FAQ Directory: HEDIS

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10.15.2018 Plan All-Cause Readmissions Organizations are instructed to use the file run date to determine the member’s SES stratification in the last 3 months of the continuous enrollment period. For the PCR measure, the continuous enrollment period is 365 days prior to the Index Discharge Date through 30 days after that date. How is a member’s SES stratification determined if the run date falls after the end of the continuous enrollment period?

When determining the SES stratification for PCR, use the last month of the continuous enrollment period, regardless of the run date. For example, if the continuous enrollment period ends July 1, use May, June and July to assess the member’s SES stratification, regardless of the run date of the July Monthly Membership Detail Data File.

HEDIS 2019

10.15.2018 Plan All-Cause Readmissions In General Guideline 15: Members With Dual Enrollment, the Medicare-Medicaid (MMP) subhead indicates that these members must be in both the Medicaid and Medicare HEDIS reports. Does this apply to Plan All-Cause Readmissions (PCR)?

No. For PCR, MMP members are removed from Medicaid reporting and are included in only Medicare reporting.

HEDIS 2019

10.15.2018 Total Membership How should organizations handle dually enrolled members for the Total Membership (TLM) measure? Should organizations follow the "total unduplicated membership" rule, or should they follow General Guideline 15 and count the member twice (where applicable)?

Organizations should refer to General Guideline 15 in the HEDIS 2019 Volume 2 publication for guidance on reporting members with dual enrollment for the TLM measure. However, when General Guideline 15 allows members to be included in more than one product line deduplicate and count members only once in the measure as follows:

 -Report members with dual Medicaid/Medicare enrollment in the Medicare product line.       

 –For other dual enrolled members report the members in the primary product line.

HEDIS 2019

9.14.2018 Risk of Continued Opioid Use In the HEDIS 2019 Volume 2 Technical Specifications, the Risk of Continued Opioid Use (COU) measure includes the Medicare product line; however, this measure was not included in the CMS Reporting Requirements memo for HEDIS 2019. Given this discrepancy, is the COU measure reported by Medicare plans?

The COU measure does include the Medicare product line, and it will be collected in IDSS by NCQA from Medicare plans; however, because it was not included in the CMS Reporting Requirements memo, it is not required to be reported to CMS for HEDIS 2019.

HEDIS 2019

7.16.2018 Use of Opioids at High Dosage Why is buprenorphine included in the Use of Opioids From Multiple Providers (UOP) and Risk of Continued Opioid Use (COU) measures, but not in the Use of Opioids at High Dosage (UOD) measure?

Unlike UOP and COU, UOD requires the conversion of all dispensed opioids into morphine milligram equivalents (MME). The most current MME conversion file, published by the Centers for Disease Control and Prevention, removes buprenorphine, a partial opioid agonist, and states that the drug is not likely to be associated with overdose in the same dose-dependent manner as pure opioid agonists. NCQA removed it from the UOD measure in HEDIS 2019. This change aligns with the decision made by the Pharmacy Quality Alliance, the organization that developed the measure from which UOD was adapted for use in HEDIS.

HEDIS 2019

7.16.2018 General Guidelines Does a member enrolled in palliative care meet criteria for the hospice exclusion outlined in General Guideline 17?

Palliative care is not the same as hospice care because it can begin when a patient is diagnosed or is undergoing treatment and may not indicate being near end of life. The hospice exclusion requires evidence that the member is receiving hospices services. Documentation that a member is in palliative care is not part of the exclusion.

HEDIS 2019

5.15.2018 ECDS Do you utilize FHIR to specify ECDS measures?

No. HEDIS ECDS measures use Quality Data Model (QDM) 5.3 as the reference model, although NCQA is researching the use of FHIR as a possible option.  

HEDIS 2018

5.15.2018 ECDS How do ECDS measures differ from the eMeasures in Meaningful Use (eCQMs)?

HEDIS ECDS measures are similar to eCQMs in structure, but although eCQMs are reported at the provider level, using data from an EHR, ECDS measures are reported at the health-plan level, using data from multiple sources to form a complete picture of the patient’s experience across the care continuum.

HEDIS 2018

5.15.2018 ECDS What data standards does NCQA use to specify ECDS measures?

HEDIS ECDS measures use the Quality Data Model (QDM) and Clinical Quality Language (CQL) HL7 standards for quality measurement.

HEDIS 2018

5.02.2018 Plan All-Cause Readmissions For the Count of Expected 30-Day Readmissions, we are using the calculation in Step 6 in HEDIS Volume 2 (pg. 384), but IDSS is calculating differently. Is this calculation correct?

The calculation for the Count of Expected 30-Day Readmissions is incorrect in Volume 2. IDSS currently calculates this field by using the formula "Count of Expected 30-Day Readmissions" = "Expected Readmission Rate" * "Count of Index Stays".

Please provide data for the Expected Readmission Rate and the Count of Index Stays and IDSS will use these values to generate the correct calculation. 
 

HEDIS 2018

3.15.2018 Transitions of Care If an organization reports the measure using the hybrid method and reports two indicators using administrative data from one provider, is the organization limited to only the medical record of that provider when searching for medical record documentation for the other indicators?

No. The Notification of Inpatient Admission and Receipt of Discharge Information indicators do not have to be documented in the same provider chart as the indicators that were reported administratively. Organizations may search the medical record of a different provider for those indicators that were not reported using administrative data.
 

HEDIS 2018

3.15.2018 Plan All-Cause Readmissions There is a discrepancy between Step 7 in the Risk Adjustment Weighting section (page 384) and in all the PCR reporting tables for how to calculate the Expected Readmissions Rate. Which one is correct?

Organizations must use the formula in Step 7 to calculate the Expected Readmissions Rate for PCR. The reference in the PCR reporting tables of the “(Expected Readmissions/Den)” is incorrect. The data element should only be “Expected Readmissions Rate.” This removal of the incorrect calculation instruction will be made in the Interactive Data Submission System (IDSS) and data dictionaries. 

HEDIS 2018