**Clinical Reporting System (CRS) Version 5.0 (2005) Patch 1**

**Indicator List and Definitions, as of January 26, 2005**

The following indicators will be reported in the Clinical Reporting
System (CRS) **2005 National GPRA report**. Indicators marked with an
asterisk (\*) will not be reported in the *IHS Annual Report to
Congress* but are included for agency use. Definitions for all indicator
topics included in CRS follow below.

**DIABETES GROUP**

\*Diabetes DX Ever

\*Documented HbA1c

Poor Glycemic Control

Good (ideal) Glycemic) Control

\*BP Assessed

Controlled BP

LDL Assessed

Nephropathy Assessed

Retinopathy Exam

\*Depression/Anxiety Screen

\*Influenza Vaccine

\*Pneumovax

Dental Access Diabetes

**DENTAL GROUP**

Dental Access General

Dental Sealants

**IMMUNIZATIONS**

Influenza Vaccine 65+

Pneumovax 65+

Childhood Immunizations (4:3:1:3:3)

**CANCER SCREENING**

Pap Smear Rates

Mammogram Rates

\*Colorectal Cancer Screen

Tobacco Assessment

\*Tobacco Use Prevalence

**BEHAVIORAL HEALTH**

FAS Prevention

DV/IPV Screen 15-40

**CARDIOVASCULAR DISEASE-RELATED**

Obesity Assessment

\*Assessed as Obese

CVD and Cholesterol Screening

**OTHER CLINICAL**

Prenatal HIV Testing

Public Health Nursing

**DENOMINATOR DEFINITIONS**

-   ***Active Clinical Population for National GPRA Reporting***

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-   Must have two visits to medical clinics in the past three years.  At
    least one visit must be to a core medical clinic.  Refer to the CRS
    2005 User Manual for listing of these clinics.

> •        Must be alive on the last day of the Report period.
>
> •        Must be American Indian/Alaska Native (AI/AN) (defined as
> Beneficiary 01).
>
> •        Must reside in a community specified in the site's GPRA
> community taxonomy, defined as all communities of residence in the
> defined CHS catchment area.

-   ***Active Clinical Population for Local Reports***

> •        Must have two visits to medical clinics in the past three
> years.  At least one visit must be to a core medical clinic.  Refer to
> the CRS 2005 User Manual for listing of these clinics.
>
> •        Must be alive on the last day of the Report period.
>
> •        User defines population type: AI/AN patients only, non AI/AN
> or both.
>
> •        User defines general population: single community; group of
> multiple communities (community taxonomy); user-defined list of
> patient (patient panel); or all patients regardless of community of
> residence.

-   ***GPRA User Population for Local Reports***

> •        Must have been seen at least once in the three years prior to
> the end of the time period, regardless of the clinic type.
>
> •        Must be alive on the last day of the Report period.
>
> •        User defines population type: AI/AN patients only, non AI/AN
> or both.
>
> •        User defines general population: single community; group of
> multiple communities (community taxonomy); user-defined list of
> patient (patient panel); or all patients regardless of community of
> residence.

