to make up missed Cortext or grace period in which to submit their application to Workgroup requirements that occurred during 1Q16 or 2Q16. NCQA for the new location. • Attending a workgroup in 1Q17 and 2Q17 will apply towards missed workgroups in 1Q16 and 2Q16 • Utilizing Cortext 3x a month in 1Q17 and 2Q17 will apply to missed Cortext utilization in 1Q16 & 2Q16

15 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 16 [ 2017 standard incentive ]

Standard

Incentive Overview

The Standard Incentive was designed to support practices in developing population health management programs, with the goal of proactively keeping patients healthy and controlling healthcare costs. Primary care physicians must learn to identify patient risks and care opportunities, even in instances where patients aren’t actively seeking care. This can be done by leveraging data from electronic medical records, claims data and other available resources, and then subsequently developing mechanisms for patient outreach and engagement.

There are two main components to the Standard Incentive – At-Risk and the Network Incentive. Both incentives are measured and assessed at the OPA network level and are paid out annually if established benchmarks are met.

At-Risk

The At-Risk Incentive is designed to facilitate coordination and cooperation among physicians to improve the quality of care for patients and reduce unnecessary costs. There will be more information about this incentive in the coming weeks.

Network Incentive Summary

It is a well-known fact that early detection is key to preventing and/or lessening the impact of chronic conditions and illnesses, however screening rates for common diseases have not changed much year over year. The Network Incentives were designed to engage our OPA partners in developing population management techniques which will be critical to future success in healthcare. The metrics identified for 2017 are built around Healthcare Effectiveness Data and Information Set (HEDIS) measurements and national engagement statistics. In this section you will find a description of each measure, national benchmarks and OPA network thresholds needed to receive payment for each measure. The baseline values represent where the OPA network stands today. In order to achieve the maximum reward for each metric, the entire network must exceed the target amount and hit the maximum amount.

17 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 18 [ primary care metrics ]

METRIC 1: Breast Cancer Screening METRIC 3: Colorectal Screening

Background GOAL Background GOAL Breast cancer is an extremely common cancer which af- The goal of this metric is for OPA providers to refocus their Colorectal cancer is a major source of morbidity and mor- The goal of this metric is for practices to identify at-risk pa- fects one (1) in eight (8) women in the United States today. efforts on breast cancer screenings and identify new mech- tality in both the male and female populations. Despite tients and to encourage them to have the recommended It is a significant source of both morbidity and mortality, anisms to engage patients and encourage them to receive the highly effective screening mechanisms available, a screening. Acceptable colorectal screening mechanisms and has a substantial impact on both the patients and their the proper evaluations. This is a network wide metric and significant portion of the population fails to adhere to the include colonoscopies, fecal occult blood test (FOBT) and families. If detected at an early stage, meaningful interven- as such, it is an opportunity to engage with our partners in screening recommendations. The intent of this metric is to flexible sigmoidoscopy. For a listing of applicable CPT and tion is possible, but unfortunately due to the perceived OPA and to share best practices. For a listing of applicable put a new focus on identifying patients who are at-risk for diagnosis codes, please see Appendix III. inconvenience, discomfort and a lack of an organized sys- CPT and diagnosis codes, please see Appendix I. colorectal cancer and to ensure that they are appropriately tem to encourage and monitor routine screenings, we have screened and treated. never been able to achieve optimal screening rates among this at-risk population.

METRIC 2: Adult Body Mass Index (BMI) Assessment METRIC 4: Osteoporosis Management Post Fracture

Background GOAL Background GOAL The obesity epidemic is dramatically changing the care The goal of this metric is to encourage practices to devel- While osteoporosis affects both genders, it predominantly The goal of this metric is to implement a practice-wide needs of both the adult and pediatric populations. With op a mechanism for actively identifying patient’s BMI and affects the postmenopausal female population. It is not population screening device, which is capable of monitor- the logic that you can't manage what you don't measure, entering that information on the claim for later analysis. uncommon for these patients to present with a fracture as ing the practice on an ongoing basis. The intent is to iden- it is hoped that this metric will help practices develop a It is recognized that most modern electronic medical re- an initial sign of bone loss. This is an opportunity for prac- tify patients who were recently diagnosed with a fracture strategy to more appropriately identify and target patients cord systems will automatically calculate body mass index tices to appropriately identify, screen, and if necessary, and have them appropriately screened and treated for who struggle with weight gain. Additionally, this data can (BMI), however this information is contained within the treat these at-risk patients. osteoporosis. For a listing of applicable CPT and diagnosis be used to develop a better understanding of the impact body of the electronic record, and not easily shared. The codes, please see Appendix IV. of obesity in our community and how to more effectively ultimate goal is to better assess this population so that address it. OPA can better focus our resources moving forward. For a listing of applicable CPT and diagnosis codes, please see Appendix II.

19 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 20 [ primary care metrics ] [ pediatric care metrics ]

METRIC 5: Diabetes Care – Eye Exam

Background GOAL Diabetes is an increasingly common public health concern The goal of this metric is to implement a practice-wide and is steadily approaching epidemic proportions. Over population management and outreach program, which the long-term, inadequate control of blood sugars can re- will identify patients with diabetes in need of screening for sult in a cascade of medical complications, including but diabetic retinopathy and to successfully engage them in a not limited to vision loss. retinopathy screening and treatment program. Depending on a practice’s needs and capabilities, this can either be METRIC 1: BMI Assessment ages 3-11 and METRIC 2: BMI Assessment ages 12-17 done internally or through a referral to an eye care special- ist. For a listing of applicable CPT and diagnosis codes, please see Appendix V. Background GOAL The obesity epidemic is dramatically changing the care The goal of this metric is to encourage practices to devel- needs of both the adult and pediatric populations. With op a mechanism for actively identifying patient’s BMI and the logic that you can't manage what you don't measure, entering that information on the claim for later analysis. METRIC 6: Diabetes Care – Monitoring for Kidney Disease it is hoped that this metric will help practices develop a It is recognized that most modern electronic medical re- strategy to more appropriately identify and target patients cord systems will automatically calculate body mass index Background GOAL who struggle with weight gain. Additionally, this data can (BMI), however this information is contained within the Diabetes mellitus with hypertension is the number one (1) The goal of this metric is to implement a practice-wide be used to develop a better understanding of the impact body of the electronic record, and not easily shared. With cause of renal failure in the United States and is a major population management and outreach program, which of obesity in our community and how to more effectively this data, we hope to better assess this population so that cost driver in the American Health System. The literature will aid practices in identifying patients who are at-risk for address it. OPA can better focus resources moving forward. For a list- supports that if we are able to identify patients with mild diabetic renal failure and to target them for appropriate ing of applicable CPT and diagnosis codes, please see Ap- renal involvement at its early stages, it will allow for inter- screenings. For a listing of applicable CPT and diagnosis pendix VII. vention, which can delay and/or prevent ultimate kidney codes, please see Appendix VI. failure.

METRIC 7: Diabetes Care – HbA1c>9 METRIC 3: Counseling for Nutrition ages 3-11 + METRIC 4: Counseling for Nutrition ages 12-17

Background GOAL Background GOAL The correlation between improved control of blood sugars The goal of this metric is to have practices develop a pro- With obesity rates on the rise, nutrition counseling, par- The goal of this metric is to develop a practice pattern and decreased diabetes related complications, has long cess for identifying patients with poorly controlled diabe- ticularly at a young age, is becoming increasingly impor- where nutritional coding is routinely submitted, with other been established in literature. This incentive is designed to tes and to deploy strategies to help bring blood sugars un- tant. While counseling for nutrition is a standard part of a evaluation and management codes. For a listing of appli- help identify and target those patients who are not effec- der better control. pediatric visit, it’s often not clearly documented and rarely cable CPT and diagnosis codes, please see Appendix VIII. tively controlling their blood sugars. included on the claim, making it difficult to realize the im- pact and value of counseling.

21 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 22 [ standard incentive metrics ]

PCP & PEDS

INCENTIVE MEASURE NATIONAL BENCHMARK OPA 2015 OPA 2016 THRESHOLD TARGET MAX PCP (95% Payout) (100% Payout) (105% Payout) Nat Av: 67.52% 74.24% BREAST CANCER SCREENING TBD 74.24% 76.47% 78.69% NYS Av: 69.05% n= 13,298 Nat Av: 77.35% 4.07% ADULT BMI ASSESSMENT TBD 72.71% 75.03% 77.35% NYS Av: 82.39% n=50,574 NAT AV: 61.80% 63.3% COLORECTAL SCREENING TBD 63.30% 65.20% 67.10% NYS AV: 62.46% n=28,210 NAT AV: 26.45% 18.55% OSTEOPOROSIS MANAGEMENT POST FRACTURE TBD 26.45% 27.24% 28.04% NYS AV: 23.07% n=124 NAT AV: 60.02% 60.98% DIABETES CARE- EYE EXAM TBD 64.35% 66.28% 68.21% NYS AV: 64.35% n=6,390 NAT AV: 85.35% 86.28% DIABETES CARE- MONITORING FOR KIDNEY DISEASE TBD 86.28% 88.87% 91.46% NYS AV: 85.39% n=6,390 DIABETES CARE- HBAIC >9 (INVERSE MEASURE, NAT AV: 38.81% 35.16% TBD 38.81% 37.65% 36.48% LOWER IS BETTER) NYS AV: 37.61% n=6,319

INCENTIVE MEASURE NATIONAL BENCHMARK OPA 2015 OPA 2016 THRESHOLD TARGET MAX PEDS (95% Payout) (100% Payout) (105% Payout) NAT AV: 51.53% 24.99% BMI ASSESSMENT AGE 3-11 TBD 48.44% 49.98% 51.53% NYS AV: 72.06% n=5,084 NAT AV: 55.53% 26.47% BMI ASSESSMENT AGE 12-17 TBD 52.20% 53.86% 55.53% NYS AV: 72.06% n=4,009 NAT AV: 52.92% 1.89% COUNSELING FOR NUTRITION 3 TO 11 YEARS TBD 49.74% 51.33% 52.92% NYS AV: 72.94% n=5,084 NAT AV: 52.92% 3.16% COUNSELING FOR NUTRITION 12-17 YEARS TBD 49.74% 51.33% 52.92% NYS AV: 72.94% n=4,009

TIER I practices will earn $3 PMPM for BCBSWNY members TIER II practices will earn $2 PMPM for BCBSWNY members TIER III practices are ineligible **PMPM will be based on membership as of December 2017

23 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 24 [ this is an overview of our centers of excellence ]

Centers

of Excellence The Centers of Excellence incentive focuses on physician engagement and encourages physicians to attend local events, network with peers in the community, and allows for the opportunity to share and receive information on both local and national healthcare trends. These incentives are paid quarterly and are based on performance at the group level. They are divided into two (2) main components: Activity Based Performance Utilization Based Performance

ACTIVITY BASED PERFORMANCE MEASURES

The Activity Based Performance Measures (ABPM) so that attendees can have productive discussions with were created to strengthen interactions across the peers, voice concerns and offer feedback. A schedule of OPA network. They also provide a forum for open and workgroups and locations can be found by visiting https:// transparent dialogue with members of the OPA team. To opawny.com/events/pcp-workgroups/. Please note that receive the maximum incentive payout, every physician you must register for these workgroups as seating is limited. in a practice must meet each metric. Below is a brief description of each metric. INCREASE IN-NETWORK REFERRALS BY 5% A physician network works bests when the members of the ALL PHYSICIANS IN A PRACTICE MUST ATTEND FOUR network work together and support one another. The more (4) QUARTERLY PRIMARY CARE WORKGROUPS OPA aligns as a cohesive network of healthcare providers, To achieve this incentive, physicians are required to the more opportunities OPA has to build a seamless attend one (1) Primary Care Workgroup, per quarter, per continuum of patient-centered care, improve collaboration year. PCP Workgroups are offered eighteen (18) times and reduce duplication in services. per quarter or six (6) workgroups monthly, at a variety of convenient locations throughout Western New York. The workgroups provide physicians with opportunities to gain more information about the goals and initiatives of OPA, healthcare trends, and how we can best prepare for the changes to come. The workgroups are kept small

