Administrative bulletin: 2026-10-003 Quality information

Professional and facility Providers

Breast Cancer Screening (BCS)

KEY POINT: Breast cancer is the most common cancer among U.S. women (excluding some skin cancers). Providers should routinely recommend and ensure mammography for patients ages 40–74 as screening saves lives, expands treatment options, and lowers overall health care costs.

Effective January 1, 2027, Capital Blue Cross will no longer reimburse for the following codes for Commercial and Medicare Advantage.

Best practices:

• Utilize Theon™ for open gap reports, to manage returned records, and supplemental data submissions.
• Submit the appropriate ICD-10 diagnosis code for a history of bilateral mastectomy or any of the other exclusionary codes, as this is an administrative measure.
• Contact your Population Health Consultant for questions or concerns.

Exclusions:

• Members who died during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
  • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
  • Living long-term in an institution any time during the measurement period.
• Members 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
  • Frailty. At least two indications of frailty with different dates of service during the measurement period.
  • Advanced illness. Either of the following during the measurement period or the year prior to the measurement period:
    • Advanced illness on at least two different dates of service.
    • Dispensed dementia medication.
• Members who had a bilateral mastectomy or both right and left unilateral mastectomies any time during their history through the last day of the measurement period.
  • Any combination that indicates a mastectomy of both the left and right sides on the same date of service or different dates of service
• Gender-affirming chest surgery with a diagnosis of gender dysmorphia at any time in the member’s history through the end of the measurement period.

Resources:

Breast Cancer Screening (BCS) - NCQA

Follow-up After Emergency Department Visit for Patients with Multiple High-Risk Chronic Conditions (FMC)

KEY POINT: Providers are encouraged to conduct and document follow up service within 7 days of the ED visit (8 total days, including same day visits) for members 18 years of age and older who have multiple high-risk chronic conditions. Tips and best practices for the FMC measure are outlined below.

The HEDIS^® measure evaluates the percentage of emergency department (ED) visits, on or between January 1 and December 24, for members 18 years of age and older who have multiple high-risk chronic conditions and who had a follow-up service within 7 days of the ED visit, including visits that occur on the date of the ED visit (8 total days).

Measure specifications:

Administrative only HEDIS^® measure. Medicare Star measure weight: 1.

Members who have been diagnosed with at least two of the following chronic conditions are included in this measure. (For example, COPD and asthma are considered the same chronic condition):

• COPD, asthma, or unspecified bronchitis.
• Alzheimer's disease and related disorders.
• Chronic kidney disease.
• Depression.
• Heart failure.
• Acute myocardial infarction.
• Atrial fibrillation.
• Stroke and transient ischemic attack.

The following meet criteria for follow-up:

• Outpatient visit, telehealth, or telephone visit.
• E-visit or virtual check-in.
• Transitional care-management services, case management visits, complex care management services.
• Outpatient or telehealth behavioral health services.
• Electroconvulsive therapy.
• Community mental health center visit.
• Intensive outpatient encounter or partial hospitalization.
• Substance use disorder service.
• Physician, Physician Assistant, Registered Nurse, Licensed Practical or Vocational Nurse, or Medical Assistant can conduct telephone visits.

Theon™ documentation requirements:

This measure is now available for supplemental data submission in Theon™.

Exclusions:

Patients are excluded from this measure if they have any of the following:

• Had an ED visit resulting in acute or non-acute inpatient care on the day of the visit or within 7 days after the ED visit, regardless of the principal diagnosis for admission.
• Utilized hospice or hospice services in the measurement year.
• Persons with a date of death in the measurement year.

Best practices:

• Utilize FMC daily report (received via email daily from Capital).
• Utilize Admission, Discharge, and Transfers (ADT) alerts.
• Optimize electronic health record integration between ED and office.
• Evaluate workflow for timeliness of follow-up.
• Educate members and caregivers on the value of follow-up.
• Schedule follow-up on behalf of the member prior to discharge.
• Assess and address barriers: cognition, language, equity, Social Determinants of Health (SDOH), etc.
• Assess member need for additional support: Care management, Pharmacy.
• Utilize Theon™ Care Collaborator's Recent ED Visit icon on the patient panel dashboard.

Please refer to Capital’s Comprehensive Performance Measures Guide for more information related to applicable coding guidance. The guidelines will be periodically updated to include new coverage guidance.

Osteoporosis Management in Women Who Had a Fracture (OMW)

KEY POINT: To ensure timely osteoporosis care and prevent future fractures, women aged 67-85 years of age who have suffered a fracture should receive a bone mineral density (BMD) test or a prescription for a drug to treat osteoporosis within 180 days (6 months) after the fracture.

Intake period: 12-month (one-year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The intake period is used to capture the first fracture.