+------------------+---------------------------------------------------+
| **Indicator      | **General Definition**                            |
| Topic Name and   |                                                   |
| Owner/Contact**  | **(NOTE: *Bold italic type*** indicates new or    |
|                  | edited definitions**)**                           |
+==================+===================================================+
| **DIABETES       |                                                   |
| GROUP**          |                                                   |
+------------------+---------------------------------------------------+
| Diabetes         | **No changes from 2004.**                         |
| Prevalence       |                                                   |
|                  | **Denominator:** User Population patients.        |
| Diabetes         |                                                   |
| Program/ Dr.     | **Numerators:** 1) Anyone diagnosed with diabetes |
| Charlton Wilson  | (POV 250.00-250.93) ever.                         |
|                  |                                                   |
|                  | 2\) Anyone diagnosed with diabetes during the     |
|                  | Report period.                                    |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes.                                         |
+------------------+---------------------------------------------------+
| ***Diabetes      | ***New indicator topic for 2005.***               |
| Comprehensive    |                                                   |
| Care***          | ***Denominator: [Active Diabetic                  |
|                  | patients]{.underline}, defined as all Active      |
| ***Diabetes      | Clinical patients diagnosed with diabetes (POV    |
| Program/ Dr.     | 250.00-250.93) at least one year prior to the     |
| Charlton         | Report period, AND at least 2 visits in the past  |
| Wilson***        | year, AND 2 DM-related visits ever.***            |
|                  |                                                   |
|                  | ***Numerators: 1) Patients with Hemoglobin A1c    |
|                  | documented during the Report Period, regardless   |
|                  | of result.***                                     |
|                  |                                                   |
|                  | ***2) Patients with Blood Pressure documented     |
|                  | during the Report Period.***                      |
|                  |                                                   |
|                  | ***3) Patients with LDL completed during the      |
|                  | Report Period, regardless of result.***           |
|                  |                                                   |
|                  | ***4) Patients with positive urine protein test   |
|                  | or, if urine protein test is negative, any        |
|                  | microalbuminuria test, regardless of result,      |
|                  | during the Report period (changed from Version    |
|                  | 5.0, which required one of these tests AND an     |
|                  | Estimated GFR).***                                |
|                  |                                                   |
|                  | ***5) Patients receiving any retinal screening    |
|                  | during the Report Period, or a documented refusal |
|                  | of a diabetic eye exam.***                        |
|                  |                                                   |
|                  | ***6) Patients with HbA1c AND Blood Pressure AND  |
|                  | LDL AND Nephropathy Assessment AND Retinal        |
|                  | exam.***                                          |
|                  |                                                   |
|                  | ***Definitions: For specific definitions, refer   |
|                  | to the following topics below: Diabetes: Poor and |
|                  | Ideal Control; Diabetes: Blood Pressure Control;  |
|                  | Diabetes: Dyslipidemia Assessment; Diabetes:      |
|                  | Nephropathy Assessment; Diabetic Retinopathy.***  |
|                  |                                                   |
|                  | ***Patient List: List of diabetic patients with   |
|                  | documented tests, if any.***                      |
+------------------+---------------------------------------------------+
| Diabetes: Poor   | **No changes from 2004.**                         |
| Glycemic Control |                                                   |
|                  | **Denominators:** 1) **GPRA:** [Active Diabetic   |
| Diabetes: Ideal  | patients]{.underline}; defined as all Active      |
| Glycemic Control | Clinical patients diagnosed with diabetes (POV    |
|                  | 250.00-250.93) at least one year prior to the     |
| Diabetes         | Report period, AND at least 2 visits in the past  |
| Program/ Dr.     | year, AND 2 DM-related visits ever. Key           |
| Charlton Wilson  | denominator for this and all diabetes-related     |
|                  | topics below.                                     |
|                  |                                                   |
|                  | 2\) All GPRA User Population patients diagnosed   |
|                  | with diabetes prior to the Report Period.         |
|                  |                                                   |
|                  | 3\) Active Adult Diabetic patients, defined by    |
|                  | meeting the following criteria: 1) who are 19 or  |
|                  | older at the beginning of the Report period, 2)   |
|                  | whose first ever DM diagnosis occurred prior to   |
|                  | the Report Period; 3) who had at least 2 DM       |
|                  | related visits ever, 4) at least one encounter    |
|                  | with DM POV in a primary clinic with a primary    |
|                  | provider during the Report Period; and 5) never   |
|                  | have had a creatinine value greater than 5.       |
|                  |                                                   |
|                  | **Numerators:**                                   |
|                  |                                                   |
|                  | 1\) **GPRA:** HgA1c documented during the Report  |
|                  | period.\                                          |
|                  | 2) **GPRA:** [Poor control]{.underline} greater   |
|                  | than (\>) 9.5\                                    |
|                  | 3) [Fair control]{.underline} HgA1c equals or     |
|                  | greater than (=\>) 8 and less than or equal to    |
|                  | (\<=) 9.5**\                                      |
|                  | **4) [Good control]{.underline} HgA1c equals or   |
|                  | greater than (=\>) 7 and less than (\<) 8\        |
|                  | 5) **GPRA:** [Ideal control]{.underline} HgA1c    |
|                  | less than (\<) 7\                                 |
|                  | 6) Undetermined HgA1c (no result)                 |
|                  |                                                   |
|                  | **Definitions:**                                  |
|                  |                                                   |
|                  | 1\) **HgA1c:** CPT 83036, LOINC taxonomy or       |
|                  | site-defined taxonomy DM AUDIT HGB A1C TAX.       |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes, with date and value of HgA1c, if any.   |
+------------------+---------------------------------------------------+
| Diabetes: Blood  | **No changes from 2004.**                         |
| Pressure Control |                                                   |
|                  | **Denominators:** Three denominators (see         |
| Diabetes         | Diabetes: Poor Glycemic Control topic above).     |
| Program/ Dr.     |                                                   |
| Charlton Wilson  | **Numerators:** 1) Total with BP value (at least  |
|                  | 2 (3 if available) non-ER BPs documented during   |
|                  | the Report period)\                               |
|                  | 2) **GPRA:** Controlled BP, \< 130/80\            |
|                  | 3) Not controlled BP                              |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes, with mean BP value if any.              |
+------------------+---------------------------------------------------+
| Diabetes: Lipids | **No changes from 2004.**                         |
| Assessment       |                                                   |
|                  | **Denominators:** Three denominators (see         |
| Diabetes         | Diabetes: Poor Glycemic Control topic above).     |
| Program/ Dr.     |                                                   |
| Charlton Wilson  | **Numerators:**                                   |
|                  |                                                   |
|                  | 1\) Documented Lipid Profile OR LDL, HDL and TG   |
|                  | (all three), regardless of result                 |
|                  |                                                   |
|                  | 2\) **GPRA:** Patients with LDL completed,        |
|                  | regardless of result                              |
|                  |                                                   |
|                  | 3\) LDL \< 130; 3A) LDL \<= 100; 3B) LDL 101-129  |
|                  |                                                   |
|                  | **Definitions:** 1) **Lipid Profile:** CPT 80061; |
|                  | LOINC taxonomy; site-defined taxonomy DM AUDIT    |
|                  | LIPID PROFILE TAX. 2) **LDL:** CPT 83721; LOINC   |
|                  | taxonomy; site-defined taxonomy DM AUDIT LDL      |
|                  | CHOLESTEROL TAX. 3) **HDL:** CPT 83718; LOINC     |
|                  | taxonomy; site-defined taxonomy DM AUDIT HDL TAX. |
|                  | 4) **Triglyceride (TG):** CPT 84478; LOINC        |
|                  | taxonomy; site-defined taxonomy DM AUDIT          |
|                  | TRIGLYCERIDE TAX                                  |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes, with date of tests and LDL value, if    |
|                  | any.                                              |
+------------------+---------------------------------------------------+
| Diabetes:        | **Denominators:** Three denominators (see         |
| Nephropathy      | Diabetes: Poor Glycemic Control topic above).     |
| Assessment       |                                                   |
|                  | **Numerators:**                                   |
| Diabetes         |                                                   |
| Program/ Dr.     | 1\) ***GPRA: Patients with positive urine protein |
| Charlton Wilson  | test or, if urine protein test is negative, any   |
|                  | microalbuminuria test, regardless of result,      |
|                  | during the Report period (changed from Version    |
|                  | 5.0, which required one of these tests AND an     |
|                  | Estimated GFR).***                                |
|                  |                                                   |
|                  | 2\) Patients with Estimated GFR with result       |
|                  | during the Report period.                         |
|                  |                                                   |
|                  | ***3) Patients who have had 1) positive urine     |
|                  | protein test or if urine protein was negative,    |
|                  | then microalbuminuria test, regardless of result  |
|                  | AND 2) an Estimated GFR with result during the    |
|                  | Report period.***                                 |
|                  |                                                   |
|                  | **Definitions:** 1) **Urine Protein:** LOINC      |
|                  | taxonomy; site-defined taxonomy DM AUDIT URINE    |
|                  | PROTEIN TAX                                       |
|                  |                                                   |
|                  | 2\) **Microalbuminuria:** CPT codes 82043, 82044; |