25 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 26 [ activity based performance measures [ utilization based performance continued ] measures ]

UTILIZE GREAT LAKES ACCESS CENTER TWICE A YEAR INCREASE ADVANCE CARE PLANNING CONVERSATION The Great Lakes Access Center (GLAC) was established as a ENCOUNTERS BY 5% one-stop-shop for a variety of adult and pediatric resourc- Conversations around end of life planning are not easy and es. GLAC can assist with referrals to specialist and PCPs, are time sensitive. This metric focuses on the importance access to care, and can help coordinate care. They also of these conversations for both patients and the physicians provide private-pay quotes for patients who choose to pay caring for them. The more we understand a patient’s needs out-of-pocket and can assist patients seeking affordable and preferences, the better positioned we are to provide health insurance. them with the most appropriate care and/or resources. The CPT codes and description for Advance Care Planning Great Lakes Access Center are as follows: 726 Exchange Street Buffalo, NY 14210 CPT CODE 99497 Advance Care Planning includes the explanation General #: 716-859-CARE (2273) and discussion of advance care directives, as well Pediatric #: 716-859-KIDS (5437) as the completion of standard forms by the phy- Email: [email protected] sician or other qualified health care profession- Website: www.kaleidahealth.org/AccessCenter als. This code should be billed for the first thirty of this incentive is to reduce overall Emergency (30) minutes, face-to-face, with the patient, family THE GOAL GROUP REPRESENTATION AT TWO (2) member(s), and/or surrogate. CARE INTEGRATION CONFERENCES Room/Urgent Care (ER/UC) utilization in an effort to ensure These interdisciplinary conferences are designed to im- CPT CODE 99498 prove working partnerships across OPA’s network, and be- patients receive the appropriate care, in the appropriate setting. This code should be billed for each additional 30 tween the health system and health plan. They will provide minutes (list separately in addition to code for pri- opportunities to network with peers, collaborate, share This measure applies to PCPs treating patients eighteen (18) mary procedure). best practices, and discuss clinical and/or administrative challenges. While speakers may present on topics of rel- years or older and physicians treating patients eighteen (18) evance, these events are designed to promote valuable years or younger, and is paid out based on group performance. interaction among the stakeholders. It is our hope that participants take away actionable ideas to help transform The incentive targets for each population can be found on the their practices and play a part in effecting real change in the WNY community. next page.

27 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 28 [ centers of excellence metrics ]

PCP/PEDS $6/PMPM

INCENTIVE MEASURES DESCRIPTION *QUARTERLY PAYMENT FOR MEETING THE METRIC

ALL PHYSICIANS ATTEND 4 QUARTERLY PRIMARY CARE CONTINUE TO BUILD A $1/PMPM WORKGROUPS COHESIVE NETWORK

INCREASE IN NETWORK REFERRALS BY 5% INCREASE INTEGRATION WITHIN OPA NETWORK $1/PMPM

PCP UTILIZE GREAT LAKES ACCESS CENTER TWICE A YEAR INCREASE USE OF THE GREAT LAKES ACCESS CENTER $1/PMPM ACTIVITY

ADVANCED CARE PLANNING CONVERSATION ENCOUNTERS INCREASE QUALITY OF CARE FOR PATIENT $1/PMPM - INCREASE 5%

GROUP REPRESENTATION AT 2 CARE INTEGRATION KALEIDA SPONSORED - 12 EVENTS PER YEAR $1/PMPM CONFERENCES (CIC) GROUP BASEDGROUP

2015 2016 QUARTERLY PAYMENT FOR INCENTIVE MEASURES PEER TARGET OPA/1000 OPA/1000 MEETING THE METRIC

OPA PCP ER/UC UTILIZATION (COMMERCIAL >18 YO) 164.22 201.60 TBD 190.00

$1/PMPM UTILIZATION OPA PEDS ER/UC UTILIZATION (COMMERCIAL <18 YO) 48.11 32.25 TBD 30.00

**PMPM will be based on membership as of December 2017

29 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 30 [ this is an overview of the practice optimization program (POP) ]

Practice Optimization

Program Guidelines OVERVIEW OPA understands that different practices have different they are aligned with the goals of OPA. In addition, the needs based on size, location, and area of focus. To that responsibility is on the practice to monitor and produce end, the Practice Optimization Program (POP) helps reports, upon request, highlighting the progress made, the physicians obtain the necessary resources to deliver high- effectiveness of the program, and/or barriers encountered. quality, high-value, efficient care. GENERAL INSTRUCTIONS FOR Consider your application an opportunity to define APPLICATION SUBMISSION for yourself, and how you envision your practice This guide includes the program outline, necessary transforming in the years to come. instructions and the applicable requirements for submission, unless otherwise noted. Submissions must Practices will be responsible and accountable for ensuring be aligned with OPA’s mission and goals, with a focus on the awarded funds are allocated and applied to achieving promoting practice transformation the objectives stated in their POP application and that

There are four (4) POP application submission cycles per year. OPA encourages early submissions. It is up to the practice to determine if more than one application is required for the calendar year.

SUBMISSION DATE AND TIMES

SUBMISSION OPEN SUBMISSION CLOSES PROGRAM EFFECTIVE DATES

NOVEMBER 14 DECEMBER 9 JANUARY 1

FEBRUARY 1 MARCH 10 APRIL 1

MAY 1 JUNE 9 JULY 1

AUGUST 1 SEPTEMBER 8 OCTOBER 1

31 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 32 [ POP guidelines ]

Program Criteria and Eligibility

• The practice must be in Tier I or Tier II. • The applicant must be a participating OPA Primary Care practice. • All eligible primary care physicians within the group must be participating in OPA. Application Due Date • Eligible primary care physicians are defined as participating OPA physicians who conduct patient care a minimum of twelve (12) hours per week at sites directly associated with the applicant’s group.

Applications must be received by 11:59 pm on the close date. Applications received after the deadline will be held until the • OPA practices must have eleven (11) or more BCBSWNY patients. Practices with ten (10) or less BCBSWNY patients are next quarterly submission. Applications will not be accepted after September 8, 2017. not eligible. • POP applications must support OPA’s goal to support physicians in their effort to transform their practices. • Eligibility is determined at the group level, not per location. Submission Methodology

Applications must be submitted electronically. Electronic copies of the application can be found at Funding and Allowable Expenses https://opawny.com/for-physicians/physician-resources/ and can be emailed to [email protected] Funds may be used for the following types of expenses provided they are directly attributable to the program and support practice transformation: Withdrawing an Application • Staffing-salaries for employees dedicated to the success of the program • Consultant fees An applicant may withdraw an application from consideration at any time. Withdrawal notifications should be sent via email • Office Equipment to [email protected]. • Technology in support of the practice

33 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 34 [ POP guidelines continued ]

Incentive Distribution Time Frame

Funding Restrictions Funds will be distributed on a quarterly basis. Payment will be determined by the dollars approved for your program and the allowable amount as defined at the bottom of page 35.

Exclusions include, but are not limited to, the following: • Construction or renovation of facilities Application Review Process • Political campaigns • Endowments Each application will be reviewed for the following: • Indirect costs and other standard expenses • Thoroughness and completeness • Debt reduction • Supporting documentation • Fundraising • Alignment to OPA’s mission and goals • Event sponsorship • Clearly defined time frame • Projects completed prior to the initiation of this program • Capital campaigns If clarification is needed, additional information may be requested. The requested information must be submitted within • Employee gifts three (3) days of the request. Applications deemed incomplete, ineligible or non-compliant will not be accepted and the • Scholarships group will be notified. • Land acquisition • Investments Clinical Review Team

Allowable Amounts The Clinical Review Team is comprised of OPA physicians who have the ultimate decision making authority to approve or deny an application. Eligible groups may request up to the maximum annual value, which is determined by using the methodology below. The POP payment will be based on the reconciled number of eligible PCPs at the time of submission. (# of eligible primary care physicians at the time of submission) x ($2,500) x (# of months) Award Notification Calendar Year Example with a Program Timeline of 01/01/16 – 12/31/16: (10 eligible PCP’s) x ($2,500) x (12 months) = $300,000 The final determination and the awarded amount will be communicated in writing to applicant within fifteen (15) days of Number of months is based on the program effective date and end date listed in the application. submission (unless additional information is needed).

35 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 36 [ POP guidelines continued ]

Practice Optimization Program Examples

The Practice Optimization Program was designed to help physicians transform their practices to prepare for the evolution of healthcare over the next decade. Included for your reference is a list of possible program topics for you to consider when completing your application.

CLINICAL CARE COORDINATION STAFF A practice may employ personnel to help with patient outreach and care coordination. Alternately, a practice may use the resources for hiring diabetic educators, nutritionists, pharmacists, trainers or other general support services, which will improve integration of patient care. If a practice does not need a full-time associate in one (1) given field or cannot afford a full-time associate in a particular field, it is permissible to use part-time resources. It is also possible to combine resources in order to bring on multiple skill sets. For example, a practice may choose to hire a part-time dietitian and a part-time pharmacist to help in the practice. Appeal Process AFTER HOURS CARE

If an application is denied, the applicant may appeal the decision within three (3) business days. Appeals must be made in A practice may wish to use the funds to pay for care outside of their current patient hours. For example, if they do not writing and should be accompanied by the denial letter. currently offer Saturday office hours, they may use the money to fund staffing to cover the additional cost of being open during that time. All documentation can be emailed to [email protected].

Denied applications may be resubmitted and will be reviewed by a separate reviewer. Each applicant is allowed one (1) TECHNOLOGY cycle of revisions. If more than one (1) cycle is needed, the application may be rejected, but can be resubmitted at the next A practice may wish to use the money to invest in technology to optimize practice transformation. Items that might be submission cycle. covered under this consideration would include, but are not limited to telehealth, remote monitoring systems, additional EMR licenses, technological enhancements. Items which would not be covered in this category include - acquisition and agreed to fees for maintenance of electronic medical record or routine subscriptions. These are part of the day-to-day cost of Audit Requirements doing business.

A random sampling of approved applicants will occur on a quarterly basis. Groups may be asked to provide a transaction OTHER report identifying cash expenditures year-to-date, process workflows, program descriptions and/or to complete a self-audit A practice may identify a need unique to their own considerations. This may be approved at the discretion of the application form. review team.

37 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 38 [ practice optimization program (POP) application 2017 ] 2017

OPTIMUM PHYSICIAN ALLIANCE

THANK YOU for your interest in participating in the 2017 Optimum Physician Alliance (OPA) Practice Optimization Program (POP). For additional information on this program, including application instructions, program rules, reimbursement methodology and the review process, please see the POP Guidelines. It is important to remember while completing this application that submissions must be aligned with OPA’s goal to support physicians in their effort to transform their practices.

APPLICATIONS MUST BE SUBMITTED ELECTRONICALLY. Electronic copies of the application can be found at https://opawny.com/for-physicians/physician-resources/ and can be emailed to [email protected]

Application Submission Date Complete Group Name

Tax Identification Number APPLICATION FORM Address(Primary Address Only) Assigned Project Administrator & Title practice optimization program Administrator Telephone Administrator Fax

Administrator Email Address Name of Physician Advisor

Number of Eligible Primary Care Physicians Amount of this Request ($) OPTIMUM PHYSICIAN ALLIANCE CONTACT Maximum Annual Value Per Eligible Group = (number of eligible primary care physicians) x ($2,500) x (twelve months). PO Box 90. Rachel Fitzgerald Example for a full year is as follows: (10 eligible PCPS) x ($2,500) x (12) = $300,000 Buffalo, New York [email protected] 14240 www.opawny.com

Time Frame in Which Funds Will Be Used From To

39 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 40 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE

Projected Project Budget 02. Program Information

Please be sure to include only eligible expenses. A. Goals: What goals do you hope to achieve by implementing this program? For a listing of ineligible expenses, please see the POP Guidelines. Goals are overarching principles that guide decision making. They reflect the big picture and clearly serve the interests of the ITEM PRACTICE CONTRIBUTION OPA CONTRIBUTION TOTAL program.

