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hedismeasure.pdf.pdf
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
HEDIS ® 101 for Providers Improving Quality of Care
Author: Provider Engagement Team Document Contact: B. Thompson-HEDIS Quality Team
Please read from page 32
Outline
2
HIPAA 3 What is HEDIS? 4 What is your role in HEDIS? 5 Annual HEDIS Calendar 6 Types of Reviews 7 Medical Record Request 8 Hybrid HEDIS Measures 9 Questions & Answers 10 Appendix 1 - Hybrid HEDIS Measures & Required Documentation
11-31
Appendix 2 - Summary List HEDIS Measures 32-38 Appendix 3 – HEDIS Physician Documentation 39-57 Appendix 4 – HEDIS Survey Data 58-64
HIPAA
3
Under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS is permitted, and the release of this information requires no special patient consent or authorization. Please be assured our members’ personal health information is maintained in accordance with all federal and state laws. Data is reported collectively without individual identifiers. All of the health plans’ contracted providers’ records are protected by this.
HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities.
• HEDIS is a performance measurement tool that is coordinated and administered by NCQA (National Committee for Quality Assurance) and used by Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of managed care organizations
• All managed care companies who are NCQA accredited perform HEDIS reviews the same time each year
• A subset of HEDIS measures will be collected and reported for the Marketplace (healthcare exchanges) product lines
• HEDIS is a retrospective review of services and performance of care
• Results are used to measure performance, identify quality initiatives, and provide educational programs for providers and members
4
What is HEDIS?
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Healthcare
Effectiveness
Data and
Information
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• You play a central role in promoting the health of our members
• You and your office staff can help facilitate the HEDIS process improvement by:
• Providing the appropriate care within the designated timeframes
• Documenting all care in the patient’s medical record
• Accurately coding all claims
• Responding to our requests for medical records within 5-7 days
5
What is your role in HEDIS?
We appreciate your cooperation and timeliness in submitting the requested medical record information
The records you provide us during this process help us to
validate the quality of care provided to our members.
NCQA has set a hard deadline of May 15 for health plans to gather HEDIS data
Annual HEDIS Calendar
6
Jan-May 15 Clinical Quality Staff collects HEDIS data (Medical Record Reviews)
July - Oct NCQA releases Quality Compass results nationwide
• July – Commercial Edition • Sep/Oct – Medicaid and
Medicare Editions
June Results are reported to NCQA
Types of Reviews
HEDIS data are collected three ways:
• Administrative Data: Obtained from our claims database
• Hybrid Data: Obtained from our claims database and medical record reviews
• Survey Data: Obtained from member and provider surveys
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• Medical Record Requests are faxed to providers
• The request includes a member list identifying their assigned measures and the minimum necessary information needed
• Data collection methods include: fax, mail, onsite visits for larger requests, remote electronic medical record (EMR) system access, and electronic data interchange via a secure site
• Due to the shortened data collection timeframe, a 5- to 7-day turnaround is appreciated.
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Medical Record Requests
EMR: If you have EMR/EHRs and would be interested in electronic data submission, please contact your state lead to see if it is possible with your system
We recommend uploading records to our secure site to allow for better tracking of information submitted.
Hybrid HEDIS Measures
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ABA - Adult Body Mass Index AWC - Adolescent Well Care Visits CBP - Controlling High Blood Pressure CCS - Cervical Cancer Screening CDC - Comprehensive Diabetes Care CIS - Childhood Immunization Status COA - Care of Older Adults (Medicare SNP*) COL - Colorectal Cancer Screening FPC - Frequency of Prenatal Care HPV - Human Papillomavirus Vaccine for Female Adolescents IMA - Immunizations for Adolescents LSC - Lead Screening in Children MRP - Medication Reconciliation Post-Discharge (Medicare SNP only*) PPC - Prenatal and Postpartum Care WCC - Weight Assessment/Counseling for Nutrition & Physical Activity for Children/Adolescents W15 - Well Child Visits in the first 15 months of life W34 - Well Child Visits in the 3rd, 4th, 5th and 6th Years of Life *SNP = Special Needs Population
Questions & Answers
Should you send the entire record? No, we ask that you only provide the minimum necessary to meet our request.
Who do I contact if I have questions about HEDIS requests? Each medical record request includes contact information for a member in Clinical Quality who is assigned to your office.