|                  | LOINC taxonomy; site-defined taxonomy DM AUDIT    |
|                  | MICROALBUMUNURIA TAX                              |
|                  |                                                   |
|                  | 3\) **Estimated GFR:** Taxonomy BGP ESTIMATED GFR |
|                  | TAX, ***LOINC 33914-3***                          |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes, with date of tests and value, if any.   |
+------------------+---------------------------------------------------+
| Diabetic         | **No changes from 2004.**                         |
| Retinopathy      |                                                   |
|                  | **Denominators:** Three denominators (see         |
| Diabetes         | Diabetes: Poor Glycemic Control topic above).     |
| Program/ Dr.     |                                                   |
| Mark Horton      | **Numerator: GPRA:** Patients receiving any       |
|                  | retinal screening during the Report period or     |
|                  | refusal of a diabetic eye exam. Retinal screening |
|                  | is defined as a diabetic retinal exam or other    |
|                  | eye exam. 1A) Patients receiving or refusing a    |
|                  | diabetic retinal exam. 1B) Patients receiving     |
|                  | other eye exams.                                  |
|                  |                                                   |
|                  | **Definitions:** 1) **Diabetic Eye Exam:** Clinic |
|                  | Code A2 (Diabetic Retinopathy) or Exam Code 03    |
|                  | (Diabetic Eye Exam)                               |
|                  |                                                   |
|                  | 2\) **Other Eye Exam:** Non-DNKA (did not keep    |
|                  | appointment) visits to ophthalmology, optometry,  |
|                  | or tele-ophthalmology retinal screening clinics,  |
|                  | and non-DNKA visits to an optometrist or          |
|                  | ophthalmologist. Searches for the following codes |
|                  | in the following order: Clinic Codes 17, 18, 64;  |
|                  | Provider Code 24, 79, 08; CPT 92250, 92002,       |
|                  | 92004, 92012, 92014, 92015                        |
|                  |                                                   |
|                  | 3\) **Refusal of Diabetic Eye Exam:** Exam Code   |
|                  | 03                                                |
|                  |                                                   |
|                  | **Patient List:** All patients diagnosed with     |
|                  | Diabetes, with date of screening and code, if     |
|                  | any.                                              |
+------------------+---------------------------------------------------+
| Oral Health --   | **Denominator: GPRA:** Active Diabetic patients   |
| Diabetic Access  | (see Diabetes Comprehensive Care above for        |
| to Dental        | definition).                                      |
| Services         |                                                   |
|                  | **Numerators:** 1) **GPRA:** Patients with a      |
| Dental Program/  | documented dental visit during the Report period, |
| Dr. Patrick      | ***including refusals***. ***1A) Patients with    |
| Blahut           | documented refusal during the Report period.***   |
|                  |                                                   |
|                  | **Definitions:** 1) **Dental Visit:** Dental ADA  |
|                  | Code 0000 or 0190, Exam Code 30                   |
|                  |                                                   |
|                  | > ***2) Refusal of Dental Exam: Exam Code 30***   |
|                  |                                                   |
|                  | **Patient List:** All diabetic patients with date |
|                  | of dental visit or refusal and code, if any.      |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
| **DENTAL GROUP** |                                                   |
+------------------+---------------------------------------------------+
| Oral Health --   | **Denominator: GPRA:** GPRA User Population       |
| Access to Dental | patients.                                         |
| Services         |                                                   |
|                  | **Numerators:** 1) **GPRA:** Patients with        |
| Dental Program/  | documented dental visit during the Report period, |
| Dr. Patrick      | ***including refusals.*** ***1A) Patients with    |
| Blahut           | documented refusal.***                            |
|                  |                                                   |
|                  | **Definitions:** 1) **Dental Visit:** Dental ADA  |
|                  | Code 0000 or 0190, Exam Code 30                   |
|                  |                                                   |
|                  | > ***2) Refusal of Dental Exam: Exam Code 30***   |
|                  |                                                   |
|                  | **Patient List:** Patients with documented dental |
|                  | visit or refusal, with date and code.             |
+------------------+---------------------------------------------------+
| Oral Health --   | **No changes from 2004.**                         |
| Dental Sealants  |                                                   |
|                  | **GPRA:** Count only (no percentage comparison to |
| Dental Program/  | denominator). Total number of dental sealants     |
| Dr. Patrick      | during the Report period. Age breakouts (HP       |
| Blahut           | 2010): \<12; 12-18; \>18.                         |
|                  |                                                   |
|                  | **Definitions: Dental Sealant:** ADA Code 1351    |
|                  |                                                   |
|                  | **Patient List:** Patients who had sealants and   |
|                  | the number of sealants received.                  |
+------------------+---------------------------------------------------+
| **IMMUNIZATION   |                                                   |
| GROUP**          |                                                   |
+------------------+---------------------------------------------------+
| Adult            | **Denominators:** 1) Active Clinical patients     |
| Immunizations:   | ages 50 or older. 1A) Ages 50-64.\                |
| Influenza        | 1B) **GPRA:** Ages 65 and older.                  |
|                  |                                                   |
| Epi Program/ Amy | 2\) Active Diabetic patients (see Diabetes        |
| Groom, MPH       | Comprehensive Care above for definition).         |
|                  |                                                   |
|                  | **Numerators:** 1) Patients with influenza        |
|                  | vaccine documented during the Report period or    |
|                  | with documented refusal.                          |
|                  |                                                   |
|                  | ***2) Documented patient refusals (REF) or not    |
|                  | medically indicated (NMI).***                     |
|                  |                                                   |
|                  | **Definitions:** 1) **Influenza Vaccine:**        |
|                  | Immunization/CVX codes 15, 16, 88, or 111; POV    |
|                  | V04.8, V04.81, V06.6; CPT 90655, ***90656,***     |
|                  | 90657-90660, 90724; ICD Procedure 99.52           |
|                  |                                                   |
|                  | > 2\) **Refusal of Influenza Vaccine:**           |
|                  | > Immunization/CVX codes: 15, 16, 88, or 111      |
|                  |                                                   |
|                  | **Patient List:** Patients ages 50 or older OR    |
|                  | with diabetes diagnosis, with date of vaccine and |
|                  | code, if any.                                     |
+------------------+---------------------------------------------------+
| Adult            | **Denominators:** 1) **GPRA:** Active Clinical    |
| Immunizations:   | patients ages 65 or older.                        |
| Pneumococcal     |                                                   |
|                  | 2\) Active Diabetic patients (see Diabetes        |
| Epi Program/ Amy | Comprehensive Care above for definition).         |
| Groom, MPH       |                                                   |
|                  | **Numerators:** 1) Patients with pneumovax        |
|                  | documented ever or who have refused a pneumovax   |
|                  | vaccine in the past year.                         |
|                  |                                                   |
|                  | 1A) **For Active Diabetics denominator only.**    |
|                  | Patients with pneumovax documented in past five   |
|                  | years or who have refused a pneumovax vaccine in  |
|                  | the past year.                                    |
|                  |                                                   |
|                  | ***2) Documented patient refusals (REF) or not    |
|                  | medically indicated (NMI).***                     |
|                  |                                                   |
|                  | **Definitions:** 1) **Pneumovax Vaccine:**        |
|                  | Immunization/CVX codes 33, 100, 109; POV V06.6,   |
|                  | V03.82, V03.89; ICD Procedure 99.55; CPT 90732,   |
|                  | 90669                                             |
|                  |                                                   |
|                  | 2\) **Refusal of Pneumovax Vaccine:**             |
|                  | Immunization/CVX codes 33, 100, 109               |
|                  |                                                   |
|                  | **Patient List:** Patients 65 or older OR with    |
|                  | diabetes diagnosis, with date and code of         |
|                  | vaccine, if any.                                  |
+------------------+---------------------------------------------------+
| ***Childhood     | ***New CRS GPRA indicator for 2005.***            |
| Immunizations*** |                                                   |
|                  | ***Denominators: GPRA: Active Clinical patients   |
| ***Epi Program/  | ages 19-35 months at end of Report period.***     |
| Amy Groom,       |                                                   |
| MPH***           | ***Numerators: 1) Patients with 4 doses of DTaP,  |
|                  | or who have evidence of the disease, a            |
|                  | contraindication, or a documented refusal.***     |
|                  |                                                   |
|                  | ***2) Patients with 3 doses of Polio, or who have |
|                  | evidence of the disease, a contraindication, or a |
|                  | documented refusal.***                            |
|                  |                                                   |
|                  | ***3) Patients with 1 dose of MMR, or who have    |
|                  | evidence of the disease, a contraindication, or a |
|                  | documented refusal.***                            |
|                  |                                                   |
|                  | ***4) Patients with 3 doses of HiB, or who have   |
|                  | evidence of the disease, a contraindication, or a |
|                  | documented refusal.***                            |
|                  |                                                   |
|                  | ***5) Patients with 3 doses of Hepatitis B, or    |
|                  | who have evidence of the disease, a               |
|                  | contraindication, or a documented refusal.***     |
|                  |                                                   |
|                  | ***6) Patients with 1 dose of Varicella, or who   |
|                  | have evidence of the disease, a contraindication, |
|                  | or a documented refusal.***                       |
|                  |                                                   |