TOTAL B. Milestones: Describe the milestones you plan to achieve as a result of the goal set above.

Budget Rationale Milestones act as landmarks along the path to achieving your goal. They should describe the anticipated outcomes and can be Explain each line item above. either qualitative or quantitative. Baseline data should be presented as a point of reference.

C. Activities: What activities are necessary to achieve your goal and address the need(s) identified in the need statement? If applicable, cite research verifying that the activities you want to adopt will be effective in addressing the need.

PLEASE COMPLETE EACH QUESTION BELOW. IF ADDITIONAL SPACE IS NEEDED, PLEASE BE SURE TO LIMIT THE LENGTH OF YOUR ANSWERS TO NO MORE THAN 6 PAGES TOTAL (FOR THE ENTIRE APPLICATION).

01. Statement of Need: Why is this program important and how will it support practice transformation? D. Key Personnel: The key personnel section should include anyone who is going to work on the project It’s very important to present a clear, compelling case about why this program is needed. and their role in your organization.

41 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 42 OPTIMUM PHYSICIAN ALLIANCE JANE DOE INDIVIDUAL RESPONSIBLE RESPONSIBLE 03. Additional Information: Please include any additional information about your organization or project that you think is relevant to this submission. Also, please list any supporting documentation that is being submitted with this application. DATE 3/1/2017 COMPLETION COMPLETION 1/1/2017 START DATE DATA PATIENT S PATIENT SOURCE OF PATIENT SURVEY PATIENT METHOD OF MEASURE OF METHOD FLOWS ACTIVITY IMPLEMENT NEWIMPLEMENT WORK OBJECTIVE SATISFACTION IMPROVE CUSTOMER EX: F. Evaluation Plan: the In grid pleaseF. include below, the objective(s) developed you’ve and the corresponding activities needed meet to each objective. Include the method measurement of (how bedata will measured) and the source that data. of Don’t forget include projected your to start and responsible ultimately andcompletion for the each date action individual(s) item.

43 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 44 [ appendix I - breast cancer screening ] [ appendix I - breast cancer screening ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Absence of Left Breast Z90.12 [Z90.12] Acquired absence of left breast and nipple ICD10CM Unilateral Mastectomy 85.47 Unil ext rad mastectomy ICD9PCS Absence of Right Breast Z90.11 [Z90.11] Acquired absence of right breast and nipple ICD10CM Unilateral Mastectomy Left 0HTU0ZZ [0HTU0ZZ] Resection of Left Breast, Open Approach ICD10PCS Bilateral Mastectomy 0HTV0ZZ [0HTV0ZZ] Resection of Bilateral Breast, Open Approach ICD10PCS Unilateral Mastectomy Right 0HTT0ZZ [0HTT0ZZ] Resection of Right Breast, Open Approach ICD10PCS Bilateral Mastectomy 85.42 Bilat simple mastectomy ICD9PCS Bilateral Mastectomy 85.44 Bilat extend simp mastec ICD9PCS Bilateral Mastectomy 85.46 Bilat radical mastectomy ICD9PCS Bilateral Mastectomy 85.48 Bil exten rad mastectomy ICD9PCS Bilateral Modifier 50 CPT Bilateral Modifier 09950 CPT History of Bilateral Z90.13 [Z90.13] Acquired absence of bilateral breasts and nipples ICD10CM Mastectomy Left Modifier LT CPT Mammography 77055 CPT Mammography 77056 CPT Mammography 77057 CPT Screening mammography, producing direct digital image, Mammography G0202 HCPCS bilateral, all views (G0202) Mammography 87.36 Breast xerography ICD9PCS Mammography 87.37 Mammography NEC ICD9PCS Mammography 0403 UBREV Right Modifier RT CPT Unilateral Mastectomy 19180 CPT Unilateral Mastectomy 19200 CPT Unilateral Mastectomy 19220 CPT Unilateral Mastectomy 19240 CPT Unilateral Mastectomy 19303 CPT Unilateral Mastectomy 19304 CPT Unilateral Mastectomy 19305 CPT Unilateral Mastectomy 19306 CPT Unilateral Mastectomy 19307 CPT Unilateral Mastectomy 85.41 Unilat simple mastectomy ICD9PCS Unilateral Mastectomy 85.43 Unilat exten simp mastec ICD9PCS Unilateral Mastectomy 85.45 Unilat radical mastectom ICD9PCS

45 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 46 [ appendix II - adult BMI codes ] [ appendix III - colorectal screening codes ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

BMI Z68.1 Body mass index (BMI) 19 or less, adult ICD-10-CM Colonoscopy 44388 CPT BMI Z68.20 Body mass index (BMI) 20.0-20.9, adult ICD-10-CM Colonoscopy 44389 CPT BMI Z68.21 Body mass index (BMI) 21.0-21.9, adult ICD-10-CM Colonoscopy 44390 CPT BMI Z68.22 Body mass index (BMI) 22.0-22.9, adult ICD-10-CM Colonoscopy 44391 CPT BMI Z68.23 Body mass index (BMI) 23.0-23.9, adult ICD-10-CM Colonoscopy 44392 CPT BMI Z68.24 Body mass index (BMI) 24.0-24.9, adult ICD-10-CM Colonoscopy 44393 CPT BMI Z68.25 Body mass index (BMI) 25.0-25.9, adult ICD-10-CM Colonoscopy 44394 CPT BMI Z68.26 Body mass index (BMI) 26.0-26.9, adult ICD-10-CM Colonoscopy 44397 CPT BMI Z68.27 Body mass index (BMI) 27.0-27.9, adult ICD-10-CM Colonoscopy 44401 CPT BMI Z68.28 Body mass index (BMI) 28.0-28.9, adult ICD-10-CM Colonoscopy 44402 CPT BMI Z68.29 Body mass index (BMI) 29.0-29.9, adult ICD-10-CM Colonoscopy 44403 CPT BMI Z68.30 Body mass index (BMI) 30.0-30.9, adult ICD-10-CM Colonoscopy 44404 CPT BMI Z68.31 Body mass index (BMI) 31.0-31.9, adult ICD-10-CM Colonoscopy 44405 CPT BMI Z68.32 Body mass index (BMI) 32.0-32.9, adult ICD-10-CM Colonoscopy 44406 CPT BMI Z68.33 Body mass index (BMI) 33.0-33.9, adult ICD-10-CM Colonoscopy 44407 CPT BMI Z68.34 Body mass index (BMI) 34.0-34.9, adult ICD-10-CM Colonoscopy 44408 CPT BMI Z68.35 Body mass index (BMI) 35.0-35.9, adult ICD-10-CM Colonoscopy 45355 CPT BMI Z68.36 Body mass index (BMI) 36.0-36.9, adult ICD-10-CM Colonoscopy 45378 CPT BMI Z68.37 Body mass index (BMI) 37.0-37.9, adult ICD-10-CM Colonoscopy 45379 CPT BMI Z68.38 Body mass index (BMI) 38.0-38.9, adult ICD-10-CM Colonoscopy 45380 CPT BMI Z68.39 Body mass index (BMI) 39.0-39.9, adult ICD-10-CM Colonoscopy 45381 CPT BMI Z68.41 Body mass index (BMI) 40.0-44.9, adult ICD-10-CM Colonoscopy 45382 CPT BMI Z68.42 Body mass index (BMI) 45.0-49.9, adult ICD-10-CM Colonoscopy 45383 CPT BMI Z68.43 Body mass index (BMI) 50-59.9 , adult ICD-10-CM Colonoscopy 45384 CPT BMI Z68.44 Body mass index (BMI) 60.0-69.9, adult ICD-10-CM Colonoscopy 45385 CPT BMI Z68.45 Body mass index (BMI) 70 or greater, adult ICD-10-CM Colonoscopy 45386 CPT Colonoscopy 45387 CPT Colonoscopy 45388 CPT Colonoscopy 45389 CPT Colonoscopy 45390 CPT Colonoscopy 45391 CPT

47 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 48 [ appendix III - colorectal screening codes ] [ appendix III - colorectal screening codes ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Colonoscopy 44388 CPT Colonoscopy 45392 CPT Colonoscopy 44389 CPT Colonoscopy 45393 CPT Colonoscopy 44390 CPT Colonoscopy 45398 CPT Colonoscopy 44391 CPT Colorectal cancer screening; colonoscopy on individual at Colonoscopy G0105 HCPCS high risk (G0105) Colonoscopy 44392 CPT Colorectal cancer screening; colonoscopy on individual not Colonoscopy G0121 HCPCS Colonoscopy 44393 CPT meeting criteria for high risk (G0121) Colonoscopy 44394 CPT Colonoscopy 45.22 Endosc lg bowel thru st ICD9PCS Colonoscopy 44397 CPT Colonoscopy 45.23 Colonoscopy ICD9PCS Colonoscopy 44401 CPT Colonoscopy 45.25 Clos large bowel biopsy ICD9PCS Colonoscopy 44402 CPT Colonoscopy 45.42 Endo polpectomy lrge int ICD9PCS Colonoscopy 44403 CPT Colonoscopy 45.43 Endosc destru lg int les ICD9PCS Colonoscopy 44404 CPT Colorectal Cancer G0213 Pet imaging whole body; diagnosis; colorectal [G0213] HCPCS Colonoscopy 44405 CPT Colorectal Cancer G0214 Pet imaging whole body; initial staging; colorectal [G0214] HCPCS Colonoscopy 44406 CPT Pet imaging whole body; restaging; colorectal cancer Colorectal Cancer G0215 HCPCS Colonoscopy 44407 CPT [G0215] Pet, whole body, for recurrence of colorectal or colorectal Colonoscopy 44408 CPT Colorectal Cancer G0231 HCPCS metastatic cancer; gamma cameras only [G0231] Colonoscopy 45355 CPT Colorectal Cancer C18.0 [C18.0] Malignant neoplasm of cecum ICD10CM Colonoscopy 45378 CPT Colorectal Cancer C18.1 [C18.1] Malignant neoplasm of appendix ICD10CM Colonoscopy 45379 CPT Colorectal Cancer C18.2 [C18.2] Malignant neoplasm of ascending colon ICD10CM Colonoscopy 45380 CPT Colorectal Cancer C18.3 [C18.3] Malignant neoplasm of hepatic flexure ICD10CM Colonoscopy 45381 CPT Colorectal Cancer C18.4 [C18.4] Malignant neoplasm of transverse colon ICD10CM Colonoscopy 45382 CPT Colorectal Cancer C18.5 [C18.5] Malignant neoplasm of splenic flexure ICD10CM Colonoscopy 45383 CPT Colorectal Cancer C18.6 [C18.6] Malignant neoplasm of descending colon ICD10CM Colonoscopy 45384 CPT Colorectal Cancer C18.7 [C18.7] Malignant neoplasm of sigmoid colon ICD10CM Colonoscopy 45385 CPT Colorectal Cancer C18.8 [C18.8] Malignant neoplasm of overlapping sites of colon ICD10CM Colonoscopy 45386 CPT Colorectal Cancer C18.9 [C18.9] Malignant neoplasm of colon, unspecified ICD10CM Colonoscopy 45387 CPT Colorectal Cancer C19 [C19] Malignant neoplasm of rectosigmoid junction ICD10CM Colonoscopy 45388 CPT Colorectal Cancer C20 [C20] Malignant neoplasm of rectum ICD10CM Colonoscopy 45389 CPT Colorectal Cancer C21.2 [C21.2] Malignant neoplasm of cloacogenic zone ICD10CM Colonoscopy 45390 CPT [C21.8] Malignant neoplasm of overlapping sites of rectum, Colorectal Cancer C21.8 ICD10CM Colonoscopy 45391 CPT anus and anal canal