How to improve scores for HEDIS measures? Use of correct diagnosis and procedure codes, timely submission of claims and encounter data, ensure presence of ALL components in the medical record documentation
How are HEDIS rates communicated to physicians? Educational articles are included in provider newsletters, which can be found on the health plan’s website
Where can I get more information about NCQA and HEDIS? More information can be found at www.ncqa.org
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Appendix 1
COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
HEDIS HYBRID Measures and Required Documentation
Documentation must include: • BMI (body mass index): Date and
Value • Weight: Date and Value
Common Chart
Deficiencies: • Height and/or weight are documented
but there is no calculation of the BMI • Ranges and thresholds are not
acceptable for this measure. A distinct BMI value or percentile is required
12
ABA – Adult BMI Assessment
Members age 18-74 who had an outpatient visit with a BMI documented during the measurement year or the year prior
May use BMI percentile for members younger than 19 years on date of
service
13
Members 12-21 years old in the measurement year that have had at least ONE “Well Care” visit with a PCP or OB/GYN (school physical, pap, post partum visit) during the measurement year
*Medicaid
AWC – Adolescent Well-Care Visits*
Documentation must include:
• Health and developmental history (physical and mental)
• Physical exam • Health education/anticipatory guidance
Preventive services may be rendered on visits other than well-child visits.
Common Chart Deficiencies:
• Lack of documentation of education and anticipatory guidance
• Adolescents being seen for sick visits only and no documentation related to well-child visits
Documentation must include: • Date of Hypertension diagnosis on or
before June 30th of the measurement year
• Last BP Reading (date and result) in the measurement year
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CBP – Controlling High Blood Pressure
Members 18-85 years old with diagnosis of Hypertension prior to June 30th of the measurement year
Diagnosis can be from progress note, problem list, consult note, hospital admission or discharge
Common Chart Deficiencies: • Rechecked elevated pressures during the
same visit not documented • Diagnosis date of hypertension is not
clearly documented
Documentation must include: • Date and result of cervical cancer
screening test –or- • Date and result of cervical cancer
screening test and date of HPV test on the same date of service –or-
• Evidence of hysterectomy with no residual cervix
Common Chart Deficiencies: • Lack of documentation related to
women’s health in PCP charts • Incomplete documentation related to
hysterectomy • HPV’s ordered due to positive PAP’s
do not count 15
CCS – Cervical Cancer Screening*
Female members 24-64 during the measurement timeframe (measurement year and two years prior) who had cervical cancer screening –or –
Female members ages 35-64 who had cervical cancer screening and HPV test (measurement year and four years prior)
*Commercial/Medicaid
Documentation must include: • Hemoglobin A1C* • Blood Pressure* • Nephropathy: Urine Tests, ACE/ARB
prescription, or visits to nephrologists • Retinal Eye Exam (during the
measurement year or year prior)
Common Chart
Deficiencies: • Incomplete information from
consultants in the PCP charts • Incomplete information related to
yearly lab testing and results
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CDC – Comprehensive Diabetes Care
Members 18-75 with Type I and II Diabetes who received proper testing and care for diabetes during the measurement year
*Date and result of last screening in the measurement year
Documentation must include: 4 DTAP 3 IPV
3 HIB 3 HEP B
1 MMR 4 Pneumococcal (PCV)
1 HEP A 2 Influenza
2 or 3 Rotavirus/RV Rotarix = 2 dose
Rota Teq = 3 dose
1 VZV or has had chickenpox
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CIS – Childhood Immunization Status
Percentage of children 2 years of age who had all of the required immunizations
If missing any immunizations, please include: • Documentation of parental refusal • Documentation of request for delayed
immunization schedules • Immunizations given at health
departments • Immunizations given in the hospital at
birth • Documentation of contraindications or
allergies
18
CIS – Childhood Immunization Status
Percentage of children 2 years of age who had all of the required immunizations
Common Chart Deficiencies: • Immunizations received after the 2nd
birthday • PCP charts do not contain
immunization records if received elsewhere
• Health Departments • Immunizations that are given in
the hospital at birth • No documentation of
Contraindications/Allergies
Documentation must include: 1. Advance care planning
Includes a discussion about preferences for resuscitation, life sustaining treatment and end of life care. Examples include:
• Advance Directives • Actionable Medical Orders • Living Will
2. Medication review Includes at least one medication review with the presence of a medication list or includes notation that the member is not taking any medication
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COA – Care of Older Adults*
The percentage of adults 66+ years who had each of the following during the measurement year.
*Medicare SNP only
Documentation must include: 3. Functional status assessment
Includes evidence of at least one functional status assessment and the date it was performed as documented by:
• Instrumental Activity of Daily Living (IADL) – or -
• Activities of Daily Living (ADL) – or - • Results of a standardized functional
status assessment tool – or – • Notation that at least 3 of the 4
following were assessed: notation of functional independence, sensory ability, cognitive status, and ambulatory status
4. Pain assessment Includes evidence of a pain assessment using a standardized pain assessment tool and the date it was performed
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COA – Care of Older Adults*
The percentage of adults 66+ years who had each of the following during the measurement year.
*Medicare SNP only
Documentation must include: Date and result of one of these screenings: • Colonoscopy (within last 10 years) • FOBT (in measurement year) • Flexible Sigmoidoscopy (within last 5
years)
21
COL - Colorectal Cancer Screening
Members age 50-75 who had appropriate screening for colorectal cancer
Patient reported data noted on a medical record is sufficient evidence with date and results noted.
