Description:  

The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN 

practitioner during the measurement year.


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.


References:  

  • Refer to Appendix 3 for the definition of PCP and OB/GYN and other prenatal care practitioners.
  • 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-care visits.


Denominator:  

Product lines
Commercial, Medicaid (report each product line separately).
Ages
12–21 years as of December 31 of the measurement year.
Continuous enrollment
The measurement year.
Allowable gap
Members who have had no more than one gap in enrollment of up to 45 days during the measurement year. 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
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.



Denominator Exclusions (when applicable):  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 replaced by a member from the oversample. Refer to General Guideline 20: Members in Hospice.


Numerator:  

At least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year, as documented through either administrative data or medical record review. The PCP does not have to be assigned to the member.
Refer to Administrative Specification to identify positive numerator hits from the administrative data.
Documentation in the medical record must include a note indicating a visit to a PCP or OB/GYN practitioner, the date when the well-care 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.

Visits to school-based clinics with practitioners whom the organization would consider PCPs may be counted if documentation that a well-care exam occurred is available in the medical record or administrative system in the time frame specified by the measure. The PCP does not have to be assigned to the member.

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