49 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 50 [ appendix III - colorectal screening codes ] [ appendix III - colorectal screening codes ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

[C78.5] Secondary malignant neoplasm of large intestine Flexible Sigmoidoscopy 45342 CPT Colorectal Cancer C78.5 ICD10CM and rectum Flexible Sigmoidoscopy 45345 CPT [Z85.038] Personal history of other malignant neoplasm of Colorectal Cancer Z85.038 ICD10CM large intestine Flexible Sigmoidoscopy 45346 CPT [Z85.048] Personal history of other malignant neoplasm of Flexible Sigmoidoscopy 45347 CPT Colorectal Cancer Z85.048 ICD10CM rectum, rectosigmoid junction, and anus Flexible Sigmoidoscopy 45349 CPT 153.0 Mal neo hepatic flexure ICD9CM Colorectal Cancer Flexible Sigmoidoscopy 45350 CPT 153.1 Mal neo transverse colon ICD9CM Colorectal Cancer Flexible Sigmoidoscopy G0104 Colorectal cancer screening; flexible sigmoidoscopy (G0104) HCPCS 153.2 Mal neo descend colon ICD9CM Colorectal Cancer Flexible Sigmoidoscopy 45.24 Flexible sigmoidoscopy ICD9PCS 153.3 Mal neo sigmoid colon ICD9CM Colorectal Cancer FOBT 82270 CPT 153.4 Malignant neoplasm cecum ICD9CM Colorectal Cancer FOBT 82274 CPT Colorectal Cancer 153.5 Malignant neo appendix ICD9CM Colorectal cancer screening; fecal occult blood test, FOBT G0328 HCPCS Colorectal Cancer 153.6 Malig neo ascend colon ICD9CM immunoassay, 1-3 simultaneous (G0328) Hemoglobin.gastrointestinal [Presence] in Stool --4th Colorectal Cancer 153.7 Mal neo splenic flexure ICD9CM FOBT 12503-9 LOINC specimen Colorectal Cancer 153.8 Malignant neo colon NEC ICD9CM Hemoglobin.gastrointestinal [Presence] in Stool --5th FOBT 12504-7 LOINC Colorectal Cancer 153.9 Malignant neo colon NOS ICD9CM specimen Colorectal Cancer 154.0 Mal neo rectosigmoid jct ICD9CM Hemoglobin.gastrointestinal [Presence] in Stool --1st FOBT 14563-1 LOINC specimen Colorectal Cancer 154.1 Malignant neopl rectum ICD9CM Hemoglobin.gastrointestinal [Presence] in Stool --2nd FOBT 14564-9 LOINC Colorectal Cancer 197.5 Sec malig neo lg bowel ICD9CM specimen Colorectal Cancer V10.05 Hx of colonic malignancy ICD9CM Hemoglobin.gastrointestinal [Presence] in Stool --3rd FOBT 14565-6 LOINC Colorectal Cancer V10.06 Hx-rectal & anal malign ICD9CM specimen 2335-8 Hemoglobin.gastrointestinal [Presence] in Stool LOINC Flexible Sigmoidoscopy 45330 CPT FOBT 27396-1 Hemoglobin.gastrointestinal [Mass/mass] in Stool LOINC Flexible Sigmoidoscopy 45331 CPT FOBT Hemoglobin.gastrointestinal [Presence] in Stool --6th Flexible Sigmoidoscopy 45332 CPT FOBT 27401-9 LOINC specimen 45333 CPT Flexible Sigmoidoscopy Hemoglobin.gastrointestinal [Presence] in Stool --7th FOBT 27925-7 LOINC Flexible Sigmoidoscopy 45334 CPT specimen Hemoglobin.gastrointestinal [Presence] in Stool --8th Flexible Sigmoidoscopy 45335 CPT FOBT 27926-5 LOINC specimen Flexible Sigmoidoscopy 45337 CPT Hemoglobin.gastrointestinal [Presence] in Stool by FOBT 29771-3 LOINC Flexible Sigmoidoscopy 45338 CPT Immunologic method Flexible Sigmoidoscopy 45339 CPT Hemoglobin.gastrointestinal [Presence] in Stool by FOBT 56490-6 LOINC Immunologic method --2nd specimen Flexible Sigmoidoscopy 45340 CPT Hemoglobin.gastrointestinal [Presence] in Stool by FOBT 56491-4 LOINC Flexible Sigmoidoscopy 45341 CPT Immunologic method --3rd specimen

51 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 52 [ appendix III - colorectal screening codes ] [ appendix IV - osteoporosis management post fracture ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Hemoglobin.gastrointestinal [Presence] in Stool by Bone Mineral Density Tests 76977 CPT FOBT 57905-2 LOINC Immunologic method --1st specimen Bone Mineral Density Tests 77078 CPT Hemoglobin.gastrointestinal [Mass/volume] in Stool by FOBT 58453-2 LOINC Immunologic method Bone Mineral Density Tests 77080 CPT Hemoglobin.gastrointestinal [Presence] in Stool by Rapid Bone Mineral Density Tests 77081 CPT FOBT 80372-6 LOINC immunoassay Bone Mineral Density Tests 77082 CPT Total Colectomy 44150 CPT Bone Mineral Density Tests 77085 CPT Total Colectomy 44151 CPT Bone Mineral Density Tests 77086 CPT Total Colectomy 44152 CPT Single energy x-ray absorptiometry (sexa) bone density Total Colectomy 44153 CPT Bone Mineral Density Tests G0130 study, one or more sites; appendicular skeleton (peripheral) HCPCS (e.g., radius, wrist, heel) (G0130) Total Colectomy 44155 CPT Bone Mineral Density Tests BP48ZZ1 [BP48ZZ1] Ultrasonography of Right Shoulder, Densitometry ICD10PCS Total Colectomy 44156 CPT Bone Mineral Density Tests BP49ZZ1 [BP49ZZ1] Ultrasonography of Left Shoulder, Densitometry ICD10PCS Total Colectomy 44157 CPT Bone Mineral Density Tests BP4GZZ1 [BP4GZZ1] Ultrasonography of Right Elbow, Densitometry ICD10PCS Total Colectomy 44158 CPT Bone Mineral Density Tests BP4HZZ1 [BP4HZZ1] Ultrasonography of Left Elbow, Densitometry ICD10PCS Total Colectomy 44210 CPT Bone Mineral Density Tests BP4LZZ1 [BP4LZZ1] Ultrasonography of Right Wrist, Densitometry ICD10PCS Total Colectomy 44211 CPT Bone Mineral Density Tests BP4MZZ1 [BP4MZZ1] Ultrasonography of Left Wrist, Densitometry ICD10PCS Total Colectomy 44212 CPT Bone Mineral Density Tests BP4NZZ1 [BP4NZZ1] Ultrasonography of Right Hand, Densitometry ICD10PCS Total Colectomy 0DTE0ZZ [0DTE0ZZ] Resection of Large Intestine, Open Approach ICD10PCS BP4PZZ1 [BP4PZZ1] Ultrasonography of Left Hand, Densitometry ICD10PCS [0DTE4ZZ] Resection of Large Intestine, Percutaneous Bone Mineral Density Tests Total Colectomy 0DTE4ZZ ICD10PCS Endoscopic Approach Bone Mineral Density Tests BQ00ZZ1 [BQ00ZZ1] Plain Radiography of Right Hip, Densitometry ICD10PCS [0DTE7ZZ] Resection of Large Intestine, Via Natural or Total Colectomy 0DTE7ZZ ICD10PCS Bone Mineral Density Tests BQ01ZZ1 [BQ01ZZ1] Plain Radiography of Left Hip, Densitometry ICD10PCS Artificial Opening Bone Mineral Density Tests BQ03ZZ1 [BQ03ZZ1] Plain Radiography of Right Femur, Densitometry ICD10PCS [0DTE8ZZ] Resection of Large Intestine, Via Natural or Total Colectomy 0DTE8ZZ ICD10PCS Artificial Opening Endoscopic Bone Mineral Density Tests BQ04ZZ1 [BQ04ZZ1] Plain Radiography of Left Femur, Densitometry ICD10PCS 45.81 Lap tot intr-ab colectmy ICD9PCS [BR00ZZ1] Plain Radiography of Cervical Spine, Total Colectomy Bone Mineral Density Tests BR00ZZ1 ICD10PCS Densitometry Total Colectomy 45.82 Op tot intr-abd colectmy ICD9PCS [BR07ZZ1] Plain Radiography of Thoracic Spine, Bone Mineral Density Tests BR07ZZ1 ICD10PCS Total Colectomy 45.83 Tot abd colectmy NEC/NOS ICD9PCS Densitometry [BR09ZZ1] Plain Radiography of Lumbar Spine, Bone Mineral Density Tests BR09ZZ1 ICD10PCS Densitometry Bone Mineral Density Tests BR0GZZ1 [BR0GZZ1] Plain Radiography of Whole Spine, Densitometry ICD10PCS Long-Acting Osteoporosis J3487 Injection, zoledronic acid (zometa), 1 mg (J3487) HCPCS Medications Long-Acting Osteoporosis J3488 Injection, zoledronic acid (reclast), 1 mg (J3488) HCPCS Medications

53 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 54 [ appendix IV - osteoporosis management [ appendix V - diabetes care - eye exam ] post fracture ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Long-Acting Osteoporosis Diabetic Retinal Screening 67028 CPT J3489 Injection, zoledronic acid, 1 mg (J3489) HCPCS Medications Diabetic Retinal Screening 67030 CPT Long-Acting Osteoporosis Injection, zoledronic acid, not otherwise specified, 1mg Q2051 HCPCS Diabetic Retinal Screening 67031 CPT Medications (Q2051) Diabetic Retinal Screening 67036 CPT Osteoporosis Medications J0630 Injection, calcitonin salmon, up to 400 units (J0630) HCPCS Diabetic Retinal Screening 67039 CPT Osteoporosis Medications J0897 Injection, denosumab, 1 mg (J0897) HCPCS Diabetic Retinal Screening 67040 CPT Osteoporosis Medications J1740 Injection, ibandronate sodium, 1 mg (J1740) HCPCS Diabetic Retinal Screening 67041 CPT Osteoporosis Medications J3110 Injection, teriparatide, 10 mcg (J3110) HCPCS Diabetic Retinal Screening 67042 CPT Osteoporosis Medications J3487 Injection, zoledronic acid (zometa), 1 mg (J3487) HCPCS Diabetic Retinal Screening 67043 CPT Osteoporosis Medications J3488 Injection, zoledronic acid (reclast), 1 mg (J3488) HCPCS Diabetic Retinal Screening 67101 CPT Osteoporosis Medications J3489 Injection, zoledronic acid, 1 mg (J3489) HCPCS Diabetic Retinal Screening 67105 CPT Injection, zoledronic acid, not otherwise specified, 1mg Osteoporosis Medications Q2051 HCPCS (Q2051) Diabetic Retinal Screening 67107 CPT Diabetic Retinal Screening 67108 CPT Diabetic Retinal Screening 67110 CPT Diabetic Retinal Screening 67112 CPT Diabetic Retinal Screening 67113 CPT Diabetic Retinal Screening 67121 CPT Diabetic Retinal Screening 67141 CPT Diabetic Retinal Screening 67145 CPT Diabetic Retinal Screening 67208 CPT Diabetic Retinal Screening 67210 CPT Diabetic Retinal Screening 67218 CPT Diabetic Retinal Screening 67220 CPT Diabetic Retinal Screening 67221 CPT Diabetic Retinal Screening 67227 CPT Diabetic Retinal Screening 67228 CPT Diabetic Retinal Screening 92002 CPT Diabetic Retinal Screening 92004 CPT Diabetic Retinal Screening 92012 CPT Diabetic Retinal Screening 92014 CPT Diabetic Retinal Screening 92018 CPT