Common Chart Deficiencies: • Colorectal screenings are not consistently
documented in health histories • Typically this information is included on
health history forms; however, this information is not always provided as part of the record submissions.
Documentation must include:
• Date and documentation of all prenatal visits
22
FPC - Frequency of Ongoing Prenatal Care*
Female members who delivered a live birth on or between November 6 of prior year to November 5 of the measurement year and were continuously enrolled 42 days prior to delivery
*Medicaid
Most of this information is found on the ACOG sheets
Common Chart Deficiencies:
• Must be “unduplicated” prenatal visits. If there is an office visit and the provider orders an U/S and labs and they are done on separate days, all three would only count as one date of service. Labs, U/S and other procedures cannot be counted separate from the visit with the prenatal care provider
Documentation must include:
• 3 HPV shots
Common Chart Deficiencies:
• HPV vaccines administered prior to a member’s 9th birthday or after the 13th birthday cannot be counted
• PCP charts do not contain immunization records if received elsewhere, i.e. Health Departments
• All three immunizations in the series not documented
23
HPV – Human Papillomavirus Vaccine for Female Adolescents
Female adolescent members who had 3 doses of the HPV vaccine on or between their 9th and 13th birthdays
If immunizations are missing please include: • Documentation of parental refusal • Health Department records • Patient Contraindications/allergies
IMA- Immunizations for Adolescents
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Adolescent members turning 13 in the measurement year who had these immunizations
Documentation must include:
• Meningococcal: 1 dose on or between 11th & 13th birthdays
• Tdap/TD: 1 dose on or between 10th & 13th birthdays
Common Chart Deficiencies:
• Immunizations not administered during appropriate timeframes
• PCP charts do not contain immunization records if received elsewhere, i.e. Health Departments
If immunizations are missing please include: • Documentation of parental refusal • Health Department records • Patient Contraindications/allergies
Documentation must include:
25
LSC – Lead Screening in Children*
• A note indicating the date the test was performed, and
• The result or finding
Common Chart Deficiencies:
• Lead assessment does not constitute a lead screening
The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday *Medicaid
Documentation includes: Medication reconciliation completed by the prescribing practitioner, clinical pharmacist or registered nurse on or within 30 days of discharge. Need documentation that it was completed and the date that it was done. Any of the following evidence meets criteria:
1. Notation that the medications prescribed upon discharge were reconciled with the current medication in the outpatient record – or -
2. A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications – or -
3. Notation that no medications were prescribed upon discharge
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MRP – Medication Reconciliation Post-Discharge*
The percentage of discharges from 1/1 – 12/1 of the measurement year for members 66+ for whom medications were reconciled on or within 30 days of discharge. *Medicare SNP
Documentation must include:
• Prenatal Care: Prenatal visit within 42 days of enrollment or during the first trimester
• Postpartum Care: Post-partum visit within 21-56 days of delivery
Common Chart Deficiencies:
• Incision check for post C-section does not constitute a postpartum visit
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PPC - Prenatal and Postpartum Care
Female members who delivered a live birth between November 6 of the year prior and November 5 of the measurement year
Most of this information is found on the ACOG sheets
Documentation must include: BMI (body mass index) Percentile
• BMI Percentile date and value • May be a BMI value for adolescents age
16-17 on date of service • Ranges and thresholds do not meet the
criteria for this measure • Weight date and value • Height date and value
Counseling for Nutrition: Discussion on diet and nutrition, anticipatory guidance or counseling on nutrition
Counseling for Physical Activity: Discussion of current physical activities, counseling for increased activity, or anticipatory guidance on activity
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WCC – Weight Assessment & Counseling for Nutrition & Physical Activity for Children/ Adolescents
Members age 3-17 who had an outpatient visit with the following components in the measurement year
Common Chart Deficiencies:
• BMI documented as number not percentile based on height, weight, age and gender
• BMI growth chart not included in records submitted
• Anticipatory guidance does not always specify what areas were addressed and are not always age appropriate
• Developmental milestones do not constitute anticipatory guidance or education for physical activity
• Preprinted forms do not always address nutrition and physical activity
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WCC – Weight Assessment & Counseling for Nutrition & Physical Activity for Children/ Adolescents
Members age 3-17 who had an outpatient visit with the following components in the measurement year
30
W15 – Well Child Visits in the First 15 Months of Life*
Children 0-15 months of age during the measurement year who had 6 or more well-child visits
*Medicaid
Preventive services may be rendered on visits other than well-child visits.
Documentation must include:
• Health and developmental history (physical and mental)
• Physical exam • Health education/anticipatory guidance
Common Chart Deficiencies:
• Lack of documentation of education and anticipatory guidance
• Children being seen for sick visits only and no documentation related to well-child visits
31
W34 – Well Child Visits in the 3rd, 4th, 5th & 6th Years of Life*
Children 3-6 years old in the measurement year that have had at least ONE “Well Care” visit with a PCP during the measurement year
*Medicaid
Preventive services may be rendered on visits other than well-child visits.
