FAQ Directory: HEDIS

General Guideline 25 in HEDIS Volume 2 explains that benefits are not assessed at the service level. Assessment of benefits must follow the measure specifications under the Benefit section of the Eligible Population criteria. Organizations may not assess benefits at a service level for an NB (No Benefit) audit designation. 

For example:

·    If the organization offers a pharmacy benefit but does not cover a specific medication class, the member has a pharmacy benefit and is included in the applicable measures requiring this benefit.

·    If the organization offers a mental health benefit but does not cover inpatient visits, the member has a mental health benefit and is included in the applicable measures requiring this benefit, unless the measure benefit requires inpatient care, per the Eligible Population benefit requirements (e.g., Follow-up After Hospitalization for Mental Illness requires both inpatient and outpatient mental health coverage).

HEDIS 2019

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be fewer than 10. Plans should determine why members are reported as “Unknown” and be able to explain the reason to their auditor.

This category should not be used for members who are disenrolled for the 2019 calendar year and consequently have no record in the December 2018 Monthly Membership Detail File. Use the October and November files for these members.

HEDIS 2019

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.

HEDIS 2019

No. When pharmacy data are used as supplemental data, a dispense date is required; a start date may not be used as a proxy. There are no exceptions to the requirements for pharmacy data, as described in General Guideline 30.

HEDIS 2019

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-A. Remove the “Total Medicare” row from Table PCR-B that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-A. The asterisked language may also be removed under these two tables.

HEDIS 2019

Yes. This meets criteria for HEDIS 2019 reporting because the documentation indicates that the eye exam was completed by an eye care professional (optometrist or ophthalmologist), the date when the procedure was performed was within the appropriate time frame and the results are present (a negative retinal exam in the year prior to the measurement year).

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

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI or 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. For all measures that require a result, the actual numeric value of the result must be present in the supplemental data to meet criteria. For example, when reporting the BP control indicator of the CDC measure, documentation of the code 3078F alone in the supplemental data cannot be used to indicate a diastolic level that is less than 80. The actual diastolic value (e.g., 79) must be present in the supplemental data to meet criteria. It is appropriate for the approved data to be mapped to code 3078F (or applicable codes) to integrate into vendor or internal systems for measure calculation. Mapping would need to be reviewed and approved by the auditor.

The only exceptions to this are described in a General Guideline FAQ posted 11/15/2018. The exceptions described in the 11/15 FAQ are for the ABA and WCC measures. When reporting the BMI indicators for both measures, height and weight do not need to be in the supplemental data, but the actual BMI value or BMI percentile, with the date, must be present. For the counseling for physical activity indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria. For counseling for nutrition indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria.

HEDIS 2019

No. The covered days are not required to be consecutive when reporting the numerators of the measure. Review all dispensed opioids on the IPSD through the 30-day or 62-day period and follow the instructions for calculating number of days covered for the numerator. For example, if the IPSD is 1/1/18 and the member has an eligible prescription with a 5-day supply and another eligible prescription with a 10-day supply on 1/10/18, the member meets criteria for the ≥15 Days Covered numerator.
 

HEDIS 2019

NCQA expects plans to disenroll deceased members. Members who died during the continuous enrollment period would not meet the measure’s eligible population criteria (e.g., continuous enrollment and anchor date requirements) and would not be included in the measure denominator. However, a member who meets the continuous enrollment criteria remains in the measure. For example, when reporting the MRP measure, a member who was discharged on July 1 and died on August 1, but enrollment data indicates the member is enrolled in the organization during the continuous enrollment period (the date of discharge through 30 days after discharge) must remain in the measure.

Keep in mind that organizations may not use other data sources (e.g., medical record data) when removing deceased members.
 

HEDIS 2019

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