55 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 56 [ appendix V - diabetes care - eye exam ] [ appendix VI - diabetes care - monitoring for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Diabetic Retinal Screening 92019 CPT CKD Stage 4 N18.4 [N18.4] Chronic kidney disease, stage 4 (severe) ICD10CM Diabetic Retinal Screening 92134 CPT CKD Stage 4 585.4 Chr kidney dis stage IV ICD9CM Diabetic Retinal Screening 92225 CPT ESRD 36147 CPT Diabetic Retinal Screening 92226 CPT ESRD 36800 CPT Diabetic Retinal Screening 92227 CPT ESRD 36810 CPT Diabetic Retinal Screening 92228 CPT ESRD 36815 CPT Diabetic Retinal Screening 92230 CPT ESRD 36818 CPT Diabetic Retinal Screening 92235 CPT ESRD 36819 CPT Diabetic Retinal Screening 92240 CPT ESRD 36820 CPT Diabetic Retinal Screening 92250 CPT ESRD 36821 CPT Diabetic Retinal Screening 92260 CPT ESRD 36831 CPT Diabetic Retinal Screening 99203 CPT ESRD 36832 CPT Diabetic Retinal Screening 99204 CPT ESRD 36833 CPT Diabetic Retinal Screening 99205 CPT ESRD 90935 CPT Diabetic Retinal Screening 99213 CPT ESRD 90937 CPT Diabetic Retinal Screening 99214 CPT ESRD 90940 CPT Diabetic Retinal Screening 99215 CPT ESRD 90945 CPT Diabetic Retinal Screening 99242 CPT ESRD 90947 CPT Diabetic Retinal Screening 99243 CPT ESRD 90957 CPT Diabetic Retinal Screening 99244 CPT ESRD 90958 CPT Diabetic Retinal Screening 99245 CPT ESRD 90959 CPT Routine ophthalmological ESRD 90960 CPT Diabetic Retinal Screening S0620 examination including refraction; new HCPCS patient (S0620) ESRD 90961 CPT Routine ophthalmological ESRD 90962 CPT Diabetic Retinal Screening S0621 examination including refraction; HCPCS ESRD 90965 CPT established patient (S0621) ESRD 90966 CPT Diabetic indicator; retinal eye exam, Diabetic Retinal Screening S3000 HCPCS dilated, bilateral (S3000) ESRD 90969 CPT Diabetic Retinal Screening Negative 3072F CPT ESRD 90970 CPT Diabetic Retinal Screening With Eye Care Professional 2022F CPT ESRD 90989 CPT Diabetic Retinal Screening With Eye Care Professional 2024F CPT ESRD 90993 CPT Diabetic Retinal Screening With Eye Care Professional 2026F CPT ESRD 90997 CPT

57 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 58 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

ESRD 90999 CPT ESRD 0802 UBREV ESRD 99512 CPT ESRD 0803 UBREV Unscheduled or emergency dialysis treatment for an esrd ESRD 0804 UBREV ESRD G0257 patient in a hospital outpatient department that is not HCPCS certified as an esrd facility (G0257) ESRD 0809 UBREV Home therapy; peritoneal dialysis, administrative services, ESRD 0820 UBREV professional pharmacy services, care coordination and all ESRD S9339 HCPCS ESRD 0821 UBREV necessary supplies and equipment (drugs and nursing visits coded separately), per diem (S9339) ESRD 0822 UBREV ESRD N18.5 [N18.5] Chronic kidney disease, stage 5 ICD10CM ESRD 0823 UBREV ESRD N18.6 [N18.6] End stage renal disease ICD10CM ESRD 0824 UBREV ESRD Z91.15 [Z91.15] Patient's noncompliance with renal dialysis ICD10CM ESRD 0825 UBREV ESRD Z99.2 [Z99.2] Dependence on renal dialysis ICD10CM ESRD 0829 UBREV [3E1M39Z] Irrigation of Peritoneal Cavity using Dialysate, ESRD 0830 UBREV ESRD 3E1M39Z ICD10PCS Percutaneous Approach ESRD 0831 UBREV ESRD 5A1D00Z [5A1D00Z] Performance of Urinary Filtration, Single ICD10PCS ESRD 0832 UBREV ESRD 5A1D60Z [5A1D60Z] Performance of Urinary Filtration, Multiple ICD10PCS ESRD 0833 UBREV ESRD 585.5 Chron kidney dis stage V ICD9CM ESRD 0834 UBREV ESRD 585.6 End stage renal disease ICD9CM ESRD 0835 UBREV ESRD V45.11 Renal dialysis status ICD9CM ESRD 0839 UBREV ESRD V45.12 Noncmplnt w renal dialys ICD9CM ESRD 0840 UBREV ESRD 38.95 Ven cath renal dialysis ICD9PCS ESRD 0841 UBREV ESRD 39.27 Dialysis arteriovenostom ICD9PCS ESRD 0842 UBREV ESRD 39.42 Revis ren dialysis shunt ICD9PCS ESRD 0843 UBREV ESRD 39.43 Remov ren dialysis shunt ICD9PCS ESRD 0844 UBREV ESRD 39.53 Arterioven fistula rep ICD9PCS ESRD 0845 UBREV ESRD 39.93 Insert ves-to-ves cannul ICD9PCS ESRD 0849 UBREV ESRD 39.94 Replac ves-to-ves cannul ICD9PCS ESRD 0850 UBREV ESRD 39.95 Hemodialysis ICD9PCS ESRD 0851 UBREV ESRD 54.98 Peritoneal dialysis ICD9PCS ESRD 0852 UBREV ESRD 65 End-Stage Renal Disease Treatment Facility POS ESRD 0853 UBREV ESRD 0800 UBREV ESRD 0854 UBREV ESRD 0801 UBREV ESRD 0855 UBREV

59 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 60 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

ESRD 0859 UBREV ESRD Obsolete 90920 CPT ESRD 0880 UBREV ESRD Obsolete 90921 CPT ESRD 0881 UBREV ESRD Obsolete 90923 CPT ESRD 0882 UBREV ESRD Obsolete 90924 CPT ESRD 0889 UBREV ESRD Obsolete 90925 CPT

ESRD 0720 UBTOB End stage renal disease (esrd) related services during the course of treatment, for patients under 2 years of ESRD 0721 UBTOB age to include monitoring for the adequacy of nutrition, ESRD Obsolete G0308 HCPCS ESRD 0722 UBTOB assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per ESRD 0723 UBTOB month [G0308] ESRD 0724 UBTOB End stage renal disease (esrd) related services during ESRD 0725 UBTOB the course of treatment for patients under 2 years of age to include monitoring for the adequacy of nutrition, ESRD Obsolete G0309 HCPCS ESRD 0727 UBTOB assessment of growth and development, and counseling of ESRD 0728 UBTOB parents; with 2 or 3 face-to-face physician visits per month [G0309] ESRD 072A UBTOB End stage renal disease (esrd) related services during ESRD 072B UBTOB the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, ESRD 072C UBTOB ESRD Obsolete G0310 HCPCS assessment of growth and development, and counseling ESRD 072D UBTOB of parents; with 1 face-to-face physician visit per month ESRD 072E UBTOB [G0310] ESRD 072F UBTOB End stage renal disease (esrd) related services during the course of treatment, for patients between 2 and 11 years ESRD 072G UBTOB of age to include monitoring for the adequacy of nutrition, ESRD Obsolete G0311 HCPCS ESRD 072H UBTOB assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per ESRD 072I UBTOB month [G0311] 072J UBTOB ESRD End stage renal disease (esrd) related services during the ESRD 072K UBTOB course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, ESRD Obsolete G0312 HCPCS ESRD 072M UBTOB assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month ESRD 072O UBTOB [G0312] ESRD 072X UBTOB End stage renal disease (esrd) related services during the ESRD 072Y UBTOB course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, ESRD 072Z UBTOB ESRD Obsolete G0313 HCPCS assessment of growth and development, and counseling ESRD Obsolete 36145 CPT of parents; with 1 face-to-face physician visit per month ESRD Obsolete 90919 CPT [G0313]

61 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 62 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

End stage renal disease (esrd) related services, during the End stage renal disease (esrd) related services less course of treatment, for patients between 12 and 19 years ESRD Obsolete G0326 than full month, per day; for patients between twelve HCPCS of age to include monitoring for the adequacy of nutrition, and nineteen years of age [G0326] ESRD Obsolete G0314 HCPCS assessment of growth and development, and counseling End stage renal disease (esrd) related services less of parents; with 4 or more face-to-face physician visits per ESRD Obsolete G0327 than full month, per day; for patients twenty years of HCPCS month [G0314] age and over [G0327]

End stage renal disease (esrd) related services during the Transluminal balloon angioplasty, percutaneous; for course of treatment, for patients between 12 and 19 years ESRD Obsolete G0392 maintenance of hemodialysis access, arteriovenous HCPCS of age to include monitoring for the adequacy of nutrition, fistula or graft; arterial [G0392] ESRD Obsolete G0315 HCPCS assessment of growth and development, and counseling of Transluminal balloon angioplasty, percutaneous; for parents; with 2 or 3 face-to-face physician visits per month ESRD Obsolete G0393 maintenance of hemodialysis access, arteriovenous HCPCS [G0315] fistula or graft; venous [G0393]

End stage renal disease (esrd) related services during the Kidney Transplant 50300 CPT course of treatment, for patients between 12 and 19 years Kidney Transplant 50320 CPT of age to include monitoring for the adequacy of nutrition, ESRD Obsolete G0316 HCPCS assessment of growth and development, and counseling Kidney Transplant 50340 CPT of parents; with 1 face-to-face physician visit per month Kidney Transplant 50360 CPT [G0316] Kidney Transplant 50365 CPT End stage renal disease (esrd) related services during the course of treatment, for patients 20 years of age and over; Kidney Transplant 50370 CPT ESRD Obsolete G0317 HCPCS with 4 or more face-to-face physician visits per month Kidney Transplant 50380 CPT [G0317] Kidney Transplant S2065 Simultaneous pancreas kidney transplantation (S2065) HCPCS End stage renal disease (esrd) related services during the ESRD Obsolete G0318 course of treatment, for patients 20 years of age and over; HCPCS Kidney Transplant Z94.0 [Z94.0] Kidney transplant status ICD10CM with 2 or 3 face-to-face physician visits per month [G0318] [0TY00Z0] Transplantation of Right Kidney, Allogeneic, Kidney Transplant 0TY00Z0 ICD10PCS End stage renal disease (esrd) related services during the Open Approach ESRD Obsolete G0319 course of treatment, for patients 20 years of age and over; HCPCS [0TY00Z1] Transplantation of Right Kidney, Syngeneic, with 1 face-to-face physician visit per month [G0319] Kidney Transplant 0TY00Z1 ICD10PCS Open Approach ESRD related services for home dialysis patients per full month; for patients 2 to 11 years of age to include [0TY00Z2] Transplantation of Right Kidney, Zooplastic, ESRD Obsolete G0321 HCPCS Kidney Transplant 0TY00Z2 ICD10PCS monitoring for adequacy of nutrition, assessment of growth Open Approach and development, and counseling of parents [G0321] [0TY10Z0] Transplantation of Left Kidney, Allogeneic, Kidney Transplant 0TY10Z0 ICD10PCS End stage renal disease (esrd) related services for home Open Approach dialysis patients per full month; for patients twelve to [0TY10Z1] Transplantation of Left Kidney, Syngeneic, Kidney Transplant 0TY10Z1 ICD10PCS ESRD Obsolete G0322 nineteen years of age to include monitoring for adequacy HCPCS Open Approach of nutrition, assessment of growth and development, and [0TY10Z2] Transplantation of Left Kidney, Zooplastic, counseling of parents [G0322] Kidney Transplant 0TY10Z2 ICD10PCS Open Approach End stage renal disease (esrd) related services for home ESRD Obsolete G0323 dialysis patients per full month; for patients twenty years of HCPCS Kidney Transplant V42.0 Kidney transplant status ICD9CM age and older [G0323] ESRD related services for home dialysis (less than full Kidney Transplant 55.61 Renal autotransplant ICD9PCS ESRD Obsolete G0325 month), per day; for patients between 2 and 11 years of age HCPCS [G0325] Kidney Transplant 55.69 Kidney transplant NEC ICD9PCS

