Use proper coding to improve HEDIS^® scores for appropriate antibiotic treatment

Antibiotic resistance is a known and growing problem, and misuse of antibiotics is the main culprit. More than 90 percent of the time, the cause of acute bronchitis is viral, yet many patients are prescribed antibiotics. Although antibiotics are inappropriate for viral infections, there are times when patients may have a compromising comorbid condition or a competing bacterial diagnosis. In situations like these, an antibiotic is appropriate and necessary.

Blue Cross Blue Shield of Michigan recently contacted a subset of Blue Cross health care providers who prescribed an antibiotic for acute bronchitis or upper respiratory infection. The outreach revealed that patients commonly had a comorbid condition to justify the antibiotic, but diagnosis codes were simply not documented.

When an antibiotic is prescribed, be sure to include the diagnosis code for the bacterial infection or comorbidity. It’s important that you include this information and the correct exclusion codes, when necessary, because HEDIS^® antibiotic measurement data is captured through diagnosis codes and prescription claims. See the table below for an overview of HEDIS antibiotic measures and exclusions.

For additional information about these measures and other key HEDIS measures, see our "Clinical quality corner tip sheets" on web-DENIS.

Want to know how you’re performing on antibiotics and other HEDIS^® measures? Access Health e-Blue and check out the quality summary report. See screen shot below for a look at the type of information you’ll find in the report.

If you have questions about this article, contact RxQualityPrograms@bcbsm.com.