FAQ Directory: HEDIS

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI percentile code only when there is an associated diagnosis (e.g., overweight, obesity) that meets the new requirements.  “Healthy weight” is not considered an associated diagnosis. As a result, members in the denominator, whose only visit is in October, November, or December of 2018, without an appropriate ICD-10 code, due to the lack of an associated diagnosis, will not have claims that meet the current numerator criteria.

NCQA’s analysis shows that, because this measure is reported primarily through the hybrid-reporting option, the effect will be small. This change does not affect organizations using the hybrid method, because the rule pertains to only the use of ICD-10 codes on claims. It does not prohibit providers from measuring and documenting a BMI in the medical record.
 

HEDIS 2019

Yes. The new rounding directions in step 4 are meant to treat the calculated decimal result as a whole number from 0%–100% for the SAA and MMA measures. For example, if a member has 291 total days covered by a medication during a 365-day treatment period, this calculates to 0.7972. Multiply this number by 100, convert it to 79.72% and round it to 80%, the nearest whole number.

HEDIS 2019

Yes. The intent is to allow organizations to apply the optional exclusion for both the administrative and hybrid specifications. When using the administrative specification, organizations must use the codes in the value sets to identify members who meet optional exclusion criteria. When using the hybrid specification, organizations should look for evidence of ESRD, kidney transplant, dialysis, pregnancy or a nonacute inpatient admission during the measurement year in order to identify members who meet optional exclusion criteria.

Keep in mind that all exclusions are subject to auditor review.

HEDIS 2019

EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.

HEDIS 2019

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events when the diagnosis category is the same for both events. For example, an ED visit for alcohol disorder that resulted in an inpatient stay for alcohol disorder is reported only once in the “Inpatient Stay” category. However, an ED visit for alcohol disorder that resulted in an inpatient stay for opioid disorder is reported in both the ED category (alcohol diagnosis category) and the Inpatient Stay category (opioid diagnosis category). An ED visit for alcohol disorder that resulted in an inpatient stay for something other than an alcohol, opioid or other or unspecified drug disorder (e.g., heart attack) is reported only once in the “ED” category.

HEDIS 2019

Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.

HEDIS 2019

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.

HEDIS 2019

No. Rural Health Clinics are not addressed in the updated PCP definition in Volume 2. All providers billing under the Rural Clinic facility codes must meet the definition of “PCP” in Appendix 3 in order to be included in the PCP-based HEDIS measures.

HEDIS 2019

Yes. Plans may use administrative data to report HEDIS ECDS measures. Administrative data are a relevant data source and are one of four categories of data for ECDS reporting. If a plan’s administrative data files contain all the information it needs for a measure, it does not need additional data.

HEDIS 2019

No. Although this plan type may have a slight advantage in accessing medical records because of its integrated system, EMRs do not necessarily contain comprehensive information on individuals. Many other data sources qualify as ECDS data sources, and plans are encouraged to utilize every reliable source of member data.

HEDIS 2019

No. Plans do not need to be able to populate information directly into a provider EMR to meet this requirement. Plans can meet the requirement if they can provide requested information (phone, secure email, direct feed, provider portal, file request) to providers who are treating their members. Plans should have documented processes for providing information on how this works to be reviewed as part of the audit.

HEDIS 2019

No, the difference in the language is not intentional and the reference to “on the discharge claim” was unintentionally excluded. Step 3 for Acute ACSC should contain the same language as step 3 for chronic ACSC. In step 3 for ACSC, for the remaining acute inpatient and observation stay discharges, organizations should identify discharges with specified criteria on the discharge.

HEDIS 2019