63 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 64 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Kidney Transplant 0367 UBREV [I13.0] Hypertensive heart and chronic kidney disease with Nephropathy Treatment I13.0 heart failure and stage 1 through stage 4 chronic kidney ICD10CM Nephropathy Treatment 3066F CPT disease, or unspecified chronic kidney disease Nephropathy Treatment 4010F CPT [I13.10] Hypertensive heart and chronic kidney disease I13.10 without heart failure, with stage 1 through stage 4 chronic ICD10CM [E08.21] Diabetes mellitus due to underlying condition Nephropathy Treatment Nephropathy Treatment E08.21 ICD10CM kidney disease, or unspecified chronic kidney disease with diabetic nephropathy [I13.11] Hypertensive heart and chronic kidney disease [E08.22] Diabetes mellitus due to underlying condition Nephropathy Treatment E08.22 ICD10CM I13.11 without heart failure, with stage 5 chronic kidney disease, ICD10CM with diabetic chronic kidney disease Nephropathy Treatment or end stage renal disease [E08.29] Diabetes mellitus due to underlying condition Nephropathy Treatment E08.29 ICD10CM [I13.2] Hypertensive heart and chronic kidney disease with with other diabetic kidney complication Nephropathy Treatment I13.2 heart failure and with stage 5 chronic kidney disease, or ICD10CM [E09.21] Drug or chemical induced diabetes mellitus with end stage renal disease Nephropathy Treatment E09.21 ICD10CM diabetic nephropathy Nephropathy Treatment I15.0 [I15.0] Renovascular hypertension ICD10CM [E09.22] Drug or chemical induced diabetes mellitus with Nephropathy Treatment E09.22 ICD10CM diabetic chronic kidney disease Nephropathy Treatment I15.1 [I15.1] Hypertension secondary to other renal disorders ICD10CM [E09.29] Drug or chemical induced diabetes mellitus with [N00.0] Acute nephritic syndrome with minor glomerular Nephropathy Treatment E09.29 ICD10CM Nephropathy Treatment N00.0 ICD10CM other diabetic kidney complication abnormality [E10.21] Type 1 diabetes mellitus with diabetic [N00.1] Acute nephritic syndrome with focal and Nephropathy Treatment E10.21 ICD10CM Nephropathy Treatment N00.1 ICD10CM nephropathy segmental glomerular lesions [E10.22] Type 1 diabetes mellitus with diabetic chronic [N00.2] Acute nephritic syndrome with diffuse Nephropathy Treatment E10.22 ICD10CM Nephropathy Treatment N00.2 ICD10CM kidney disease membranous glomerulonephritis [E10.29] Type 1 diabetes mellitus with other diabetic [N00.3] Acute nephritic syndrome with diffuse mesangial Nephropathy Treatment E10.29 ICD10CM Nephropathy Treatment N00.3 ICD10CM kidney complication proliferative glomerulonephritis [E11.21] Type 2 diabetes mellitus with diabetic [N00.4] Acute nephritic syndrome with diffuse Nephropathy Treatment E11.21 ICD10CM Nephropathy Treatment N00.4 ICD10CM nephropathy endocapillary proliferative glomerulonephritis [E11.22] Type 2 diabetes mellitus with diabetic chronic [N00.5] Acute nephritic syndrome with diffuse Nephropathy Treatment E11.22 ICD10CM Nephropathy Treatment N00.5 ICD10CM kidney disease mesangiocapillary glomerulonephritis [E11.29] Type 2 diabetes mellitus with other diabetic [N00.6] Acute nephritic syndrome with dense deposit Nephropathy Treatment E11.29 ICD10CM Nephropathy Treatment N00.6 ICD10CM kidney complication disease [E13.21] Other specified diabetes mellitus with diabetic [N00.7] Acute nephritic syndrome with diffuse crescentic Nephropathy Treatment E13.21 ICD10CM Nephropathy Treatment N00.7 ICD10CM nephropathy glomerulonephritis [E13.22] Other specified diabetes mellitus with diabetic [N00.8] Acute nephritic syndrome with other morphologic Nephropathy Treatment E13.22 ICD10CM Nephropathy Treatment N00.8 ICD10CM chronic kidney disease changes [E13.29] Other specified diabetes mellitus with other [N00.9] Acute nephritic syndrome with unspecified Nephropathy Treatment E13.29 ICD10CM Nephropathy Treatment N00.9 ICD10CM diabetic kidney complication morphologic changes [I12.0] Hypertensive chronic kidney disease with stage 5 Nephropathy Treatment I12.0 ICD10CM chronic kidney disease or end stage renal disease [N01.0] Rapidly progressive nephritic syndrome with Nephropathy Treatment N01.0 ICD10CM [I12.9] Hypertensive chronic kidney disease with stage 1 minor glomerular abnormality Nephropathy Treatment I12.9 through stage 4 chronic kidney disease, or unspecified ICD10CM chronic kidney disease

65 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 66 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

[N01.1] Rapidly progressive nephritic syndrome with focal Nephropathy Treatment N01.1 ICD10CM [N02.4] Recurrent and persistent hematuria with diffuse and segmental glomerular lesions Nephropathy Treatment N02.4 ICD10CM endocapillary proliferative glomerulonephritis [N01.2] Rapidly progressive nephritic syndrome with Nephropathy Treatment N01.2 ICD10CM diffuse membranous glomerulonephritis [N02.5] Recurrent and persistent hematuria with diffuse Nephropathy Treatment N02.5 ICD10CM [N01.3] Rapidly progressive nephritic syndrome with mesangiocapillary glomerulonephritis Nephropathy Treatment N01.3 ICD10CM diffuse mesangial proliferative glomerulonephritis [N01.4] Rapidly progressive nephritic syndrome with [N02.6] Recurrent and persistent hematuria with dense Nephropathy Treatment N01.4 ICD10CM Nephropathy Treatment N02.6 ICD10CM diffuse endocapillary proliferative glomerulonephritis deposit disease [N01.5] Rapidly progressive nephritic syndrome with Nephropathy Treatment N01.5 ICD10CM [N02.7] Recurrent and persistent hematuria with diffuse diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N02.7 ICD10CM crescentic glomerulonephritis [N01.6] Rapidly progressive nephritic syndrome with Nephropathy Treatment N01.6 ICD10CM dense deposit disease [N02.8] Recurrent and persistent hematuria with other Nephropathy Treatment N02.8 ICD10CM [N01.7] Rapidly progressive nephritic syndrome with morphologic changes Nephropathy Treatment N01.7 ICD10CM diffuse crescentic glomerulonephritis [N02.9] Recurrent and persistent hematuria with [N01.8] Rapidly progressive nephritic syndrome with other Nephropathy Treatment N02.9 ICD10CM Nephropathy Treatment N01.8 ICD10CM unspecified morphologic changes morphologic changes

[N01.9] Rapidly progressive nephritic syndrome with [N03.0] Chronic nephritic syndrome with minor glomerular Nephropathy Treatment N01.9 ICD10CM Nephropathy Treatment N03.0 ICD10CM unspecified morphologic changes abnormality

[N02.0] Recurrent and persistent hematuria with minor [N03.1] Chronic nephritic syndrome with focal and Nephropathy Treatment N02.0 ICD10CM Nephropathy Treatment N03.1 ICD10CM glomerular abnormality segmental glomerular lesions

[N02.1] Recurrent and persistent hematuria with focal and [N03.2] Chronic nephritic syndrome with diffuse Nephropathy Treatment N02.1 ICD10CM Nephropathy Treatment N03.2 ICD10CM segmental glomerular lesions membranous glomerulonephritis

[N02.2] Recurrent and persistent hematuria with diffuse [N03.3] Chronic nephritic syndrome with diffuse mesangial Nephropathy Treatment N02.2 ICD10CM Nephropathy Treatment N03.3 ICD10CM membranous glomerulonephritis proliferative glomerulonephritis

[N03.7] Chronic nephritic syndrome with diffuse crescentic Nephropathy Treatment N03.7 ICD10CM [N02.3] Recurrent and persistent hematuria with diffuse glomerulonephritis Nephropathy Treatment N02.3 ICD10CM mesangial proliferative glomerulonephritis [N03.8] Chronic nephritic syndrome with other Nephropathy Treatment N03.8 ICD10CM [N03.4] Chronic nephritic syndrome with diffuse morphologic changes Nephropathy Treatment N03.4 ICD10CM endocapillary proliferative glomerulonephritis [N03.9] Chronic nephritic syndrome with unspecified Nephropathy Treatment N03.9 ICD10CM [N03.5] Chronic nephritic syndrome with diffuse morphologic changes Nephropathy Treatment N03.5 ICD10CM mesangiocapillary glomerulonephritis

[N04.0] Nephrotic syndrome with minor glomerular [N03.6] Chronic nephritic syndrome with dense deposit Nephropathy Treatment N04.0 ICD10CM Nephropathy Treatment N03.6 ICD10CM abnormality disease

67 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 68 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

[N04.1] Nephrotic syndrome with focal and segmental [N05.7] Unspecified nephritic syndrome with diffuse Nephropathy Treatment N04.1 ICD10CM Nephropathy Treatment N05.7 ICD10CM glomerular lesions crescentic glomerulonephritis [N05.8] Unspecified nephritic syndrome with other [N04.2] Nephrotic syndrome with diffuse membranous Nephropathy Treatment N05.8 ICD10CM Nephropathy Treatment N04.2 ICD10CM morphologic changes glomerulonephritis [N05.9] Unspecified nephritic syndrome with unspecified Nephropathy Treatment N05.9 ICD10CM morphologic changes [N04.3] Nephrotic syndrome with diffuse mesangial Nephropathy Treatment N04.3 ICD10CM proliferative glomerulonephritis [N06.0] Isolated proteinuria with minor glomerular Nephropathy Treatment N06.0 ICD10CM abnormality [N04.4] Nephrotic syndrome with diffuse endocapillary Nephropathy Treatment N04.4 ICD10CM [N06.1] Isolated proteinuria with focal and segmental proliferative glomerulonephritis Nephropathy Treatment N06.1 ICD10CM glomerular lesions