Documentation must include:
• Health and developmental history (physical and mental)
• Physical exam • Health education/anticipatory guidance
Common Chart Deficiencies:
• Lack of documentation of education and anticipatory guidance
• Children being seen for sick visits only and no documentation related to well-child visits
Appendix 2 Summary List of HEDIS Measures
Summary List of HEDIS Measures
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HEDIS 2015 Measures Applicable to:
Data Source Commercial Medicaid Medicare
Effectiveness of Care
Adult BMI Assessment 9 9 9 Hybrid Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents
9 9 Hybrid
Childhood Immunization Status 9 9 Hybrid
Immunizations for Adolescents 9 9 Hybrid
Human Papillomavirus Vaccine for Female Adolescents 9 9 Hybrid
Lead Screening in Children 9 Hybrid
Breast Cancer Screening 9 9 9 Admin
Cervical Cancer Screening 9 9 Hybrid
Non-recommended Cervical Cancer Screening in Adolescent Females 9 9 Admin
Colorectal Cancer Screening 9 9 Hybrid
Chlamydia Screening in Women 9 9 Admin Non-Recommended PSA-Based Screening in Older Men (PSA) (New) 9 Admin
Care for Older Adults 9 (SNP only) Hybrid
Appropriate Testing for Children With Pharyngitis 9 9 Admin
Summary List of HEDIS Measures
34
HEDIS 2015 Measures Applicable to:
Data Source Commercial Medicaid Medicare Effectiveness of Care
Appropriate Treatment for Children With Upper Respiratory Infection 9 9 Admin
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 9 9 Admin
Use of Spirometry Testing in the Assessment and Diagnosis of COPD 9 9 9 Admin
Pharmacotherapy Management of COPD Exacerbation 9 9 9 Admin
Use of Appropriate Medications for People With Asthma 9 9 Admin
Medication Management for People With Asthma 9 9 Admin
Asthma Medication Ratio 9 9 Admin
Controlling High Blood Pressure 9 9 9 Hybrid Persistence of Beta-Blocker Treatment After a Heart Attack 9 9 9 Admin
Comprehensive Diabetes Care 9 9 9 Hybrid
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 9 9 9 Admin
Osteoporosis Management in Women Who Had a Fracture 9 Admin
Use of Imaging Studies for Low Back Pain 9 9 Admin
Summary List of HEDIS Measures
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HEDIS 2015 Measures Applicable to:
Commercial Medicaid Medicare Data Source Effectiveness of Care
Antidepressant Medication Management 9 9 9 Admin
Follow-Up Care for Children Prescribed ADHD Medication 9 9 Admin
Follow-Up After Hospitalization for Mental Illness 9 9 9 Admin
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
9 Admin
Diabetes Monitoring for People With Diabetes and Schizophrenia 9 Admin
Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia 9 Admin
Adherence to Antipsychotic Medications for Individuals With Schizophrenia 9 Admin
Use of Multiple Concurrent Antipsychotics in Children and Adolescents (NEW) 9 9 Admin
Metabolic Monitoring for Children and Adolescents on Antipsychotics (NEW) 9 9 Admin
Annual Monitoring for Patients on Persistent Medications 9 9 9 Admin
Medication Reconciliation Post-Discharge 9 (SNP only) Hybrid Potentially Harmful Drug-Disease Interactions in the Elderly 9 Admin
Use of High-Risk Medications in the Elderly 9 Admin
Summary List of HEDIS Measures
36
HEDIS 2015 Measures Applicable to:
Data Source Commercial Medicaid Medicare
Medicare Health Outcomes Survey 9 HOS Survey
Fall Risk Management 9 HOS Survey
Management of Urinary Incontinence in Older Adults 9 HOS Survey
Osteoporosis Testing in Older Women 9 HOS Survey
Physical Activity in Older Adults 9 HOS Survey
CAHPS Health Plan Survey 9 9 9 CAHPS Survey
Aspirin Use and Discussion 9 9 CAHPS Survey
Flu Shots for Adults Ages 18 –64 9 9 CAHPS Survey
Flu Shots for Adults Ages 65 & Older 9 CAHPS Survey
Medical Assistance With Smoking and Tobacco Use Cessation 9 9 9 CAHPS Survey
Pneumococcal Vaccination Status for Older Adults 9 CAHPS Survey
Access/Availability of Care
Adults’ Access to Preventive/ Ambulatory Health Services 9 9 9 Admin
Children’s and Adolescents’ Access to Primary Care Practitioners 9 9 Admin
Annual Dental Visit 9 Admin
Summary List of HEDIS Measures
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HEDIS 2015 Measures Applicable to:
Data Source Commercial Medicaid Medicare
Access/Availability of Care Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 9 9 9 Admin
Prenatal and Postpartum Care 9 9 Hybrid
Call Answer Timeliness 9 9 9 Admin Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (NEW)