|                  | ***Also included for numerators 1-6 are           |
|                  | sub-numerators:***                                |
|                  |                                                   |
|                  | ***A) Patients with a documented refusal.***      |
|                  |                                                   |
|                  | ***B) Patients with either (1) evidence of the    |
|                  | disease, (2) a contraindication, or (3) a         |
|                  | documented not medically indicated (NMI)          |
|                  | refusal.***                                       |
|                  |                                                   |
|                  | ***7) Patients who have received all of their     |
|                  | childhood immunizations (i.e. 4 DTaP, 3 Polio, 1  |
|                  | MMR, 3 HiB, 3 Hepatitis B, 1 Varicella, including |
|                  | refusals, contraindications, and evidence of      |
|                  | disease).***                                      |
|                  |                                                   |
|                  | ***8) Patients who have received the 4:3:1        |
|                  | combination (i.e. 4 DTaP, 3 Polio, 1 MMR),        |
|                  | including refusals, contraindications, and        |
|                  | evidence of disease.***                           |
|                  |                                                   |
|                  | ***9) GPRA: Patients who have received the        |
|                  | 4:3:1:3:3 combination (i.e. 4 DTaP, 3 Polio, 1    |
|                  | MMR, 3 HiB, 3 Hepatitis B), including refusals,   |
|                  | contraindications, and evidence of disease.***    |
|                  |                                                   |
|                  | ***9A) Patients with a documented refusal.***     |
|                  |                                                   |
|                  | ***9B) Patients with either (1) evidence of the   |
|                  | disease, (2) a contraindication, or (3) a         |
|                  | documented not medically indicated (NMI)          |
|                  | refusal.***                                       |
|                  |                                                   |
|                  | ***10) Immunization Program Numerator: Patients   |
|                  | who have received all of their childhood          |
|                  | immunizations, defined as 4 DTaP, 3 Polio, 1 MMR, |
|                  | 3 HiB, 3 Hepatitis B, 1 Varicella (i.e.,          |
|                  | 4:3:1:3:3:1) NOT including refusals,              |
|                  | contraindications, and patients with evidence of  |
|                  | disease.***                                       |
|                  |                                                   |
|                  | ***11) Immunization Program Numerator: Patients   |
|                  | who have received the 4:3:1 combination (i.e. 4   |
|                  | DTaP, 3 Polio, 1 MMR) NOT including refusals,     |
|                  | contraindications, and patients with evidence of  |
|                  | disease.***                                       |
|                  |                                                   |
|                  | ***12) Immunization Program Numerator: Patients   |
|                  | who have received the 4:3:1:3:3 combination (i.e. |
|                  | 4 DTaP, 3 Polio, 1 MMR, 3 HiB, 3 Hepatitis B),    |
|                  | NOT including refusals, contraindications, and    |
|                  | patients with evidence of disease.***             |
|                  |                                                   |
|                  | ***Definitions: Detailed descriptions of all      |
|                  | codes for these immunizations will be listed in   |
|                  | the CRS 2005 User Manual, due to length.***       |
|                  |                                                   |
|                  | ***Patient List: Patients ages 19-35 months who   |
|                  | have not received ALL of their childhood          |
|                  | immunizations, indicating which immunizations     |
|                  | they have not received.***                        |
+------------------+---------------------------------------------------+
| **CANCER         |                                                   |
| SCREENING        |                                                   |
| GROUP**          |                                                   |
+------------------+---------------------------------------------------+
| Cancer           | **Denominator: GPRA:** Female Active Clinical     |
| Screening: Pap   | patients ages 18 through 64 without a documented  |
| Smear Rates      | history of hysterectomy.                          |
|                  |                                                   |
| Epi Program/ Dr. | **Numerators:** 1) Patients with documented pap   |
| Nathaniel Cobb   | smear in past three years or refusal in ***past   |
|                  | year***.                                          |
|                  |                                                   |
|                  | 1A) Patients with documented refusal ***in past   |
|                  | year***.                                          |
|                  |                                                   |
|                  | **Definitions:** 1) **Hysterectomy:** V           |
|                  | Procedure: ***68.4-68.8 (revised from 68.3, 68.7, |
|                  | 68.9)***; CPT ***51925, 56308, 58150, 58152,      |
|                  | 58200-58294 (removed 58180),*** 58550-54,         |
|                  | ***58951,*** ***58953-58954, 59135, 59525***.     |
|                  |                                                   |
|                  | 2\) **Pap Smear:** A) V Lab: PAP SMEAR; B) POV:   |
|                  | V76.2; C) V Procedure: 91.46;\                    |
|                  | D) V CPT: 88141-88167, ***88174-88175;*** E)      |
|                  | Women's Health: Procedure called Pap Smear; F)    |
|                  | LOINC taxonomy; G) Site-defined taxonomy BGP GPRA |
|                  | PAP SMEAR; H) Refusal Lab Test Pap Smear          |
|                  | ***(removed Exam 15 (Pelvic))***                  |
|                  |                                                   |
|                  | **Patient List:** All patients in the             |
|                  | denominator, with date and code of test, if any.  |
+------------------+---------------------------------------------------+
| Cancer           | **Denominator: GPRA:** Female Active Clinical     |
| Screening:       | patients ages 50 through 64, without a documented |
| Mammogram Rates  | bilateral mastectomy ***or two separate           |
|                  | unilateral mastectomies***.                       |
| Epi Program/ Dr. |                                                   |
| Nathaniel Cobb   | **Numerators:** 1) **GPRA:** Patients with        |
|                  | documented mammogram in past two years or refusal |
|                  | in ***past year***. 1A) Patients with documented  |
|                  | refusal ***in past year***.                       |
|                  |                                                   |
|                  | **Definitions:** 1) **Bilateral Mastectomy**:     |
|                  | ***V CPT: 19180.50 or 19180 w/modifier 09950      |
|                  | (modifier codes .50 and 09950 indicate            |
|                  | bilateral); 19200.50 or 19200 w/modifier 09950;   |
|                  | 19220.50 or 19220 w/modifier 09950; 19240.50 or   |
|                  | 19240 w/modifier 09950;*** ICD Operation codes:   |
|                  | 85.42; 85.44; 85.46; 85.48                        |
|                  |                                                   |
|                  | 2\) ***Unilateral Mastectomy: Requires two        |
|                  | separate occurrences for either CPT or procedure  |
|                  | codes on 2 different dates of service. V CPT:     |
|                  | 19180, 19200, 19220, 19240; V Procedures: 85.41,  |
|                  | 85.43, 85.45, 85.47***                            |
|                  |                                                   |
|                  | 3\) **Mammogram**: A) V Radiology or V CPT:       |
|                  | 76090, 76091, 76092***, G0206 (Diagnostic         |
|                  | Mammography, Unilateral), G0204 (Diagnostic       |
|                  | Mammography, Bilateral), G0202 (Screening         |
|                  | Mammography, Bilateral)***; B) POV: V76.11,       |
|                  | V76.12; C) V Procedures: ***87.36, 87.37 (removed |
|                  | 87.35);*** D) Women's Health: Screening           |
|                  | Mammogram, Mammogram Dx Bilat, Mammogram Dx       |
|                  | Unilat; 4)**Refusal Mammogram: *V Radiology       |
|                  | MAMMOGRAM for CPT 76090, 76091, 76092, G0206,     |
|                  | G0204, G0202.***                                  |
|                  |                                                   |
|                  | **Patient List:** Patients in the denominator,    |
|                  | with date and code of procedure, if any.          |
+------------------+---------------------------------------------------+
| Colorectal       | **Denominator:** Active Clinical patients ages 50 |
| Cancer Screening | and older ***without a documented history of      |
|                  | colorectal cancer***, broken out by gender.       |
|                  |                                                   |
|                  | **Numerators:** Patients who have had colorectal  |
|                  | screening ***or a documented refusal***, defined  |
|                  | as any of the following: a Fecal Occult Blood     |
|                  | test (FOBT) or Rectal Exam in the past two years; |
|                  | flexible sigmoidoscopy or double contrast barium  |
|                  | enema in the past five years; or colonoscopy in   |
|                  | the past 10 years ***(removed*** ***rigid         |
|                  | proctosigmoidoscopy as definition)***.            |
|                  |                                                   |
|                  | A\) Patients with Fecal Occult Blood test in the  |
|                  | past two years.                                   |
|                  |                                                   |
|                  | B\) Patients with Rectal Exam in past two years.  |
|                  |                                                   |
|                  | **Definitions:** 1) ***Colorectal Cancer: POV:    |
|                  | 153.\*, 154.0, 154.1, 197.5.***                   |
|                  |                                                   |
|                  | 2\) **Fecal Occult Blood lab test (FOBT):** CPT   |
|                  | 82270, 82274, G0107, 89205 (old); LOINC taxonomy, |
|                  | or site-defined taxonomy BGP GPRA FOB TESTS       |
|                  |                                                   |
|                  | 3\) **Rectal Exam:** V76.41; V Procedure          |
|                  | 48.24-29, 89.34 ; V Exam 14                       |
|                  |                                                   |
|                  | 4\) **Flexible Sigmoidoscopy:** V Procedure       |
|                  | 45.22***-45.25 (added codes 45.23, 45.25)***,     |
|                  | 45.42; CPT 45330-45345, ***G0104***               |
|                  |                                                   |
|                  | 5\) **Double Contrast Barium Enema: *(removed     |
|                  | procedure 87.64); ***CPT or VRad: 74270-74280***, |
|                  | G0106, G0120***                                   |
|                  |                                                   |
|                  | 6\) **Colonoscopy:** V76.51; CPT 44388-44394,     |
|                  | ***44397,*** 45355***, 45378-45385,*** 45387      |
|                  | ***(removed 45386)***, 45325 (old), ***G0105,     |
|                  | G0121***                                          |
|                  |                                                   |
