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FAQ Directory: HEDIS

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11.15.2018 Transitions of Care When reporting Notification of Inpatient Admission and Receipt of Discharge Information indicators using an integrated EMR system, is a “received date” required in the EMR if the information was in the shared EMR on the day of admission/discharge or on the following day?

No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.

HEDIS 2019

11.15.2018 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis If a member is included in the ART measure due to a rule-out diagnosis, may the member be removed from the denominator based on medical record documentation indicating an incorrect diagnosis of rheumatoid arthritis?

No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.

HEDIS 2019

11.15.2018 Transitions of Care When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?

Yes. When the PCP or ongoing care provider is the discharging provider, they must document the required discharge information specified in the measure. This must be done in the patient's outpatient medical record on the day of discharge or on the following day.

HEDIS 2019

11.15.2018 SES Guidelines To calculate a member’s SES stratification, the instructions say to evaluate whether the member’s LIS values (item 35) are the same or different in the last 3 months of continuous enrollment (CE). How do you determine if a value is the same or different?

A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:

  • Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.
           Example:
           October       LIS = 35
           November   LIS = 40
           December   LIS = -35
  • Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.
          Example:
          October       LIS = 0
          November   LIS = -35
          December   LIS = 35

 

HEDIS 2019

11.15.2018 All ECDS Measures What is Source of Payment (SOP) Typology?

The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.  

Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.

SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.  
Example steps for plan classification using SOP Typology: 

1. Plan needing typology classification: Harvard Pilgrim Health  
2. Determine main category for first digit: 5 (Commercial) 
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO) 
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)  

HEDIS 2019

11.15.2018 Transitions of Care When reporting the Patient Engagement After Inpatient Discharge indicator, if the member is unable to communicate with the provider, does an interaction between the member’s caregiver and the provider meet criteria?

Yes, if the interaction meets criteria based on the measure specifications. The caregiver is not required to be designated as the patient’s legal guardian for the interaction to count toward the measure.  

HEDIS 2019

10.15.2018 Standardized Healthcare-Associated Infection Ration The HEDIS® 2019 Volume 2 Technical Specifications Update announced the suspension of the Standardized Healthcare-Associated Infection Ration (HAI) measure for all product lines. This change causes a discrepancy between the CMS Reporting Memo and HEDIS 2019 Volume 2 Technical Specifications. Will CMS clarify what must be reported for HEDIS 2019 for Medicare?

Yes. CMS released a clarification, through Health Plan Management System (HPMS) on October 12, 2018, that HAI has been suspended and is not required for HEDIS 2019 reporting. If you have additional questions about CMS requirements, contact HEDISquestions@cms.hhs.gov.

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

10.15.2018 Rules for Allowable Adjustments The General Guidelines in the Rules for Allowable Adjustments states, “use the separate HEDIS Adjustments VSD to calculate measure rates stemming from adjusted measure specification.” Does this mean that ONLY the HEDIS Adjustments VSD must be used?

No. The Allowable Adjustments VSD does not contain the standard HEDIS value sets; standard HEDIS value sets are in the HEDIS 2019 Volume 2 VSD. The Allowable Adjustments VSD includes only SNOMED and LOINC codes that are not in the Volume 2 VSD. Organizations collecting data using the rules for allowable adjustments can elect (but are not required) to use the value sets in the Allowable Adjustments VSD.

HEDIS 2019

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 Required Exclusions Are members who are excluded because of hospice, advanced illness, frailty, Institutional SNP (I-SNP) or living long-term in an institution (LTI) included in the “Number of required exclusions” data element?

No. Only members who meet the criteria in the section of the measure labeled “Required exclusions” are included when reporting the “Number of required exclusions” data element.

HEDIS 2019

10.15.2018 Follow-Up After ED visit for People With Multiple High-Risk Chronic Conditions In Step 2 (Exclusions), ED visits followed by admission to an inpatient care setting on the date of the visit or within 7 days after the visit are excluded. Should ED visits that result in an inpatient stay (when the ED date of service occurs any time during the admission [admission date through discharge date]) also be excluded?

Yes. Exclude ED visits that result in an inpatient stay.

HEDIS 2019