9 9 Admin
Experience of Care
CAHPS Health Plan Survey 5.0H, Adult Version 9 9 Survey
CAHPS Health Plan Survey 5.0H, Child Version 9 9 Survey
Children With Chronic Conditions 9 9 Survey
Utilization and Relative Resource Use
Guidelines for Utilization Measures 9 9 9 Admin and Hybrid
Frequency of Ongoing Prenatal Care 9 Hybrid
Well-Child Visits in the First 15 Months of Life 9 9 Commercial - Admin Medicaid - Hybrid
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 9 9
Commercial - Admin Medicaid - Hybrid
Adolescent Well-Care Visits 9 9 Commercial - Admin Medicaid - Hybrid
Frequency of Selected Procedures 9 9 9 Admin
Summary List of HEDIS Measures
38
HEDIS 2015 Measures Applicable to:
Data Source Commercial Medicaid Medicare
Utilization and Relative Resource Use
Ambulatory Care 9 9 9 Admin Inpatient Utilization—General Hospital/ Acute Care 9 9 9 Admin
Identification of Alcohol and Other Drug Services 9 9 9 Admin
Mental Health Utilization 9 9 9 Admin
Antibiotic Utilization 9 9 9 Admin
Plan All-Cause Readmissions 9 9 Admin
Guidelines for Relative Resource Use Measures 9 9 9 Admin
Relative Resource Use for People With Diabetes 9 9 9 Admin Relative Resource Use for People With Cardiovascular Conditions 9 9 9 Admin
Relative Resource Use for People With Hypertension 9 9 9 Admin
Relative Resource Use for People With COPD 9 9 9 Admin
Relative Resource Use for People With Asthma 9 9 Admin
Appendix 3 HEDIS ® 2015 Physician Documentation
HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
Each HEDIS measure identified below has criteria that is required for your patient’s chart or claims review to be considered valid towards HEDIS measurement. To make the most of your office visits towards meeting HEDIS measures, please document the following criteria as applicable.
HEDIS Measure Member Description Documentation Requirements Codes
Adolescent Well-Care Visits (AWC) 12-21 year old members Well-Care visits during the measurement year with the following: • Health Education/Anticipatory Guidance (diet,
exercise, junk food, drugs, smoking, suicide, contraception) and
• Health & Developmental History (peer relationships, school achievement, hobbies, sexually active or not) and
• Physical Exam (height, weight, BMI, blood pressure, heart, lungs, abdomen)
CPT®: 99381-99385, 99391-99395, 99461
ICD-9-CM: V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8 and V70.9
HCPCS:G0438, G0439
Adult BMI Assessment (ABA) Medicare Health Plan Rating Measure
18-74 year old members BMI documented during the measurement year or the year prior to the measurement year: • BMI: date and result • Weight: date and result
ICD-9-CM: V85.0-V85.5
Codes To Identify Outpatient Visits:
CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
HCPCS: G0402, G0438, G0439, G0463
UB Revenue: 0510-0517, 0519-0523, 0526-0529, 0982, 0983
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®HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Current Procedural Terminology © 2014 American Medical Association. All rights reserved. 1CPT codes copyright 2014 American Medical Association. All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
HEDIS Measure Member Description
Documentation Requirements Codes
Breast Cancer Screening (BCS) 50-74 year old women One or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.
CPT®: 77055-77057 ICD-9-CM: 87.36, 87.37 HCPCS: G0202, G0204, G0206 UB Revenue: 0401, 0403
Mastectomy Codes: ICD-9-CM: 85.41-85.48
CPT®: 19180, 19200, 19220, 19240, 19303-7
Bilateral Modifiers: 50, 09950 Cervical Cancer Screening (CCS) Women age 21-64 who
had cervical cytology performed every 3 years
Evidence of cervical cytology within last 3 years (date and result)
CPT®: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Revenue: 0923
LOINC® (Cervical): 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
Same as above and one of the following:
CPT®: 87620-87622
LOINC® (HPV): 21440-3, 30167-1, 38372-9, 49896-4, 59420-0
Women age 30-64 who had cervical cytology/HPV co-testing performed every 5 years
For women that do not meet above criteria, evidence of cervical cytology and an HPV test on the same date of service during the measurement year or the four years prior to the measurement year. (date and result)
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LOINC® is a registered trademark of the Regenstrief Institute.
HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
HEDIS Measure Member Description Documentation Requirements Codes
Childhood Immunization Status (CIS) Members turning 2 years of age
Vaccines administered on or before 2nd birthday: 3 IPV 1 VZV 4 DTaP 1 MMR 3 Hib 1 Hep A 3 Hep B 2 Flu 4 PCV/ Prevnar 2-3 RV
IPV CPT®: 90698, 90713, 90723 DTaP CPT®: 90698, 90700, 90719, 90721, 90723; Hib CPT®: 90645-90648, 90698, 90721, 90748 Hep B CPT®: 90723, 90740, 90744, 90747, 90748; HCPCS: G0010 ICD-9-CM: 070.2x, 070.3x and V02.61 Prevnar CPT®: 90669, 90670; HCPCS: G0009 VZV CPT®: 90710, 90716: ICD-9-CM: 052.x, 053.x MMR CPT®: 90707, 90710 Measles CPT®: 90705 ICD-9-CM: 055.x Measles and Rubella CPT®: 90708 Mumps CPT®: 90704 ICD-9-CM: 072.x Rubella CPT®: 90706 ICD-9-CM: 056.x Rubella Antibody CPT®: 86762 LOINC®: 13279-5, 13280-3, 17550-5, 22496-4, 22497-2, 24116-6, 25298-1, 25420-1, 25514-1, 31616-6, 34421-8, 40667-8, 41763-4, 43810-1, 49107-6, 50694-9, 51931-4, 52986-7, 5330-6, 5331-4, 5332-2, 5333-0, 5334-8, 5335-5, 63462- 6, 8013-5, 8014-3, 8015-0 Hep A CPT®: 90633; ICD-9-CM: 070.0, 070.1 Flu CPT®: 90655, 90657, 90661, 90662, 90673, 90685 HCPCS: G0008 RV 90681 (2 dose) and RV 90680 (3 dose) Varicella Zoster (VZV) CPT®: 90710, 90716 ICD-9-CM: 052.0, 052.1, 052.2, 052.7, 052.8, 052.9, 053.0, 053.1x, 053.2x, 053.71, 053.79, 053.8, 053.9
42
HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
HEDIS Measure Member Description Documentation Requirements Codes
Children and Adolescents’ Access to Primary Care Practitioners (CAP)
Members 12 months– 19 years of age
The percentage of children 12 months - 19 years of age who had a visit with a PCP during the measurement year.
Codes to Identify Outpatient Visits: CPT®: 99201-99205, 99211-99215, 99241-99245,99341-99345, 99347- 99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429 UB Revenue: 0510-0517, 0519-0523, 0526-0529, 0982, 0983 HCPCS: G0402, G0438, G0439, G0463 Codes to identify general medical exams: ICD-9-CM: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Colorectal Cancer Screening (COL) Medicare Health Plan Rating Measure
50-75 year old members
Documentation (date and result) of one or more of these screenings: • Colonoscopy during measurement year or 9
years prior; • FOBT during measurement year; • Flexible Sigmoidoscopy during measurement
year or 4 years prior or • Diagnosis of colorectal cancer
FOBT: CPT®: 82270, 82274 HCPCS: G0328 LOINC®: 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 2335-8, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56790-6, 56491-4, 57905-2, 58453-2
Flexible Sigmoidoscopy:
CPT®: 45330-45335, 45337-45342, 45345 HCPCS: G0104 ICD-9-CM: 45.24
Colonoscopy:
CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 HCPCS: G0105, G0121; ICD-9-CM: 45.22, 45.23, 45.25, 45.42, 45.43
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HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
HEDIS Measure Member Description Documentation Requirements Codes
Comprehensive Diabetes Care (CDC) Medicare Health Plan Rating Measure
18-75 year old members with type 1 or type 2 diabetes
The percentage of members 18-75 with diabetes who had each of the following: • HbA1c testing and result* • Blood Pressure* • Medical attention to nephropathy (micro/macro urine,
ACE/ARB medication therapy) in measurement year • Retinal eye exam performed by an eye care
professional in measurement year or year prior *Date and result of last screening in the measurement year
Diabetes Diagnosis ICD-9-CM: 250.0x-250.9x, 357.2, 362.01-362.07, 366.41, 648.0x
HbA1c Screen CPT®: 83036 and 83037
CPT ®Cat II: 3044F, 3045F, 3046F
LOINC® : 17856-6, 4548-4, and 4549-2
Eye Exams CPT®: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203- 99205, 99213-99215, 99242-99245 CPT ®Cat II: 2022F, 2024F, 2026F, 3072F HCPCS: S0620, S0621, S0625, S3000
Nephropathy Screen CPT®: 82042, 82043, 82044 and 84156 CPT ® Cat II: 3060F, 3061F
LOINC®: 11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 1753-3, 1754-1, 1755-8, 1757-4, 18373-1, 20621-9, 20159-1, 21482-5, 26801-1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 9318-7
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HEDIS Measure Member Description Documentation Requirements Codes
Comprehensive Diabetes Care (CDC) – Continued
Medicare Health Plan Rating Measure
Nephropathy Treatment
CPT®: 3066F, 4010F
ICD-9-CM: 250.40-250.43, 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.0x, 404.90-404.93, 405.01, 405.11, 405.91, 580.0, 580.4, 580.81, 580.89, 589.9, 581.0, 581.1-581.3, 581.81, 581.89, 581.9, 582.0-582.4, 582.81, 582.89, 582.9, 583.0-583.7, 583.81, 583.89, 583.9, 584.5-584.9, 585.1- 585.3, 585.9, 586, 587, 588.0, 588.1, 588.81, 588.89, 588.9, 753.0, 753.10- 753.19, 791.0
Controlling High Blood Pressure (CBP) Medicare Health Plan Rating Measure
18-85 year old members with diagnosis of hypertension