|                  | ***7) Refusals for any tests listed above.***     |
|                  |                                                   |
|                  | **Patient List:** Patients ages 52 and older,     |
|                  | with date and code of any related test or         |
|                  | procedure, if any.                                |
+------------------+---------------------------------------------------+
| Tobacco Use      | **Denominator:** **GPRA:** Active Clinical        |
| Assessment       | patients ages 5 and older, broken down by gender  |
|                  | and age groups: 5-13, 14-17, 18-24, 25-44, 45-64, |
|                  | 65 and older (HP 2010).                           |
|                  |                                                   |
|                  | 2\) Pregnant female patients ***with no           |
|                  | documented miscarriage or abortion during the     |
|                  | past 20 months***.                                |
|                  |                                                   |
|                  | **Numerators:** 1) **GPRA:** Patients screened    |
|                  | for tobacco use during the Report period          |
|                  | ***(during the past 20 months for pregnant female |
|                  | patients denominator)***.                         |
|                  |                                                   |
|                  | 2\) Patients identified during the Report period  |
|                  | ***(during the past 20 months for pregnant female |
|                  | patients denominator)*** as current tobacco       |
|                  | users.                                            |
|                  |                                                   |
|                  | 2A) Current smokers.                              |
|                  |                                                   |
|                  | 2B) Current smokeless tobacco users               |
|                  |                                                   |
|                  | 3\) Patients exposed to environmental tobacco     |
|                  | smoke (ETS) during the Report period ***(during   |
|                  | the past 20 months for pregnant female patients   |
|                  | denominator)***.                                  |
|                  |                                                   |
|                  | **Definitions:** 1) **Pregnancy:** At least 2     |
|                  | visits with POV: V22.0-V23.9, 640.\*-648.\*,      |
|                  | 651.\*-676.\* during the ***past 20 months, with  |
|                  | one diagnosis occurring during the reporting      |
|                  | period***.                                        |
|                  |                                                   |
|                  | ***2) Miscarriage: Occurring after the second     |
|                  | pregnancy POV. POV: 630, 631, 632, 633\*, 634\*,  |
|                  | CPT: 59812, 59820, 59821, 59830***                |
|                  |                                                   |
|                  | ***3) Abortion: Occurring after the second        |
|                  | pregnancy POV. POV: 635\*, 636\*, 637\*, CPT:     |
|                  | 59840, 59841, 59850, 59851, 59852, 59855, 59856,  |
|                  | 59857***                                          |
|                  |                                                   |
|                  | 4\) **Tobacco Screening:** A) Any Health Factor   |
|                  | for category Tobacco. B) POV or Current PCC       |
|                  | Problem List 305.1\*, V15.82 (tobacco-related     |
|                  | diagnosis). C) Dental code 1320.\                 |
|                  | D) Patient Education codes containing "TO-",      |
|                  | "-TO", or ***"-SHS".***                           |
|                  |                                                   |
|                  | 5\) **Tobacco Users:** A) Health Factors: Current |
|                  | Smoker, Current Smokeless, Current Smoker and     |
|                  | Smokeless. B) POV 305.1, 305.10, 305.11, 305.12   |
|                  | or V15.82. C) Dental 1320                         |
|                  |                                                   |
|                  | 6\) **Current Smokers:** A) Health Factors:       |
|                  | Current Smoker, Current Smoker and Smokeless. B)  |
|                  | 305.1, 305.10, 305.11, 305.12 or V15.82. C)       |
|                  | Dental code 1320                                  |
|                  |                                                   |
|                  | 7\) **Current Smokeless:** A) Health Factors:     |
|                  | Current Smokeless, Current Smoker and Smokeless   |
|                  |                                                   |
|                  | 8\) **Environmental Tobacco Smoke (ETS):** Health |
|                  | Factors: Smoker in Home, Exposure to              |
|                  | Environmental Tobacco Smoke                       |
|                  |                                                   |
|                  | **Patient List:** Patients with no screening      |
|                  | identified                                        |
+------------------+---------------------------------------------------+
| Tobacco          | **No changes from 2004**                          |
| Cessation        |                                                   |
|                  | **Denominator:** Active Clinical patients         |
|                  | identified as current tobacco users prior to the  |
|                  | Report period.                                    |
|                  |                                                   |
|                  | **Numerators:** 1) Patients who have received     |
|                  | tobacco cessation counseling during the Report    |
|                  | period.                                           |
|                  |                                                   |
|                  | 2\) Patients counseled during the Report period   |
|                  | on smoking cessation medications.                 |
|                  |                                                   |
|                  | 3\) Patients identified during the Report period  |
|                  | as having quit tobacco use.                       |
|                  |                                                   |
|                  | **Definitions:**                                  |
|                  |                                                   |
|                  | 1\) **Current Tobacco Users:** A) Health Factors: |
|                  | Current Smoker, Current Smokeless, Current Smoker |
|                  | and Smokeless. B) Tobacco-related Diagnoses (POV  |
|                  | or active Problem List): 305.1, 305.10, 305.11,   |
|                  | 305.12 or V15.82. C) Dental code 1320             |
|                  |                                                   |
|                  | 2\) **Tobacco Cessation Counseling:** Patient     |
|                  | Education codes containing "TO-Q", code TO-LA;    |
|                  | Clinic Code 94, or Dental Code 1320               |
|                  |                                                   |
|                  | 3\) **Smoking Cessation Medications:** Patient    |
|                  | Education code TO-M                               |
|                  |                                                   |
|                  | 4\) **Quit Smoking:** POV or Current Active       |
|                  | Problem List 305.13, Health Factors               |
|                  | Cessation-Smoker, Cessation-Smokeless, Previous   |
|                  | Smoker, Previous Smokeless.                       |
|                  |                                                   |
|                  | **Patient List:** Patients with counseling, if    |
|                  | any.                                              |
+------------------+---------------------------------------------------+
| **BEHAVIORAL     |                                                   |
| HEALTH GROUP**   |                                                   |
+------------------+---------------------------------------------------+
| Alcohol          | **Denominator:** **GPRA:** Female Active Clinical |
| Screening (FAS   | patients ages 15 to 44 (child-bearing age).       |
| Prevention)      |                                                   |
| Indicator        | **Numerators: GPRA:** Patients screened for       |
|                  | alcohol use, who have alcohol-related diagnoses,  |
|                  | or who have received alcohol-related education or |
|                  | counseling during the Report period.              |
|                  |                                                   |
|                  | A\) Patients with any Alcohol Health Factor or    |
|                  | other screening.                                  |
|                  |                                                   |
|                  | B\) Patients with alcohol-related diagnoses.      |
|                  |                                                   |
|                  | C\) Patients with alcohol-related patient         |
|                  | education or counseling.                          |
|                  |                                                   |
|                  | **Definitions:**                                  |
|                  |                                                   |
|                  | 1\) **Alcohol Screening:** Any Alcohol Health     |
|                  | Factor; Other Screening: V11.3; V79.1\            |
|                  | 2**) Alcohol-related Diagnoses:** POV, Current    |
|                  | PCC or BHS Problem List: 303.\*, 305.0\*; 291.\*; |
|                  | 357.5\*; BHS diagnoses 10, 27, 29\                |
|                  | 2**) Alcohol Education:** All Patient Education   |
|                  | codes containing "CD-" ***or "-CD"***             |
|                  |                                                   |
|                  | **Patient List:** Women [not]{.underline}         |
|                  | screened.                                         |
+------------------+---------------------------------------------------+
| Intimate Partner | **Denominators:** 1) Female Active Clinical       |
| (Domestic)       | patients ages 13 and older at beginning of Report |
| Violence         | period. 1A) **GPRA:** Female Active Clinical      |
| Screening        | patients ages ***15-40 (previously 16-24).***     |
|                  |                                                   |
| Dr. Theresa      | **Numerators: GPRA:** Patients screened for or    |
| Cullen/ Denise   | diagnosed with intimate partner (domestic)        |
| Grenier, MSW     | violence during the Report period***, including   |
|                  | documented refusals in past year.***              |
|                  |                                                   |
|                  | A\) Patients with documented IPV/DV exam.         |
|                  |                                                   |
|                  | B\) Patients with IPV/DV related diagnoses.       |
|                  |                                                   |
|                  | C\) Patients provided with IPV/DV patient         |
|                  | education or counseling.                          |
|                  |                                                   |
|                  | ***D)*** ***Patients with documented refusal in   |
|                  | past year of an IPV/DV exam or IPV/DV-related     |
|                  | education.***                                     |
|                  |                                                   |
|                  | **Definitions:** 1) **IPV/DV Screening: *PCC***   |
|                  | Exam Code 34 ***or BHS IPV/DV exam***             |
|                  |                                                   |
|                  | 2\) **IPV/DV Related Diagnoses:** POV, Current    |
|                  | PCC or BHS Problem List 995.50, 995.51, 995.53,   |
|                  | 995.54, 995.59, 995.8083, 995.85, V15.41, V15.42, |
|                  | V15.49; BHS diagnoses 43.\*, 44.\*                |