[N04.5] Nephrotic syndrome with diffuse mesangiocapillary [N06.2] Isolated proteinuria with diffuse membranous Nephropathy Treatment N04.5 ICD10CM Nephropathy Treatment N06.2 ICD10CM glomerulonephritis glomerulonephritis [N06.3] Isolated proteinuria with diffuse mesangial Nephropathy Treatment N06.3 ICD10CM Nephropathy Treatment N04.6 [N04.6] Nephrotic syndrome with dense deposit disease ICD10CM proliferative glomerulonephritis [N06.4] Isolated proteinuria with diffuse endocapillary Nephropathy Treatment N06.4 ICD10CM [N04.7] Nephrotic syndrome with diffuse crescentic proliferative glomerulonephritis Nephropathy Treatment N04.7 ICD10CM glomerulonephritis [N06.5] Isolated proteinuria with diffuse mesangiocapillary Nephropathy Treatment N06.5 ICD10CM glomerulonephritis [N04.8] Nephrotic syndrome with other morphologic Nephropathy Treatment N04.8 ICD10CM changes Nephropathy Treatment N06.6 [N06.6] Isolated proteinuria with dense deposit disease ICD10CM [N06.7] Isolated proteinuria with diffuse crescentic Nephropathy Treatment N06.7 ICD10CM [N04.9] Nephrotic syndrome with unspecified morphologic glomerulonephritis Nephropathy Treatment N04.9 ICD10CM changes Nephropathy Treatment N06.8 [N06.8] Isolated proteinuria with other morphologic lesion ICD10CM [N05.0] Unspecified nephritic syndrome with minor [N06.9] Isolated proteinuria with unspecified morphologic Nephropathy Treatment N05.0 ICD10CM Nephropathy Treatment N06.9 ICD10CM glomerular abnormality lesion [N07.0] Hereditary nephropathy, not elsewhere classified [N05.1] Unspecified nephritic syndrome with focal and Nephropathy Treatment N07.0 ICD10CM Nephropathy Treatment N05.1 ICD10CM with minor glomerular abnormality segmental glomerular lesions [N07.1] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N07.1 ICD10CM [N05.2] Unspecified nephritic syndrome with diffuse with focal and segmental glomerular lesions Nephropathy Treatment N05.2 ICD10CM membranous glomerulonephritis [N07.2] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N07.2 ICD10CM with diffuse membranous glomerulonephritis [N05.3] Unspecified nephritic syndrome with diffuse Nephropathy Treatment N05.3 ICD10CM [N07.3] Hereditary nephropathy, not elsewhere classified mesangial proliferative glomerulonephritis Nephropathy Treatment N07.3 ICD10CM with diffuse mesangial proliferative glomerulonephritis [N05.4] Unspecified nephritic syndrome with diffuse [N07.4] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N05.4 ICD10CM Nephropathy Treatment N07.4 ICD10CM endocapillary proliferative glomerulonephritis with diffuse endocapillary proliferative glomerulonephritis [N07.5] Hereditary nephropathy, not elsewhere classified [N05.5] Unspecified nephritic syndrome with diffuse Nephropathy Treatment N07.5 ICD10CM Nephropathy Treatment N05.5 ICD10CM with diffuse mesangiocapillary glomerulonephritis mesangiocapillary glomerulonephritis

[N05.6] Unspecified nephritic syndrome with dense deposit [N07.6] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N05.6 ICD10CM Nephropathy Treatment N07.6 ICD10CM disease with dense deposit disease

69 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 70 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

[N07.7] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N26.1 [N26.1] Atrophy of kidney (terminal) ICD10CM Nephropathy Treatment N07.7 ICD10CM with diffuse crescentic glomerulonephritis Nephropathy Treatment N26.2 [N26.2] Page kidney ICD10CM [N07.8] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment N07.8 ICD10CM with other morphologic lesions Nephropathy Treatment N26.9 [N26.9] Renal sclerosis, unspecified ICD10CM [N07.9] Hereditary nephropathy, not elsewhere classified Nephropathy Treatment Q60.0 [Q60.0] Renal agenesis, unilateral ICD10CM Nephropathy Treatment N07.9 ICD10CM with unspecified morphologic lesions Nephropathy Treatment Q60.1 [Q60.1] Renal agenesis, bilateral ICD10CM N08 [N08] Glomerular disorders in diseases classified elsewhere ICD10CM Nephropathy Treatment Nephropathy Treatment Q60.2 [Q60.2] Renal agenesis, unspecified ICD10CM N14.0 [N14.0] Analgesic nephropathy ICD10CM Nephropathy Treatment Nephropathy Treatment Q60.3 [Q60.3] Renal hypoplasia, unilateral ICD10CM [N14.1] Nephropathy induced by other drugs, medicaments Nephropathy Treatment N14.1 ICD10CM Nephropathy Treatment Q60.4 [Q60.4] Renal hypoplasia, bilateral ICD10CM and biological substances Q60.5 [Q60.5] Renal hypoplasia, unspecified ICD10CM [N14.2] Nephropathy induced by unspecified drug, Nephropathy Treatment Nephropathy Treatment N14.2 ICD10CM medicament or biological substance Nephropathy Treatment Q60.6 [Q60.6] Potter's syndrome ICD10CM Nephropathy Treatment N14.3 [N14.3] Nephropathy induced by heavy metals ICD10CM Nephropathy Treatment Q61.00 [Q61.00] Congenital renal cyst, unspecified ICD10CM Nephropathy Treatment N14.4 [N14.4] Toxic nephropathy, not elsewhere classified ICD10CM Nephropathy Treatment Q61.01 [Q61.01] Congenital single renal cyst ICD10CM Nephropathy Treatment N17.0 [N17.0] Acute kidney failure with tubular necrosis ICD10CM Nephropathy Treatment Q61.02 [Q61.02] Congenital multiple renal cysts ICD10CM Nephropathy Treatment N17.1 [N17.1] Acute kidney failure with acute cortical necrosis ICD10CM Nephropathy Treatment Q61.11 [Q61.11] Cystic dilatation of collecting ducts ICD10CM Nephropathy Treatment N17.2 [N17.2] Acute kidney failure with medullary necrosis ICD10CM Nephropathy Treatment Q61.19 [Q61.19] Other polycystic kidney, infantile type ICD10CM Nephropathy Treatment N17.8 [N17.8] Other acute kidney failure ICD10CM Nephropathy Treatment Q61.2 [Q61.2] Polycystic kidney, adult type ICD10CM Nephropathy Treatment N17.9 [N17.9] Acute kidney failure, unspecified ICD10CM Nephropathy Treatment Q61.3 [Q61.3] Polycystic kidney, unspecified ICD10CM Nephropathy Treatment N18.1 [N18.1] Chronic kidney disease, stage 1 ICD10CM Nephropathy Treatment Q61.4 [Q61.4] Renal dysplasia ICD10CM Nephropathy Treatment N18.2 [N18.2] Chronic kidney disease, stage 2 (mild) ICD10CM Nephropathy Treatment Q61.5 [Q61.5] Medullary cystic kidney ICD10CM Nephropathy Treatment N18.3 [N18.3] Chronic kidney disease, stage 3 (moderate) ICD10CM Nephropathy Treatment Q61.8 [Q61.8] Other cystic kidney diseases ICD10CM Nephropathy Treatment N18.4 [N18.4] Chronic kidney disease, stage 4 (severe) ICD10CM Nephropathy Treatment Q61.9 [Q61.9] Cystic kidney disease, unspecified ICD10CM Nephropathy Treatment N18.5 [N18.5] Chronic kidney disease, stage 5 ICD10CM Nephropathy Treatment R80.0 [R80.0] Isolated proteinuria ICD10CM Nephropathy Treatment N18.6 [N18.6] End stage renal disease ICD10CM Nephropathy Treatment R80.1 [R80.1] Persistent proteinuria, unspecified ICD10CM Nephropathy Treatment N18.9 [N18.9] Chronic kidney disease, unspecified ICD10CM Nephropathy Treatment R80.2 [R80.2] Orthostatic proteinuria, unspecified ICD10CM Nephropathy Treatment N19 [N19] Unspecified kidney failure ICD10CM Nephropathy Treatment R80.3 [R80.3] Bence Jones proteinuria ICD10CM Nephropathy Treatment N25.0 [N25.0] Renal osteodystrophy ICD10CM Nephropathy Treatment R80.8 [R80.8] Other proteinuria ICD10CM Nephropathy Treatment N25.1 [N25.1] Nephrogenic diabetes insipidus ICD10CM Nephropathy Treatment R80.9 [R80.9] Proteinuria, unspecified ICD10CM Nephropathy Treatment N25.81 [N25.81] Secondary hyperparathyroidism of renal origin ICD10CM Nephropathy Treatment 250.40 DMII renl nt st uncntrld ICD9CM [N25.89] Other disorders resulting from impaired renal Nephropathy Treatment N25.89 ICD10CM Nephropathy Treatment 250.41 DMI renl nt st uncntrld ICD9CM tubular function Nephropathy Treatment 250.42 DMII renal uncntrld ICD9CM [N25.9] Disorder resulting from impaired renal tubular Nephropathy Treatment N25.9 ICD10CM Nephropathy Treatment 250.43 DMI renal uncntrld ICD9CM function, unspecified Nephropathy Treatment 403.00 Mal hy kid w cr kid I-IV ICD9CM

71 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 72 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Nephropathy Treatment 403.01 Mal hyp kid w cr kid V ICD9CM Nephropathy Treatment 582.0 Chr proliferat nephritis ICD9CM Nephropathy Treatment 403.10 Ben hy kid w cr kid I-IV ICD9CM Nephropathy Treatment 582.1 Chr membranous nephritis ICD9CM Nephropathy Treatment 403.11 Ben hyp kid w cr kid V ICD9CM Nephropathy Treatment 582.2 Chr membranoprolif nephr ICD9CM Nephropathy Treatment 403.90 Hy kid NOS w cr kid I-IV ICD9CM Nephropathy Treatment 582.4 Chr rapid progr nephrit ICD9CM Nephropathy Treatment 403.91 Hyp kid NOS w cr kid V ICD9CM Nephropathy Treatment 582.81 Chr nephritis in oth dis ICD9CM Nephropathy Treatment 404.00 Mal hy ht/kd I-IV w/o hf ICD9CM Nephropathy Treatment 582.89 Chronic nephritis NEC ICD9CM Nephropathy Treatment 404.01 Mal hyp ht/kd I-IV w hf ICD9CM Nephropathy Treatment 582.9 Chronic nephritis NOS ICD9CM Nephropathy Treatment 404.02 Mal hy ht/kd st V w/o hf ICD9CM Nephropathy Treatment 583.0 Proliferat nephritis NOS ICD9CM Nephropathy Treatment 404.03 Mal hyp ht/kd stg V w hf ICD9CM Nephropathy Treatment 583.1 Membranous nephritis NOS ICD9CM Nephropathy Treatment 404.10 Ben hy ht/kd I-IV w/o hf ICD9CM Nephropathy Treatment 583.2 Membranoprolif nephr NOS ICD9CM Nephropathy Treatment 404.11 Ben hyp ht/kd I-IV w hf ICD9CM Nephropathy Treatment 583.4 Rapidly prog nephrit NOS ICD9CM Nephropathy Treatment 404.12 Ben hy ht/kd st V w/o hf ICD9CM Nephropathy Treatment 583.6 Renal cort necrosis NOS ICD9CM Nephropathy Treatment 404.13 Ben hyp ht/kd stg V w hf ICD9CM Nephropathy Treatment 583.7 Nephr NOS/medull necros ICD9CM Nephropathy Treatment 404.90 Hy ht/kd NOS I-IV w/o hf ICD9CM Nephropathy Treatment 583.81 Nephritis NOS in oth dis ICD9CM Nephropathy Treatment 404.91 Hyp ht/kd NOS I-IV w hf ICD9CM Nephropathy Treatment 583.89 Nephritis NEC ICD9CM Nephropathy Treatment 404.92 Hy ht/kd NOS st V w/o hf ICD9CM Nephropathy Treatment 583.9 Nephritis NOS ICD9CM Nephropathy Treatment 404.93 Hyp ht/kd NOS st V w hf ICD9CM Nephropathy Treatment 584.5 Ac kidny fail, tubr necr ICD9CM Nephropathy Treatment 405.01 Mal renovasc hypertens ICD9CM Nephropathy Treatment 584.6 Ac kidny fail, cort necr ICD9CM Nephropathy Treatment 405.11 Benign renovasc hyperten ICD9CM Nephropathy Treatment 584.7 Ac kidny fail, medu necr ICD9CM Nephropathy Treatment 405.91 Renovasc hypertension ICD9CM Nephropathy Treatment 584.8 Acute kidney failure NEC ICD9CM Nephropathy Treatment 580.0 Ac proliferat nephritis ICD9CM Nephropathy Treatment 584.9 Acute kidney failure NOS ICD9CM Nephropathy Treatment 580.4 Ac rapidly progr nephrit ICD9CM Nephropathy Treatment 585.1 Chro kidney dis stage I ICD9CM Nephropathy Treatment 580.81 Ac nephritis in oth dis ICD9CM Nephropathy Treatment 585.2 Chro kidney dis stage II ICD9CM Nephropathy Treatment 580.89 Acute nephritis NEC ICD9CM Nephropathy Treatment 585.3 Chr kidney dis stage III ICD9CM Nephropathy Treatment 580.9 Acute nephritis NOS ICD9CM Nephropathy Treatment 585.9 Chronic kidney dis NOS ICD9CM Nephropathy Treatment 581.0 Nephrotic syn, prolifer ICD9CM Nephropathy Treatment 586 Renal failure NOS ICD9CM Nephropathy Treatment 581.1 Epimembranous nephritis ICD9CM Nephropathy Treatment 587 Renal sclerosis NOS ICD9CM Nephropathy Treatment 581.2 Membranoprolif nephrosis ICD9CM Nephropathy Treatment 588.0 Renal osteodystrophy ICD9CM Nephropathy Treatment 581.3 Minimal change nephrosis ICD9CM Nephropathy Treatment 588.1 Nephrogen diabetes insip ICD9CM Nephropathy Treatment 581.81 Nephrotic syn in oth dis ICD9CM Nephropathy Treatment 588.81 Sec hyperparathyrd-renal ICD9CM Nephropathy Treatment 581.89 Nephrotic syndrome NEC ICD9CM Nephropathy Treatment 588.89 Impair ren funct dis NEC ICD9CM Nephropathy Treatment 581.9 Nephrotic syndrome NOS ICD9CM Nephropathy Treatment 588.9 Impaired renal funct NOS ICD9CM