• Date of diagnosis of hypertension before June 30 of the measurement year from a problem list, office note, SOAP note, encounter form, diagnostic report or hospital discharge summary and
• Last BP reading (date & result) in the measurement year (if elevated, document all BP readings)
Hypertension diagnosis: ICD-9-CM: 401.0, 401.1, 401.9
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HEDIS Measure Member Description Documentation Requirements Codes
Disease-modifying Antirheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis (ART) Medicare Health Plan Rating Measure
Members diagnosed with rheumatoid arthritis and dispensed at least one ambulatory prescription for a DMARD in 2014
Assess all members with diagnosis of rheumatoid arthritis for DMARD treatment in 2014 All members not currently treated with a DMARD should be referred for rheumatology consultation to confirm diagnosis and assess for DMARD therapy
DMARDS include: Aminoquinolines: Hydroxychloroquine 5-Aminosalicylates: Sulfasalazine Alkylating agents: Cyclophosphamide Anti-rheumatics: Auranofin, gold sodium thiomalate,
leflunomide, methotrexate, penicillamine Immunomodulators: Abatacept, adalimumab,
anakinra, certolizumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, Tocilizumab
Immunosuppressive agents: Azathioprine, cyclosporine, mycophenolate
Tetracyclines: Minocycline Janus kinase inhibitor (JAK): Tofacitinib
Codes To Identify Rheumatoid Arthritis:
ICD-9-CM: 714.0, 714.1, 714.2, 714.81 HCPCS: J0129, J0135, J0717, J0718, J1438, J1600, J1602, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310
Codes To Identify Outpatient Visits:
CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347- 99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
HCPCS: G0402, G0438, G0439, G0463 UB Revenue:
0510-0517, 0519-0523, 0526-0529, 0982, 0983
AND/OR Pharmacy claim for DMARD in 2014
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HEDIS Measure Member Description Documentation Requirements Codes
Follow-up After Hospitalization for Mental Illness (FUH)
Members 6 years and older with a follow up visit after hospitalization for mental illness
The percentage of discharges for members who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, intensive outpatient encounter of partial hospitalization with a mental health practitioner.
The percentage of discharges for which the member received follow-up within 7 days and 30 days of discharge
ICD-9-CM: 290, 293-299, 300, 301, 302, 306-316
CPT® Stand Alone Visits: 98960- 98962, 99078, 99201-99205, 99211-99220, 99241-99245, 99341-99350, 99383-99387, 99393-99397, 99401-99404, 99411-99412, 99510
CPT® FUH Visits: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90870, 90875-90876, 99221-99223, 99231-99233, 99238-99239, 99251-99255
CPT® Transitional Care Management: 99495-99496
HCPCS: G0155, G0176-G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0040, H2000-H2001, H2010-H2020, M0064, S0201, S9480, S9484- S9485
UBREV: 0513, 0900-0907, 0911- 0919, 0510, 0515-0529, 0982- 0983
HEDIS® Measure 2015 Physician Documentation Guidelines and Administrative Codes
HEDIS Measure Member Description Documentation Requirements Codes
Frequency of Ongoing Prenatal Care (FPC)
Women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year
All prenatal records for a delivery that occurred between November 6 of the year prior to the measurement year and November 5 of the measurement year
Refer to Prenatal and Postpartum Care - Prenatal Rate - (PPC)
Human Papillomavirus Vaccine for Female Adolescents (HPV)
13 year old female adolescents
3 doses of HPV vaccine administered on or between ages 9 and 13 years old
CPT®: 90649, 90650
Immunizations for Adolescents (IMA)
13 year old adolescents Vaccines administered on or before their 13th birthday: • 1 MCV/meningococcal vaccine on or between 11th & 13th
birthdays –and- • 1 Tdap or 1 Td vaccine on or between their 10th and 13th
birthdays
Meningococcal CPT:® 90733 and 90734
Tdap CPT®: 90715
Td CPT®: 90714 and 90718
Tetanus CPT®: 90703
Diphtheria CPT:® 90719 Lead Screening in Children (LSC) Members 0-2 years of age At least one capillary or venous blood lead test report
dated on or before the second birthdate CPT®: 83655
LOINC®: 10368-9, 10912-4, 14807-2, 17052- 2, 25459-9, 27129-6, 32325-3, 5671-3, 5674- 7
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Medication Management For People with Asthma (MMA)
Members 5–64 years of age
Members having persistent asthma who met at least one of the following criteria during 2014 and 2013.
• At least one ED visit with a principal diagnosis of asthma.
• At least one acute inpatient encounter with a principal diagnosis of asthma.
• At least four outpatient visits or observation visits on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events.
• At least four asthma medication dispensing events.