|                  |                                                   |
|                  | 3\) **IPV/DV Patient Education:** Patient         |
|                  | Education codes containing "DV-" ***or "-DV"***   |
|                  |                                                   |
|                  | 4\) **IPV/DV Counseling:** POV V61.11             |
|                  |                                                   |
|                  | ***5) Refusals: A) [Any]{.underline} PCC refusal  |
|                  | in past year with Exam Code 34 or BHS refusal in  |
|                  | past year of IPV/DV exam; B) [Any]{.underline}    |
|                  | refusal in past year with Patient Education codes |
|                  | containing \"DV-\" or "-DV".***                   |
|                  |                                                   |
|                  | **Patient List:** Women [not]{.underline}         |
|                  | screened ***and without documented refusal***.    |
+------------------+---------------------------------------------------+
| ***De            | ***New indicator topic for 2005. Moved previous   |
| pression/Anxiety | Diabetes: Mental Health to this topic.***         |
| Screening***     |                                                   |
|                  | **Denominators: *1) Active Clinical patients ages |
| ***Dr. Theresa   | 40 and older.***                                  |
| Cullen/ Denise   |                                                   |
| Grenier, MSW***  | 2\) Active Diabetes patients, defined as: all     |
|                  | Active Clinical patients diagnosed with diabetes  |
|                  | prior to the Report period, AND at least 2 visits |
|                  | during the Report period, AND 2 DM-related visits |
|                  | ever.                                             |
|                  |                                                   |
|                  | ***3) All patients diagnosed with ischemic heart  |
|                  | disease prior to the Report period and with at    |
|                  | least two CVD-related visits during the Report    |
|                  | period.***                                        |
|                  |                                                   |
|                  | **Numerators: *Patients screened for or counseled |
|                  | about depression OR diagnosed with                |
|                  | depressive/anxiety/adjustment disorders during    |
|                  | the Report period.***                             |
|                  |                                                   |
|                  | A\) Patients screened for or counseled about      |
|                  | depression.                                       |
|                  |                                                   |
|                  | B\) Patients with a diagnosis of                  |
|                  | depressive/anxiety/ adjustment***.***             |
|                  |                                                   |
|                  | **Definitions: *1) Ischemic heart disease         |
|                  | diagnosis: POV 410.0-412.\*, 414.0-414.9, 428.\*, |
|                  | 429.2.***                                         |
|                  |                                                   |
|                  | 2\) Depression Screening or Counseling: POV       |
|                  | V79.0, Patient Education codes containing "DEP-"  |
|                  | (depression), "SB-" (suicidal behavior), "GAD-"   |
|                  | (generalized anxiety disorder), "BH-" (behavioral |
|                  | and social health), ***or \"PDEP-\" (postpartum   |
|                  | depression)***.                                   |
|                  |                                                   |
|                  | 3\) Depressive/Anxiety/Adjustment Disorders: At   |
|                  | least 2 visits with POV 296.\*, 300.\*, 301.13,   |
|                  | 308.3, 309.\*, 311.\* or BHS codes 14, 15, 18, 24 |
|                  |                                                   |
|                  | **Patient List:** Patients who have not been      |
|                  | screened for depressive/anxiety disorders.        |
+------------------+---------------------------------------------------+
| **CARDIOVASCULAR |                                                   |
| DISEASE RELATED  |                                                   |
| GROUP**          |                                                   |
+------------------+---------------------------------------------------+
| Obesity          | **No changes from 2004**                          |
| Assessment       |                                                   |
|                  | **Denominators:** Active Clinical patients ages 2 |
| Nutrition        | through 74, broken down into gender and age       |
| Program/ Jean    | groups: 2-5, 6-11, 12-19, 20-24, 25-34, 35-44,    |
| Charles-Azure    | 45-54, 55-74.                                     |
|                  |                                                   |
|                  | **Numerators:** 1) **GPRA:** All patients for     |
|                  | whom BMI can be calculated.\                      |
|                  | A) Of Numerator 1, patients considered            |
|                  | overweight, adults BMI 25-29, age 18 and under    |
|                  | based on standard tables.\                        |
|                  | B) Of Numerator 1, patients considered obese,     |
|                  | adults BMI =\>30, age 18 and under based on       |
|                  | standard tables.\                                 |
|                  | C) Of Numerator 1, total overweight and obese.    |
|                  |                                                   |
|                  | **Definitions:** 1) **BMI:** Calculated using     |
|                  | NHANES II. For 18 and under, a height and weight  |
|                  | must be taken on the same day any time during the |
|                  | Report period. For 19 through 50, height and      |
|                  | weight within last five years, not required to be |
|                  | on same day. For over 50, height and weight       |
|                  | within last two years, not required to be on same |
|                  | day.                                              |
|                  |                                                   |
|                  | **Patient List:** Patients for whom a BMI could   |
|                  | NOT be calculated.                                |
+------------------+---------------------------------------------------+
| ***Childhood     | ***New indicator topic for 2005.***               |
| Obesity          |                                                   |
| Reduction***     | ***Denominator: Active Clinical Patients 2-6,     |
|                  | broken out by age groups.***                      |
|                  |                                                   |
|                  | ***Numerators: 1) Patients for whom a BMI could   |
|                  | be calculated.***                                 |
|                  |                                                   |
|                  | ***A) Patients with BMI 85-94%. B) Patients with  |
|                  | a BMI 95% and up. C)*** ***Patients with a BMI    |
|                  | =\>85%.***                                        |
|                  |                                                   |
|                  | ***Definitions: 1) Age: All patients who are      |
|                  | between the ages of 2 and 6 at the beginning of   |
|                  | the Report Period and who do not turn age 7       |
|                  | during the Report Period are included in this     |
|                  | indicator. Age in the age groups is calculated    |
|                  | based on the date of the most current BMI found.  |
|                  | If no BMI is found then the patient falls into    |
|                  | the age group for the age they were on the first  |
|                  | day of the report period. For example, a patient  |
|                  | may be 2 at the beginning of the time period but  |
|                  | is 3 at the time of the most current BMI found.   |
|                  | That patient will fall into the age 3 group.***   |
|                  |                                                   |
|                  | ***2) BMI: CRS looks for the most recent BMI in   |
|                  | the report period. CRS calculates BMI at the time |
|                  | the report is run, using NHANES II. A height and  |
|                  | weight must be taken on the same day any time     |
|                  | during the Report Period. The BMI values for this |
|                  | indicator reported differently than in Obesity    |
|                  | Assessment since this age group is children ages  |
|                  | 2-6, whose BMI values are age-dependent. The BMI  |
|                  | values are categorized as At-risk for Overweight  |
|                  | for patients with a BMI between 85-94% and        |
|                  | Overweight for patients with a BMI of 95%.        |
|                  | Patients whose BMI either is greater or less than |
|                  | the Data Check Limit range shown below will not   |
|                  | be included in the report counts for At-risk for  |
|                  | Overweight or Overweight.***                      |
|                  |                                                   |
|                  | ***Patient List: Patients ages 2-6, with current  |
|                  | BMI, if any.***                                   |
+------------------+---------------------------------------------------+
| Nutrition and    | **No changes from 2004**                          |
| Exercise         |                                                   |
| Education for At | **Denominators:** 1) Active Clinical patients     |
| Risk Patients    | ages 6 and older considered overweight (including |
|                  | obese), defined as adults with BMI =\>25, ages 18 |
| Patient          | and under based on standard tables.               |
| Education        |                                                   |
| Program/ Mary    | 1A) Patients considered obese, defined as adults  |
| Wachacha         | with BMI =\>30, ages 18 and under based on        |
|                  | standard tables. Broken out by gender and age     |
| Nutrition        | groups: 6-11, 12-19, 20-39, 40-59, =\>60 (HP      |
| Program/ Jean    | 2010).                                            |
| Charles-Azure    |                                                   |
|                  | 2\) Active Diabetic patients (see Diabetes        |
|                  | Comprehensive Care above for definition).         |
|                  |                                                   |
|                  | **Numerators:** During the Report period: 1)      |
|                  | Patients provided with medical nutrition          |
|                  | counseling.                                       |
|                  |                                                   |
|                  | 2\) Patients provided with nutrition education.\  |
|                  | 3) Patients provided with exercise education.\    |
|                  | 4) Patients provided with other related           |
|                  | education.                                        |
|                  |                                                   |
|                  | **Definitions:** 1) **Medical Nutrition           |
|                  | Counseling:** CPT 97802-97804, G0270, G0271; or   |
|                  | provider codes 07, 29, 97 or 99; or clinic codes  |
|                  | 67 or 36                                          |
|                  |                                                   |
|                  | 2\) **Nutrition Education:** Patient Education    |
|                  | codes ending "-N" or old codes containing "-DT"   |
|                  | (diet); POV V65.3                                 |
|                  |                                                   |
|                  | 3\) **Exercise Education:** Patient Education     |
|                  | codes ending "-EX"; POV V65.41                    |
|                  |                                                   |