Routes of closure: Claims or supplemental submission through Theon™

Medicare star measure weight: 1

Codes included in the current HEDIS^® measure

Exclusions:

• Fractures of finger, toe, face, and skull are not included in this measure.
• A BMD in any setting during the 24 months prior to the date of the fracture.
• Members who, 12 months prior to the fracture:
  • Had claims or encounters for osteoporosis therapy, OR
  • Were dispensed prescription medication or had an active therapy to treat osteoporosis.
• Medicare enrollees, 67 years of age and older as of the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
  • Enrolled in an Institutional SNP (I-SNP) any time during the intake period through the last day of the measurement period.
• Living long-term in an institution any time during the measurement period as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the intake period through the last day of the measurement period.
• Persons 67–80 years of age by the last day of the measurement period, with both frailty and advanced illness.
  • Frailty. At least two indications of frailty with different dates of service during the measurement period.
  • Advanced illness. Either of the following during the measurement period or the year prior to the measurement period: Advanced illness on at least two different dates of service. OR Dispensed dementia medication (Donepezil, Donepezil/Memantine, Galantamine, Memantine, Rivastigmine).
• Persons 81 years of age and older as of the last day of the measurement period, with frailty.
  • Persons with at least two indications of frailty with different dates of service during the measurement period.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Members who died during the measurement year.

Theon™ documentation requirements:

• Member’s name.
• 2nd identifier (e.g., DOB).
• A 3rd identifier is required for a recent name change that does not match in Theon™. Accepted 3rd identifiers are the member's address, subscriber ID, or last 4 digits of social security number.
• Bone mineral density (BMD) test.
• Osteoporosis therapy.
• Dispensed osteoporosis medications.

Best practices:

• Schedule members for an office visit as soon as possible after an event occurs.
• To help prevent women from being included in this measure incorrectly, please check that fracture codes are not used before a fracture has been verified through imaging.
• Utilize Theon™ for open gap reports, to manage returned records and supplemental data submissions. Use of data reports included in the clinical package had information on the members that are recoverable and non-recoverable.
• Contact your Population Health Consultant for questions or concerns.

Plan All-Cause Readmission (PCR)

KEY POINT: Helpful information is provided about the PCR measure, including tips for addressing the measure.

Measure importance:

Health risks associated with hospitalization are high and often include infection, adverse drug events, loss of function, isolation, negative quality of life, and even costly readmissions. Managing care transitions is an essential point in managing members’ overall care. Literature supports that, often costly, readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse outcomes for patients.¹

Not all preventable readmissions can be avoided; most potentially preventable readmissions can be prevented if the best quality of care is rendered and clinicians are using current standards of care. Hospital readmissions may indicate poor care or missed opportunities to coordinate care better. Research shows that specific hospital-based initiatives to improve communication with beneficiaries and their caregivers, coordinate care after discharge, and improve the quality of care during the initial admission can avert many readmissions.²

The Plan All-Cause Readmission (PCR) HEDIS measure aims to distinguish readmissions from complications of care and pre-existing comorbidities.³ This measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days for members 18 years of age and older in the following categories:

• Count of Index Hospital Stays.
• Count of 30-Day Readmissions.
• Average Adjusted Probability of Readmission.

Exclusions:

• In hospice or using hospice services anytime during the measurement year.
• Admission date is the same as the discharge date.
• Member died during inpatient stay.
• Acute inpatient hospital admission for a principal diagnosis of pregnancy.
• Principal diagnosis originating in the perinatal period.
• Hospital Stays if the direct transfer's discharge date is after December 1 of the measurement year.

Which services count?

Include all services, whether they are paid or expecting to pay (include denied claims) when applying risk adjustment in the Risk Adjusted Utilization measures. Do not include denied services (only include paid services and services expected to be paid) when identifying all other events (e.g., the IHS in the PCR measure or observed events in the other risk-adjusted utilization measures).

Best practices:

• Establish clinical pathways and standardized EMR order sets to manage and document discharges and follow-up outreach effectively.
• Educate patients on understanding their diagnosis, managing their medications, self-care, learning to understand discharge instructions, diet, and communicating with their healthcare team. Assess patient understanding and provide re-teaching or referrals to condition educators as needed.
• Perform medication reconciliation with the patient/caregiver to verify current medications, adverse side effects affecting the desire to take medications, any changes or additions to the medication regimen, and the patient’s ability to afford prescribed medications and take them as directed.
• Identify and manage barriers to non-compliance: knowledge gaps, health literacy, language, cost, cognition, transportation, financial, etc.
• Contact Capital's Care Management at 888.545.4512 to support transitions in care.
• Use motivational interviewing to help members commit to required visits with their primary care provider and set goals for taking their medications.
• Refer to Capital's Comprehensive Performance Measures Guide for information about CPT codes, exclusions, and documentation requirements. The most recent version of Capital's Comprehensive Performance Measures Guide can be found on Capital's Clinical Quality and Education page. The page provides easy access to various resources, including Capital's HEDIS Measure Exclusion Guide and Theon™ Guidance, as well as additional materials.

Contact your Provider Engagement or Population Health consultant with any questions.

¹Medicare Payment Advisory Commission. “Data Book: Health Care Spending and the Medicare Program.” Baltimore, MD: MedPAC, 2015. Available at http://medpac.gov/documents/reports/june-2015-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf?sfvrsn=0 (Accessed May 4, 2016)

²Gallagher, B., L. Cen and E.L. Hannan. 2005. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.1636 (Accessed October 13, 2008)

³Gallagher, B., L. Cen and E.L. Hannan. 2005. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.1636 (Accessed October 13, 2008)