FAQ Directory: HEDIS

Yes. According to the CMS HEDIS 2016 reporting requirements memo, MMPs are required to report all measures in Table 3. This includes COA, even though it is referenced as being SNP-only.

HEDIS 2016

Yes. As a result of changes to the measure, the two example lists were combined into a single list to remove redundancy. All examples that met criteria in HEDIS 2015 meet criteria for HEDIS 2016. Urine dipsticks are considered “spot urine” tests so they meet criteria based on the example, “Spot urine for albumin or protein.”

HEDIS 2016

No. Because CPT Category II codes and HCPCS are standard codes they are not eligible for mapping (the value sets include all standard codes that have been identified as appropriate for use in HEDIS reporting). The Category II and HCPCS codes included in PQRS measures were created specifically for use in PQRS reporting and are not appropriate for use in reporting HEDIS measures. If a service or procedure was rendered by a provider, the expectation is that the provider will submit a claim to the health plan for the service or procedure; the codes expected to be on the claim are included in the HEDIS value sets and identify the member for the HEDIS measure.

HEDIS 2016

No. The WHP 2016 Reporting Tool audit designations will not be updated because the tool and specifications were released prior to these changes. Organizations should report WHP measures for 2016 using the existing WHP Reporting Tool. Any updates will be included in the 2017 WHP Reporting Tool, which will be released on March 31, 2016.

HEDIS 2016

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

HEDIS 2016

Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.

HEDIS 2016

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

HEDIS 2016

Yes. Unless the measure specification directs otherwise, use diagnosis and procedure codes from both facility and professional claims to identify an admission or discharge event.

HEDIS 2016

When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.

The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).

HEDIS 2016

Yes. For Medicare reporting, exclude members who elect to use the hospice benefit (i.e., use hospice service) any time during the measurement year. These members must be removed prior to determining the measure’s eligible population and drawing the sample for hybrid measures.

HEDIS 2016

The reported rate calculation is the sum of all numerator events by administrative data, medical record data and supplemental data, divided by the eligible population for administrative measures, or by the denominator for hybrid measures (i.e., reported rate = numerator events by administrative data + numerator events by medical record data + numerator events by supplemental data / eligible population or denominator).

HEDIS 2016

If any data is found in a supplemental data source, it is considered a supplemental data hit because the member would not be compliant for the measure/indicator without the data source.

HEDIS 2016