Description:


The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP 

during their first 15 months of life:

  • No well-child visits.
  • One well-child visit.
  • Two well-child visits.
  • Three well-child visits.
  • Four well-child visits.
  • Five well-child visits.
  • Six or more well-child visits.


Note 

  • This measure has the same structure as measures in the Effectiveness of Care domain. 

          The organization must follow the Guidelines for Effectiveness of Care Measures when calculating this measure. 

  • Only the Administrative Method of data collection may be used when reporting this measure for the commercial population.


Denominator:  


Product lines
Commercial, Medicaid (report each product line separately).
Age
15 months old during the measurement year.
Continuous enrollment
31 days–15 months of age. Calculate 31 days of age by adding 31 days to the child’s date of birth. Calculate the 15-month birthday as the child’s first birthday plus 90 days. For example, a child born on January 9, 2015, turns 15 months old on April 9, 2016.
Allowable gap
No more than one gap in enrollment of up to 45 days during the continuous enrollment period. To determine continuous enrollment for a Medicaid member for whom enrollment is verified monthly the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled).
Anchor date
Day the child turns 15 months old.
Benefit
Medical.
Event/diagnosis
None.


Denominator Exclusions (when applicable):   Note: Members in hospice are excluded from the eligible population. 

If an organization reports this measure for the Medicaid product line using the Hybrid method, and a member is found to

be in hospice or using hospice services during medical record review, the member is removed from the sample and 

eplaced by a member from the oversample. Refer to General Guideline 20: Members in Hospice.


Numerator:  

Seven separate numerators are calculated, corresponding to the number of members who had 0, 1, 2, 3, 4, 5, 6 or more complete well-child visits, on different dates of service, with a PCP during their first 15 months of life.

The well-child visit must occur with a PCP. but the PCP does not have to be the practitioner assigned to the child.

Administrative

Refer to Administrative Specification to identify positive numerator hits from administrative data.
Documentation from the medical record must include a note indicating a visit with a PCP, the date when the well-child visit occurred and evidence of all of the following:
  • A health history.
  • A physical developmental history.
  • A mental developmental history.
  • A physical exam.
  • Health education/anticipatory guidance.
Do not include services rendered during an inpatient or ED visit.

Preventive services may be rendered on visits other than well-child visits. Well-child preventive services count toward the measure, regardless of the primary intent of the visit, but services that are specific to the assessment or treatment of an acute or chronic condition do not count toward the measure.

The organization may count services that occur over multiple visits, as long as all services occur in the time frame specified by the measure.


References:

  • Refer to Appendix 3 for the definition of PCP.
  • This measure is based on the CMS and American Academy of Pediatrics guidelines for EPSDT visits. Refer to the 

            American Academy of Pediatrics Guidelines for Health Supervision at www.aap.org and Bright Futures: Guidelines 

            for Health Supervision of Infants, Children and Adolescents (published by the National Center for Education in Maternal

            and Child Health) at www.Brightfutures.org for more information about well-child visits.