|                  | 4\) **Other Related Education:** Patient          |
|                  | Education codes ending "-LA" or containing "OBS-" |
|                  |                                                   |
|                  | **Patient List:** Patients defined as at risk,    |
|                  | with date and codes, if any.                      |
+------------------+---------------------------------------------------+
| *                | ***CRS GPRA indicator for 2005, renamed from      |
| **Cardiovascular | Cardiovascular Disease Prevention: Cholesterol    |
| Disease and      | Screening***                                      |
| Cholesterol      |                                                   |
| Screening***     | **Denominators:** Active Clinical patients ages   |
|                  | 23 ***and older (previously 23-70);*** broken out |
| Dr. James        | by gender.                                        |
| Galloway/ Mary   |                                                   |
| Wachacha         | **Numerators:** 1) **GPRA:** Patients with        |
|                  | documented cholesterol screening any time during  |
|                  | past five years, regardless of result.            |
|                  |                                                   |
|                  | ***2) With high cholesterol, defined as =\>       |
|                  | 240.***                                           |
|                  |                                                   |
|                  | ***3) With LDL completed, regardless of result.\  |
|                  | 4) LDL \<= 100. 5) LDL 101-130. 6) LDL 131-160.   |
|                  | 7) LDL \>160.***                                  |
|                  |                                                   |
|                  | **Definitions:** 1) **Total Cholesterol Panel:**  |
|                  | CPT 82465; LOINC taxonomy; site-defined taxonomy  |
|                  | DM AUDIT CHOLESTEROL TAX. ***Removed Lipid        |
|                  | Profile as definition.***                         |
|                  |                                                   |
|                  | 2\) **LDL:** CPT 83721; LOINC taxonomy;           |
|                  | site-defined taxonomy DM AUDIT LDL CHOLESTEROL    |
|                  | TAX                                               |
|                  |                                                   |
|                  | **Patient List:** Patients in the denominator,    |
|                  | with date and test, if any.                       |
+------------------+---------------------------------------------------+
| *                | ***Renamed from Cardiovascular Disease            |
| **Cardiovascular | Prevention: Blood Pressure Control***             |
| Disease and      |                                                   |
| Blood Pressure   | **Denominators: *1) All Active Clinical patients  |
| Control***       | ages 20 and over, broken down by gender (removed  |
|                  | exclusion for patients with any diabetes          |
| Dr. James        | diagnosis).***                                    |
| Galloway/ Mary   |                                                   |
| Wachacha         | ***2) All User Population patients ages 20 and    |
|                  | older, broken down by gender (removed exclusion   |
|                  | for patients with any diabetes diagnosis).***     |
|                  |                                                   |
|                  | **Numerators:** 1) Patients with BP values        |
|                  | documented.                                       |
|                  |                                                   |
|                  | 2\) Patients with normal BP, \<120/80.            |
|                  |                                                   |
|                  | 3\) Pre-hypertension I, =\> 120/80 and \< 130/80. |
|                  |                                                   |
|                  | 4\) Pre-hypertension II, =\>130/80 and \< 140/90. |
|                  |                                                   |
|                  | 5\) Stage 1 hypertension, =\> 140/90 and          |
|                  | \<160/100.                                        |
|                  |                                                   |
|                  | 6\) Stage 2 hypertension, =\> 160/100.            |
|                  |                                                   |
|                  | **Definitions:** 1) **BP Values (all              |
|                  | numerators):** Uses the last 2 blood pressures    |
|                  | documented on non-ER visits for the patient in    |
|                  | the past two years. If the systolic and diastolic |
|                  | values do not BOTH meet one of the five           |
|                  | categories listed above, then the value that is   |
|                  | [least]{.underline} controlled determines the     |
|                  | category.                                         |
|                  |                                                   |
|                  | **Patient List:** Patients =\> 20 w/ denominator  |
|                  | identified & mean BP, if any.                     |
+------------------+---------------------------------------------------+
| Controlling High | **Denominator:** Active Clinical patients ages 46 |
| Blood Pressure   | through 85 diagnosed with hypertension.           |
|                  |                                                   |
| Dr. James        | **Numerators:** 1) Patients with BP values        |
| Galloway/ Mary   | documented.                                       |
| Wachacha         |                                                   |
|                  | 2\) Patients with normal BP, \<120/80.            |
|                  |                                                   |
|                  | 3\) Pre-hypertension I, =\> 120/80 and \< 130/80. |
|                  |                                                   |
|                  | 4\) Pre-hypertension II, =\>130/80 and \< 140/90. |
|                  |                                                   |
|                  | 5\) Stage 1 hypertension, =\> 140/90 and          |
|                  | \<160/100.                                        |
|                  |                                                   |
|                  | 6\) Stage 2 hypertension, =\> 160/100.            |
|                  |                                                   |
|                  | **Definitions:** 1) **Hypertension:** Diagnosis   |
|                  | (POV or problem list) 401.\* ***(changed from     |
|                  | 401.\*-405)*** prior to the Report period, and at |
|                  | least one hypertension POV during the Report      |
|                  | period. 2) **BP Values (all numerators):** Uses   |
|                  | the last 2 blood pressures documented on non-ER   |
|                  | visits for the patient in the past two years. If  |
|                  | the systolic and diastolic values do not BOTH     |
|                  | meet one of the five categories listed above,     |
|                  | then the value that is [least]{.underline}        |
|                  | controlled determines the category.               |
|                  |                                                   |
|                  | **Patient List:** Patients in the denominator,    |
|                  | with BP value, if any.                            |
+------------------+---------------------------------------------------+
| ***Comprehensive | ***New indicator topic for 2005.***               |
| CVD-Related      |                                                   |
| Assessment***    | ***Denominators: 1) Patients ages 46 and older    |
|                  | who are not diabetic.***                          |
| ***Dr. James     |                                                   |
| Galloway/ Mary   | ***2) Active Diabetic patients (see Diabetes      |
| Wachacha***      | Comprehensive Care above for definition)***       |
|                  | ***ages 46 and older.***                          |
|                  |                                                   |
|                  | ***Numerators: 1) Patients with Blood Pressure    |
|                  | value documented at least twice in prior two      |
|                  | years.***                                         |
|                  |                                                   |
|                  | ***2) With LDL completed in past five years,      |
|                  | regardless of result.***                          |
|                  |                                                   |
|                  | ***3) Screened for tobacco use during the Report  |
|                  | period.***                                        |
|                  |                                                   |
|                  | ***4) For whom a BMI could be calculated.***      |
|                  |                                                   |
|                  | ***5) Who have received any lifestyle adaptation  |
|                  | counseling, including medical nutrition           |
|                  | counseling, or nutrition, exercise or other       |
|                  | lifestyle education during the Report period.***  |
|                  |                                                   |
|                  | ***6) Screened/counseled/diagnosed with           |
|                  | depression or anxiety disorders at any time       |
|                  | during the Report period.***                      |
|                  |                                                   |
|                  | ***7) Patients with ALL assessments above.***     |
|                  |                                                   |
|                  | ***Definitions: Age of the patient is calculated  |
|                  | at beginning of the Report period. Patients       |
|                  | without diabetes are defined as no diabetes       |
|                  | diagnosis ever (POV 250.00-250.93).***            |
|                  |                                                   |
|                  | ***For specific definitions, refer to the         |
|                  | following topics above: Controlling High Blood    |
|                  | Pressure; Diabetes and Lipids Assessment; Tobacco |
|                  | Use Assessment; Obesity Assessment; Nutrition and |
|                  | Exercise Education for At Risk Patients; and      |
|                  | Depression/Anxiety Screening.***                  |
|                  |                                                   |
|                  | ***Patient List: TBD.***                          |
+------------------+---------------------------------------------------+
| **STD-RELATED    |                                                   |
| GROUP**          |                                                   |
+------------------+---------------------------------------------------+
| Prenatal HIV     | ***CRS GPRA indicator for 2005***                 |
| Testing and      |                                                   |
| Education        | **Denominator: GPRA:** All pregnant patients with |
|                  | no documented ***miscarriage or abortion***       |
| Dr. Theresa      | ***during the past 20 months*** and NO recorded   |
| Cullen/ Dr.      | HIV diagnosis ever***.***                         |
| Charlton Wilson/ |                                                   |
| Jeanne Bertolli, | **Numerators:** 1) Patients who received          |
| PhD              | counseling and/or patient education about HIV and |
|                  | testing during ***the past 20 months.***          |
|                  |                                                   |
|                  | 2\) **GPRA:** Patients who received HIV test      |
|                  | during ***the past 20 months***, including        |
|                  | refusals.                                         |
|                  |                                                   |
|                  | 2A) Number of documented refusals.                |
|                  |                                                   |
|                  | **Definitions:** 1) **Pregnancy:** At least 2     |
