FAQ Directory: HEDIS

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3.15.2018 Care for Older Adults If the medical record contains a notation of a type of advance care plan (e.g., advance directive, actionable medical orders, living will, surrogate decision maker, full code, DNR) with documentation of “yes” or “no,” does this meet criteria?

If “yes” is documented for a type of advance care plan, this is considered evidence that a member has an advance care plan in place and meets criteria. If “no” is documented, this is considered evidence that the member does not have this type of advance care plan in place and does not meet criteria. For example, documentation of “DNR – No” indicates “the member does not have a DNR,” and does not meet criteria. In addition, documentation of “no” is not considered evidence of an advance care planning discussion (asking if a member has an advance care plan in place and documenting “no” is not considered a discussion). 

HEDIS 2018

2.15.2018 Transitions of Care A member is admitted to the hospital on December 30, 2016, and discharged in January 2017. To meet criteria, the Notification of Inpatient Admission must occur on either December 30 or 31, 2016, but the measure description states that the four elements must occur during the measurement year. Can we count the Notification of Inpatient Admission that occurs in the year prior to the measurement year?

Yes. In the scenario above, Notification of Inpatient Admission may be on the admission date or on the following date, even if it occurs in the year prior to the measurement year. The member in this example remains in the measure because the discharge date was in January 2017. Unless the patient’s PCP or ongoing care provider was involved in the patient’s care prior to the admission (e.g., conducted the patient’s pre-admission exam), a communication on the admission date or the date following meets criteria for the Notification of Inpatient Admission numerator.

HEDIS 2018

2.15.2018 ECDS General Guidelines Should organizations include only paid claims for ECDS measures?

No. Organizations must include all paid, suspended, pending and denied claims for ECDS measures. Currently, ECDS General Guideline 4 states to include only services for which the reporting entity has paid or expects to pay, but because none of the other eligible sources require payment status, any claims should be accepted. The guideline is incorrect and will be corrected for HEDIS 2019

HEDIS 2018

2.15.2018 Adolescent Well-Care Visits Does sports participation meet the criterion for physical developmental history?

Yes. Documentation of participation in sports or in physical activity meets the criterion for physical developmental history. Bright Futures states that a goal of observing development in adolescents is to determine whether they are developing skills for becoming healthy adults—such as good nutrition and physical activity.

HEDIS 2018

1.15.2018 Prenatal and Postpartum Care Is the ability to choose EDD or date of delivery based on the member level or on the organization level?

The determination whether to use EDD or date of delivery is made at the member level. Flexibility is allowed because in the case of pre- or post-term deliveries, the delivery date may not be the most accurate date for determining the first trimester.

HEDIS 2018

1.15.2018 Transitions of Care The criteria for TRC Notification of Inpatient Admission states that notification should occur on the day of admission or the following day. However, one bullet states that evidence of tests ordered by the PCP during the inpatient stay is valid, as well. If a member stays in the hospital for 10 days, and there is no evidence of the PCP ordering tests until day 4 of the stay, it is this compliant for the indicator?

No. To be compliant for the indicator, documentation that the PCP/care provider ordered tests/ treatment to occur during the inpatient stay must be documented on the day of admission or on the following day. Documentation on day 4 does not count.

HEDIS 2018

12.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update states that documenting preadmission exams and communicating planned admissions are not limited to the time frame criteria as other evidence for the Notification of Inpatient Admission indicator. Are there time frames that must be met?

No. There are no additional time frame requirements for preadmission exams or communicating about planned admissions, other than what is documented in the measure specifications. For example, it may meet the standard time frame (on the day of admission or the following day) or it may occur earlier. To prevent information from "different discharges" from being counted, the measure requires that it "must clearly pertain to the denominator event."

HEDIS 2018

12.15.2017 Controlling High Blood Pressure When confirming a hypertension diagnosis, a code from the Essential Hypertension Value Set can be used. This value set includes only ICD-10 codes. May ICD-9 codes be used to confirm the diagnosis?

Yes. Organizations may look back any time during a member’s history to confirm the diagnosis (including when ICD-9 codes were in use). Documentation of ICD-9 diagnosis codes 401.0, 401.1 or 401.9 may also confirm a diagnosis of hypertension.

HEDIS 2018

12.15.2017 Reporting Requirements Last year, NCQA added the IS 3.1 standard in the Roadmap, stipulating that if a facility is mapped to a provider type, all providers at the facility must be of that provider type. Clarify this standard and whether a majority-mapping should be allowed this year. If so, at what level should it be enforced? Should a percentage of providers on the facility roster be of the mapped type, or is it preferable to review for whether a certain percentage of sampled services on claims be those typically received with the provider type? Should all mapped facilities be investigated individually, or is it acceptable to review the two or three with the highest volume?

For HEDIS reporting, NCQA does not allow blanket mapping a facility to a provider type, unless all providers who render services at the facility meet requirements for the provider type.

For HEDIS measures with a provider-type requirement, the information must be present for the service to be counted. For a facility to be mapped to a PCP (or another provider type) the organization must provide evidence that everyone at the facility meets the provider type requirement.

NCQA does not have an acceptable threshold allowance for auditors to audit against. Each facility must be reviewed individually. The auditor determines the impact of each facility's data on measures that require a particular provider type. From there, the auditor must review, with a level of certainty, who practices at the facility, the services they are contracted to perform and the potential impact to measures if an unacceptable provider renders a service that might count for a measure.

HEDIS 2018

12.15.2017 Unhealthy Alcohol Use Screening and Follow-Up In the HEDIS 2018 Volume 2 Technical Update memo, the updated measure specification for Unhealthy Alcohol Use Screening and Follow-Up (ASF) now indicates there are three strata, but the specifications still note there are four. Which is correct?

There are three strata. The text should be revised in the following two places:

  • Page 43, under “Single-Question (Positive) Response,” bullet 1 should reference “Males (Male AdministrativeGender Value Set) in Strata 1–2”; bullet 3 should reference “All members in Stratum 3.”
  • Page 44, “Single-Question (Negative) Response,” bullet 1 should reference “Males (Male AdministrativeGender Value Set) in Strata 1–2 and bullet 3 should reference “All adults in Stratum 3.”

HEDIS 2018

11.15.2017 Hospitalization for Potentially Preventable Complications On Page 37 of the HEDIS 2018 Volume 2 Technical Update memo, the “Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers” and “Number of Chronic ACSC Outliers and Acute ACSC Outliers” reporting categories have the same description.
Should the first reporting category listed above state ‘non-outlier’ instead of ‘outlier’?

Yes; the specifications should read “Reporting: Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers:The number of chronic ACSC non-outlier members and the number of acute ACSC non-outliers for each age and gender group and the overall total.”

HEDIS 2018

11.15.2017 Supplemental Data Is it acceptable to flag records in a supplemental data file as paid or denied when there is no payment attached to the records in the file?

No. It is not acceptable to classify a supplemental data source as paid or denied unless it is known whether the data in the data source were paid or denied. This is especially true when the data are being used for measures that require claims payment statuses (e.g. LBP, NCS). Organizations should not assume services were denied services just because there isn't a payment status associated with them. For measures where payment status is required, the auditor must be able to validate that the payment status is accurate.

HEDIS 2018