Michigan: Updates to the 2022 Care Management and Quality Incentive Program for UnitedHealthcare Community Plan Primary Care Physicians (PCPs)

Combo 10 Completion: $100 for complete series
Criteria: Must be completed on or before 2^nd birthday and consist of the following: 4 DTaP, 3 IPV, 1 MMR, 3 HiB, 3 Hepatitis B, 1 VZV, 4 PCV, 1 Hepatitis A, 2 or 3 RV (2 or 3 dose schedule), 2 Influenza

Administration fee is paid in addition to incentive on FFS basis via claim payment.

Lead Screening Completion: $25
Criteria: Member must have at least 1 capillary or venous lead screening on or before 2^nd birthday.

CPT code: 83655

Appropriate Testing for Pharyngitis: $10
Criteria: Members between the ages of 3-65+ who are diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

Diagnosis codes: J02.0; J02.8; J02.9; J03.00–01; J03.80–81; J03.90–91
Group A Strep Tests: 87070–87071; 87081; 84730; 87650–87652; 87880
Antibiotics: Amoxicillin; Amoxicillin-clavulanate; Ampicillin; Azithromycin; Cefaclor; Cefadroxil; Cefazolin; Cefdinir; Cefditoren; Cefixime; Cefpodoxime; Cefprozil; Ceftibuten; Ceftriaxone; Cefuroxime; Cephalexin; Ciprofloxacin; Clarithromycin; Clindamycin; Dicloxacillin; Doxycycline; Erythromycin; Erythromycin ethylsuccinate; Erythromycin lactobionate; Erythromycin stearate; Levofloxacin; Minocycline; Moxifloxacin; Ofloxacin; Penicillin G benzathine; Penicillin G potassium; Penicillin G sodium; Penicillin V potassium; Sulfamethoxazole-trimethoprim; Tetracycline; Trimethoprim

Cervical Cancer Screening: $20
Criteria: Women between the ages of 21–64 who are screened for cervical cancer

CPT code: 88141–88143; 88147–88148; 88150; 88152–88154; 88164–88167; 88174–88175; 87620–87622; 87624–87625; G0123–G0124; G0141; G0143–G0145; G0147–G0148; G0476; P3000; P3001; Q0091

Breast Cancer Screening: $20
Criteria: Women between the ages of 50–74 who had a mammogram to screen for breast cancer
CPT code: 77055–77057; 77061–77063; 77065–77067; G0202; G0204; G0206

Chlamydia Screening: $20
Criteria: Women between the ages of 16–24 who had a chlamydia screening (urine or culture)
CPT code: 87110; 87270; 87320; 87490–87492; 87810

Prenatal Care: $20
Criteria: Multiple qualifying CPT codes as defined by HEDIS^® specifications

Postnatal Care: $20
Criteria: Multiple qualifying CPT codes as defined by HEDIS^® specifications

Tobacco Cessation Counseling: $5
Criteria: Members, ages 14 and older, in which had a smoking and tobacco use cessation visit
CPT code: 99406; 99407

Members must have at least 2 face-to-face (i.e., E&M) claims in a 2-year period with a diagnosis of diabetes

HbA1c Control (<8.0%): $15
Criteria: Members between the ages of 18–75 whose most recent HbA1c level is <8.0%
CPT codes: 83036; 83037
CPT Category II: 3044F; 3051F

Completion of Diabetic Eye Exam: $15
Criteria: Members between the ages of 18–75 who have been screened or being monitored for diabetic retinal disease

Services include: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a retinal or dilated eye exam that is negative for retinopathy by an eye care professional within the past 2 years; Bilateral eye enucleation any time during the member’s history through Dec. 31

CPT Category II: 2022F–2026F; 2033F

Kidney Evaluation for Diabetes: $15
Criteria: Members between the ages of 18–85 who must have both the serum eGFR (estimated glomerular filtration rate) and a urine ACR (albumin creatinine ratio) lab tests

CPT codes: 80047; 80048; 80050; 80053; 80069; 82565; 82570; 82042–82044; 84156
CPT Category II: 3060F; 3061F; 3062F

Antipsychotic Medication Adherence: $25
Criteria: Members, 18 years and older, who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period

Asthma Medication Ratio: $25
Criteria: Members between the ages of 5–64 who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications

Well-Child Visits in the First 30 Months of Life: $75
Criteria: Children who turned 15 months old must have 6 or more well-child visits. Children who turned 30 months old must have 2 or more well-child visits.

Diagnosis codes: Z00.110; Z00.111; Z00.121; Z00.129
CPT codes: 99381–99382; 99391–99392

Child and Adolescent Well-Care Visits: $15
Criteria: Members between the ages of 3–21 who had at least 1 comprehensive well-care visit with their PCP
Diagnosis codes: Z00.121; Z00.129

CPT codes: 99382–99385; 99392–99395

Completion of Healthy Michigan Health Risk Assessment: $25

$25 received by fax
$50 entered into CHAMPS

Criteria: One per member per measurement year; members must maintain or select a healthy behavior

$50 for each of these CM/CC codes that does not have a state assigned Medicaid rate:

• G9001 Comprehensive Assessment
• G9002 In-Person Care Management/Care Coordination Encounter
• G9007 Care Team Conferences
• G9008 Provider Oversight
• 98966 Telephone Care Management/Care Coordination Services
• 98967 Telephone Care Management/Care Coordination Services
• 98968 Telephone Care Management/Care Coordination Services
• 98961 Education/Training for Patient Self-Management
• 98962 Education/Training for Patient Self-Management
• S0257 End of Life Counseling
  

PCPs have a new opportunity to earn incentives for the submission of Social Determinant of Health (SdoH) ICD-10 Z codes (Z55-Z65 and Z75) based on the results of SdoH assessments. Providers who submit SdoH-related Z codes for 5% of their seen members will earn a $0.50 PMPM payment while providers who submit these codes for 10% of their seen members will earn a $1.00 PMPM payment. Membership for the PMPM payment will be based on the provider’s entire assigned membership for the year. Z code incentives will be paid annually at the time of quality incentive payments.