|                  | visits with POV: V22.0-V23.9, 640.\*-648.\*,      |
|                  | 651.\*-676.\* ***during the past 20 months, with  |
|                  | one diagnosis occurring during the reporting      |
|                  | period***.                                        |
|                  |                                                   |
|                  | 2\) ***Miscarriage: Occurring after the second    |
|                  | pregnancy POV and during the past 20 months. POV: |
|                  | 630, 631, 632, 633\*, 634\*, CPT: 59812, 59820,   |
|                  | 59821, 59830***                                   |
|                  |                                                   |
|                  | ***3) Abortion: Occurring after the second        |
|                  | pregnancy POV and during the past 20 months. POV: |
|                  | 635\*, 636\*, 637\*, CPT: 59840, 59841, 59850,    |
|                  | 59851, 59852, 59855, 59856, 59857***              |
|                  |                                                   |
|                  | 4\) **HIV:** V POV or Problem List: 042.0-044.9,  |
|                  | V08, 795.71                                       |
|                  |                                                   |
|                  | 5\) **HIV Counseling/Patient Education:** POV:    |
|                  | V65.44, Patient Education codes containing "HIV-" |
|                  | or HIV diagnosis 042.0-044.9, V08, 795.71         |
|                  |                                                   |
|                  | 6\) **HIV Test:** CPT: 86689, 86701-86703, 87390, |
|                  | 87391; LOINC taxonomy; site-defined taxonomy BGP  |
|                  | GPRA HIV TESTS                                    |
|                  |                                                   |
|                  | 7\) **Refusal of HIV Test:** Lab Test HIV         |
|                  |                                                   |
|                  | **Patient List:** Patients not screened.          |
+------------------+---------------------------------------------------+
| HIV Quality of   | **No changes from 2004.**                         |
| Care             |                                                   |
|                  | **Denominator:** Patients 13 and older with at    |
| Dr. Theresa      | least 2 direct care visits (i.e. not              |
| Cullen/ Dr.      | contract/CHS) during the Report period with HIV   |
| Charlton Wilson/ | diagnosis AND 1 HIV visit in last 6 months.       |
| Jeanne Bertolli, | Broken out by gender.                             |
| PhD              |                                                   |
|                  | **Numerators:** 1) Patients who received CD4 test |
|                  | only (without PCR viral load) during the Report   |
|                  | period.                                           |
|                  |                                                   |
|                  | 2\) Patients who received HIV Viral load only     |
|                  | (without CD4), as measured by PCR or a comparable |
|                  | test, during the Report period.                   |
|                  |                                                   |
|                  | 3\) Patients who received both CD4 and HIV viral  |
|                  | load tests during the Report period.              |
|                  |                                                   |
|                  | 4\) Total patients receiving tests.               |
|                  |                                                   |
|                  | **Definitions:** 1) **HIV:** POV or Problem List  |
|                  | 042.0-044.9, V08, or 795.71                       |
|                  |                                                   |
|                  | 2\) **CD4:** CPT 86361; LOINC taxonomy;           |
|                  | site-defined taxonomy BGP CD4 TAX                 |
|                  |                                                   |
|                  | 3\) **HIV Viral Load:** CPT 87536, 87539; LOINC   |
|                  | taxonomy; site-defined taxonomy BGP HIV VIRAL TAX |
|                  |                                                   |
|                  | **Patient List:** None                            |
+------------------+---------------------------------------------------+
| Chlamydia        | **Denominators:** 1) Female Active Clinical       |
| Screening        | patients ages 16 through 25, broken down into age |
|                  | groups 16-20 and 21-25.                           |
|                  |                                                   |
|                  | **Numerator:** Patients tested for chlamydia      |
|                  | trachomatis during the Report period.             |
|                  |                                                   |
|                  | **Definitions: Chlamydia:** V73.88, V73.98; CPT:  |
|                  | 87110, 87270, 87320, ***(removed 87485-87487; not |
|                  | for genital Chlamydia infection),*** 87490-87492, |
|                  | 87810; site-defined taxonomy BGP GPRA CHLAMYDIA   |
|                  | TESTS; LOINC taxonomy                             |
|                  |                                                   |
|                  | **Patient List:** Patients with no documented     |
|                  | screening.                                        |
+------------------+---------------------------------------------------+
| **DI             |                                                   |
| SEASE-SPECIFIC** |                                                   |
+------------------+---------------------------------------------------+
| Asthma           | **No changes from 2004**                          |
|                  |                                                   |
|                  | **Denominators:** 1) Active Clinical patients,    |
|                  | broken out by age groups: \<5, 5-64; 65 and older |
|                  | (HP 2010)                                         |
|                  |                                                   |
|                  | **Numerators:** 1) Patients who have had 2        |
|                  | asthma-related visits during the Report period OR |
|                  | who are Active patients in the Asthma Register    |
|                  | System (ARS) and categorized as persistent (i.e.  |
|                  | Severity 2, 3 or 4).\                             |
|                  | 2) Patients from the first numerator who have     |
|                  | hospital visits for asthma during the Report      |
|                  | period.                                           |
|                  |                                                   |
|                  | **Definitions:** 1) **Asthma**: POV 493.\*        |
|                  |                                                   |
|                  | 2\) **Hospital Visit:** Service Category H with   |
|                  | [primary]{.underline} POV 493.\*                  |
|                  |                                                   |
|                  | **Patient List:** Patients in the numerator.      |
+------------------+---------------------------------------------------+
| ***Chronic       | ***Denominator: All patients 17 and older with    |
| Kidney Disease   | serum creatinine test in past year.***            |
| Assessment***    |                                                   |
|                  | ***Numerators: 1) Patients with Estimated GFR     |
| ***Kidney        | result (lab test Estimated GFR).***               |
| Disease Program/ |                                                   |
| Dr. Andrew       | ***1A) with GFR \<60***                           |
| Narva***         |                                                   |
|                  | ***Definitions: 1) Creatinine definition: CPT     |
|                  | 82540, 82565-75; LOINC taxonomy; site-defined     |
|                  | taxonomy DM AUDIT CREATININE TAX. 2) Estimated    |
|                  | GFR definition: site-defined taxonomy BGP GPRA    |
|                  | ESTIMATED GFR TAX, LOINC code 33914-3.***         |
+------------------+---------------------------------------------------+
| **OTHER CLINICAL |                                                   |
| INDICATORS**     |                                                   |
+------------------+---------------------------------------------------+
| Medications      | **Denominator:** 1) Active Clinical patients with |
| Education        | medications dispensed [at their                   |
|                  | facility]{.underline} during the Report period.   |
| Patient          |                                                   |
| Education        | **Numerator:** 1) Patients who were provided      |
| Program/ Mary    | patient education about their medications in ANY  |
| Wachacha         | location.                                         |
|                  |                                                   |
|                  | **Definitions:** 1) **Dispensed Medications:**    |
|                  | Any entry in the VMed file for your facility.     |
|                  |                                                   |
|                  | 2\) **Medication Education:** Patient Education   |
|                  | codes M-I, M-DI, M-FU, M-L, ***DMC-IN***, or any  |
|                  | Patient Education containing "-M".                |
|                  |                                                   |
|                  | **Patient List:** Patients in the denominator,    |
|                  | with date and Patient Education codes, if any.    |
+------------------+---------------------------------------------------+
| Public Health    | **No changes from 2004.**                         |
| Nursing          |                                                   |
|                  | **Denominators:** 1) User Population patients.    |
| Barbara Fine, RN |                                                   |
|                  | 2\) **GPRA:** Number of [visits]{.underline} by   |
|                  | PHNs in any setting, including Home, broken down  |
|                  | into age groups: 0-28 days (neonate), 29 days-12  |
|                  | months (infants), 1-64 years, 65 and older        |
|                  | (elders).                                         |
|                  |                                                   |
|                  | 3\) **GPRA:** Number of [visits]{.underline} by   |
|                  | PHNs in Home setting, broken down into age        |
|                  | groups: 0-28 days (neonate), 29 days-12 months    |
|                  | (infants), 1-64 years, 65 and older (elders).     |
|                  |                                                   |
|                  | **Numerators:**                                   |
|                  |                                                   |
|                  | 1\) For User Population denominator only, the     |
|                  | number of patients in the denominator served by   |
|                  | PHNs in any setting.                              |
|                  |                                                   |
|                  | 2\) For User Population denominator only, the     |
|                  | number of patients in the denominator served by   |
|                  | PHNs in a Home setting.                           |
|                  |                                                   |
|                  | **Definitions:** 1) **PHN Visit-Any Setting:**    |
|                  | Any visit with primary or secondary provider      |
|                  | codes 13 or 32 or clinic code 45.                 |
|                  |                                                   |
|                  | 2\) **PHN Visit-Home:** Any visit with A) clinic  |
|                  | code 11 or Location Home (as defined in Site      |
|                  | Parameters) [and]{.underline} B) primary or       |
|                  | secondary provider code 13 or 32.                 |
|                  |                                                   |
|                  | **Patient List:** Any patient who received any    |
|                  | PHN visit.                                        |
+------------------+---------------------------------------------------+