73 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 74 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Nephropathy Treatment 753.0 Renal agenesis ICD9CM Urine Protein Tests 3061F CPT Nephropathy Treatment 753.10 Cystic kidney diseas NOS ICD9CM Urine Protein Tests 3062F CPT Nephropathy Treatment 753.11 Congenital renal cyst ICD9CM Urine Protein Tests 11218-5 Microalbumin [Mass/volume] in Urine by Test strip LOINC Nephropathy Treatment 753.12 Polycystic kidney NOS ICD9CM Urine Protein Tests 12842-1 Protein [Mass/volume] in 12 hour Urine LOINC Nephropathy Treatment 753.13 Polycyst kid-autosom dom ICD9CM Urine Protein Tests 13705-9 Albumin/Creatinine [Mass Ratio] in 24 hour Urine LOINC Nephropathy Treatment 753.14 Polycyst kid-autosom rec ICD9CM Urine Protein Tests 13801-6 Protein/Creatinine [Mass Ratio] in 24 hour Urine LOINC Nephropathy Treatment 753.15 Renal dysplasia ICD9CM Urine Protein Tests 14585-4 Albumin/Creatinine [Molar ratio] in Urine LOINC Nephropathy Treatment 753.16 Medullary cystic kidney ICD9CM Urine Protein Tests 14956-7 Microalbumin [Mass/time] in 24 hour Urine LOINC Nephropathy Treatment 753.17 Medullary sponge kidney ICD9CM Urine Protein Tests 14957-5 Microalbumin [Mass/volume] in Urine LOINC Nephropathy Treatment 753.19 Cystic kidney diseas NEC ICD9CM Urine Protein Tests 14958-3 Microalbumin/Creatinine [Mass Ratio] in 24 hour Urine LOINC Nephropathy Treatment 791.0 Proteinuria ICD9CM Urine Protein Tests 14959-1 Microalbumin/Creatinine [Mass Ratio] in Urine LOINC [I12.9] Hypertensive chronic kidney disease with stage 1 Urine Protein Tests 1753-3 Albumin [Presence] in Urine LOINC I12.9 through stage 4 chronic kidney disease, or unspecified ICD10CM Stage I-IV Kidney Disease Urine Protein Tests 1754-1 Albumin [Mass/volume] in Urine LOINC chronic kidney disease 1755-8 Albumin [Mass/time] in 24 hour Urine LOINC [I13.10] Hypertensive heart and chronic kidney disease Urine Protein Tests Stage I-IV Kidney Disease I13.10 without heart failure, with stage 1 through stage 4 chronic ICD10CM Urine Protein Tests 1757-4 Albumin renal clearance in 24 hour LOINC kidney disease, or unspecified chronic kidney disease Urine Protein Tests 18373-1 Protein [Mass/time] in 6 hour Urine LOINC Stage I-IV Kidney Disease 403.00 Mal hy kid w cr kid I-IV ICD9CM Urine Protein Tests 20454-5 Protein [Presence] in Urine by Test strip LOINC Stage I-IV Kidney Disease 403.10 Ben hy kid w cr kid I-IV ICD9CM Urine Protein Tests 20621-9 Albumin/Creatinine [Presence] in Urine by Test strip LOINC Stage I-IV Kidney Disease 403.90 Hy kid NOS w cr kid I-IV ICD9CM Urine Protein Tests 21059-1 Albumin [Mass/volume] in 24 hour Urine LOINC Stage I-IV Kidney Disease 404.00 Mal hy ht/kd I-IV w/o hf ICD9CM Urine Protein Tests 21482-5 Protein [Mass/volume] in 24 hour Urine LOINC Stage I-IV Kidney Disease 404.10 Ben hy ht/kd I-IV w/o hf ICD9CM Urine Protein Tests 26801-1 Protein [Mass/time] in 12 hour Urine LOINC Stage I-IV Kidney Disease 404.90 Hy ht/kd NOS I-IV w/o hf ICD9CM Urine Protein Tests 27298-9 Protein [Units/volume] in Urine LOINC Stage I-IV Kidney Disease 483.0 Pneu mycplsm pneumoniae ICD9CM Urine Protein Tests 2887-8 Protein [Presence] in Urine LOINC Urine Protein Tests 81000 CPT Urine Protein Tests 2888-6 Protein [Mass/volume] in Urine LOINC Urine Protein Tests 81001 CPT Urine Protein Tests 2889-4 Protein [Mass/time] in 24 hour Urine LOINC Urine Protein Tests 81002 CPT Urine Protein Tests 2890-2 Protein/Creatinine [Mass Ratio] in Urine LOINC Urine Protein Tests 81003 CPT Urine Protein Tests 30000-4 Microalbumin/Creatinine [Ratio] in Urine LOINC Urine Protein Tests 81005 CPT Urine Protein Tests 30001-2 Microalbumin/Creatinine [Ratio] in Urine by Test strip LOINC Urine Protein Tests 82042 CPT Urine Protein Tests 30003-8 Microalbumin [Mass/volume] in 24 hour Urine LOINC Urine Protein Tests 82043 CPT Urine Protein Tests 32209-9 Protein [Presence] in 24 hour Urine by Test strip LOINC Urine Protein Tests 82044 CPT Urine Protein Tests 32294-1 Albumin/Creatinine [Ratio] in Urine LOINC Urine Protein Tests 84156 CPT Urine Protein Tests 3060F CPT Urine Protein Tests 32551-4 Protein [Mass] in Urine collected for unspecified duration LOINC

75 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 76 [ appendix VI - diabetes care - monitoring [ appendix VI - diabetes care - monitoring for kidney disease ] for kidney disease ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

Urine Protein Tests 34366-5 Protein/Creatinine [Ratio] in Urine LOINC Albumin [Moles/volume] in Urine by Detection limit <= 3.0 Urine Protein Tests 77158-4 LOINC mg/L Protein [Mass/volume] in Urine collected for unspecified Urine Protein Tests 35663-4 LOINC duration Microalbumin/Creatinine [Ratio] in Urine by Detection limit Urine Protein Tests 77253-3 LOINC <= 1.0 mg/L Urine Protein Tests 40486-3 Protein/Creatinine [Ratio] in 24 hour Urine LOINC Microalbumin/Creatinine [Ratio] in 24 hour Urine by Urine Protein Tests 77254-1 LOINC Urine Protein Tests 40662-9 Protein [Mass/time] in 12 hour Urine --resting LOINC Detection limit <= 1.0 mg/L Urine Protein Tests 40663-7 Protein [Mass/time] in 12 hour Urine --upright LOINC Urine Protein Tests 9318-7 Albumin/Creatinine [Mass Ratio] in Urine LOINC Urine Protein Tests 43605-5 Microalbumin [Mass/volume] in 4 hour Urine LOINC Urine Protein Tests 43606-3 Microalbumin [Mass/time] in 4 hour Urine LOINC Urine Protein Tests 43607-1 Microalbumin [Mass/time] in 12 hour Urine LOINC Urine Protein Tests 44292-1 Microalbumin/Creatinine [Mass Ratio] in 12 hour Urine LOINC Urine Protein Tests 47558-2 Microalbumin/Protein.total in 24 hour Urine LOINC Microalbumin [Mass/time] in Urine collected for unspecified Urine Protein Tests 49023-5 LOINC duration Urine Protein Tests 50561-0 Protein [Mass/volume] in Urine by Automated test strip LOINC Urine Protein Tests 50949-7 Albumin [Presence] in Urine by Test strip LOINC Urine Protein Tests 53121-0 Protein [Mass/time] in 1 hour Urine LOINC Urine Protein Tests 53525-2 Protein [Presence] in Urine by SSA method LOINC Microalbumin [Mass/volume] in 24 hour Urine by Detection Urine Protein Tests 53530-2 LOINC limit <= 1.0 mg/L Microalbumin [Mass/volume] in Urine by Detection limit <= Urine Protein Tests 53531-0 LOINC 1.0 mg/L Microalbumin [Mass/time] in 24 hour Urine by Detection Urine Protein Tests 53532-8 LOINC limit <= 1.0 mg/L Urine Protein Tests 56553-1 Microalbumin [Mass/time] in 8 hour Urine LOINC Urine Protein Tests 57369-1 Microalbumin [Mass/volume] in 12 hour Urine LOINC Urine Protein Tests 57735-3 Protein [Presence] in Urine by Automated test strip LOINC Urine Protein Tests 5804-0 Protein [Mass/volume] in Urine by Test strip LOINC Urine Protein Tests 58448-2 Microalbumin ug/min [Mass/time] in 24 hour Urine LOINC Urine Protein Tests 58992-9 Protein [Mass/time] in 18 hour Urine LOINC Urine Protein Tests 59159-4 Microalbumin/Creatinine [Ratio] in 24 hour Urine LOINC Urine Protein Tests 60678-0 Protein/Creatinine [Mass Ratio] in 12 hour Urine LOINC Urine Protein Tests 63474-1 Microalbumin [Mass/time] in 18 hour Urine LOINC

Urine Protein Tests 76401-9 Albumin/Creatinine [Ratio] in 24 hour Urine LOINC

77 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 78 [ appendix VII - pediatric BMI codes ] [ appendix VIII - pediatric nutrition counseling ]

Code Code Value Set Name Code Definition Value Set Name Code Definition System System

BMI Z68.52 th percentile to less than 85th percentile for age ICD-10-CM Nutrition Counseling 97802 CPT BMI Z68.53 85th percentile to less than 95th percentile for age ICD-10-CM Nutrition Counseling 97803 CPT BMI Z68.54 greater than or equal to 95th percentile for age ICD-10-CM Nutrition Counseling 97804 CPT Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment Nutrition Counseling G0270 HCPCS regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes (G0270) Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment Nutrition Counseling G0271 HCPCS regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes (G0271) Face-to-face behavioral counseling for obesity, 15 minutes Nutrition Counseling G0447 HCPCS (G0447) Weight management classes, non-physician provider, per Nutrition Counseling S9449 HCPCS session (S9449) Nutrition classes, non-physician provider, per session Nutrition Counseling S9452 HCPCS (S9452) Nutrition Counseling S9470 Nutritional counseling, dietitian visit (S9470) HCPCS Nutrition Counseling Z71.3 [Z71.3] Dietary counseling and surveillance ICD10CM Nutrition Counseling V65.3 Dietary surveil/counsel ICD9CM

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