Mount Carmel Health Partners HEDIS Tip Sheets

HEDIS Tip Sheet Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy for Rheumatic Arthritis (RA) Definition: Percentage of members ages 18 and older who were diagnosed with rheumatoid arthritis (RA) and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). Service Needed: At least one ambulatory prescription dispensed for a DMARD during the measurement year (this can be fulfilled through pharmacy data or claim/encounter data). Coding: HCPCS Injection, abatacpet, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self- administered) Injection, adalimumab, 20 mg Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is selfadministered) Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) Injection, gold sodium thiomalate, up to 50 mg Injection, golimumab, 1 mg, for intravenous use Injection, infliximab, excludes biosimilar, 10 mg Injection, tocilizumab, 1 mg Cyclosporine, oral, 100 mg Cyclosporine, oral, 25 mg Cyclosporine, parenteral, 250 mg Mycophenolate mofetil, 180 mg Mycophenolic acid, oral, 180 mg Methotrexate sodium, 5 mg Methotrexate sodium, 50 mg Injection, rituximab, 100 mg J0129 J0135 J0717 J1438 J1600 J1602 J1745 J3262 J7502 J7515 J7516 J7517 J7518 J9250 J9260 J9310 Exclusions: One of the following: • Diagnosis of pregnancy in the measurement year. • Diagnosis of HIV at any time in the past through December 31 of the measurement year. • Hospice care in the measurement year. Chart Review Tips: • Review the "Notes", "Medical History", or "Consult" section to find the diagnosis from either primary care physician or specialist and for any exclusions. • If patients have a diagnosis of RA, review their medication list to ensure they are on one of the below medications. 23

Mount Carmel Health Partners HEDIS Tip Sheets | Page 23