Asthma ICD-9-CM: 493.00-493.02, 493.10- 493.12, 493.81-493.82, 493.90-493.92
Codes To Identify Outpatient Visits: CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347- 99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
HCPCS: G0402, G0438,G0439,G0463 UB Revenue: 0510-0517, 0519-0523, 0526-0529, 0982, 0983
Codes to Identify Observation Visits: CPT®: 99217-99220 Codes To Identify ED Visits: CPT®: 99281-99285 UB Revenue: 0450-0452, 0456, 0459, 0981 Codes to Identify Acute inpatient Visit: CPT®: 99221-99223, 99231-99233, 99238, 99239, 99251-99255, 99291 UB Revenue: 0100-0101, 0110-0114, 0119-0124, 0129- 0134, 0139-0144, 0149-0154, 0159, 0160, 0164, 0167, 0169, 0200- 0204, 0206-0214, 0219, 0720-0724, 0729, 0987
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HEDIS Measure Member Description Documentation Requirements Codes
Osteoporosis Screening and Management after Fracture (OMW) Medicare Health Plan Rating Measure
Women 67–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.
Perform bone mineral density testing within six months on members 67 years old and older who experience a fracture (fractures of finger, toe, face and skull are not included in this measure.) AND/OR Prescribe a medication to treat osteoporosis FDA-Approved Osteoporosis Therapies
Biphosphonates: Alendronate, alendronate- cholecalciferol, calcium carbonate-risendrate, ibandronate, risedronate, zoledronic acid Other agents: Calcitonin, denosumab, raloxifene, teriparatide
Bone Density Mineral Test CPT®: 76977, 77078, ICD-9-CM: 88.98 HCPCS: G0130, J3489
AND/OR
Osteoporosis Medications HCPCS: J0630, J0897, J1000, J1740, J3110, J3487-J3489
Plan All -Cause Readmissions (PCR) Medicare Health Plan Rating Measure
Members 18 years of age and older; Note: For commercial, report only members 18–64 years of age.
The number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Includes acute readmit to behavioral health facilities.
Acute inpatient: CPT®: 90867-90869, 99221-99223, 99231-99233, 99238, 99239, 99251- 99255, 99291 UB Revenue: 0100-0101, 0110-0114, 0119, 0120- 0124, 0129, 0130-0134, 0139, 0140- 0144, 0149, 0150-0154, 0159, 0160, 0164, 0167, 0169, 0200-0204, 0206- 0214, 0219, 0720-0724, 0729, 0987
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Prenatal and Postpartum Care - Prenatal Rate - (PPC)
NOTE: There are additional antibody LOINC codes for Toxoplasma, Rubella, Cytomegalovirus, and Herpes Simplex that are not included in this slide due to the volume.
Women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year
Prenatal Care visit in the first trimester or within 42 days of enrollment to an OB/GYN practitioner, other prenatal care practitioner or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation must include the visit date and evidence of one of the following: 1) A basic physical obstetrical examination that includes
• Auscultation for fetal heart tone, or • Pelvic exam with obstetric observations, or • Measurement of fundus height (a
standardized prenatal flow sheet may be used),
2) Prenatal Care Procedure: Could be: • Screening test/obstetric panel or • TORCH antibody panel alone, or • A rubella antibody test/titer with an Rh
incompatibility (ABO/Rh) blood typing, or • Ultrasound/Echography of a pregnant
uterus 3) Documentation of LMP or EDD with either
prenatal risk assessment & counseling/education, or complete obstetrical history
CPT®: 59400, 59510, 59610, 59618, 59425, 59426 and 99500 CPT® Cat II: 0500F, 0501F, 0502F HCPCS: H1000-H1004, H1005 UB Rev: 0514 Prenatal Visit - CPT®: 99201-99205, 99211-99215, 99241-99245 with one of the following: • OB Panel CPT®: 80055 • Prenatal Ultrasound CPT®: 76801,
76805, 76811, 76813, 76815- 76821, 76825-76828 ICD-9-CM: 88.78
• Pregnancy Diagnosis ICD-9-CM: 630-679, V22, V23, V28
• Toxoplasma Antibody CPT®: 86777 or Rubella Antibody CPT® : 86782 or Cytomegalovirus Antibody CPT®: 86644 or Herpes Simplex Antibody CPT®: 86694-86696
• Rubella Antibody CPT®: 86782 and ABO CPT®: 86900
• Rubella Antibody CPT®: 86782 and Rh CPT®: 86901
• Rubella Antibody CPT®: 86782 and ABO and RH LOINC: 882-1, 884-7
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HEDIS Measure Member Description Documentation Requirements Codes
Prenatal and Postpartum Care - Postpartum Rate - (PPC)
Women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year
Postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other PCP on or between 21 and 56 days after delivery. Documentation must indicate visit date & evidence of: • Pelvic exam, or • Examination of breasts (or notation of
breastfeeding), abdomen, weight and blood pressure or
• Notation of postpartum care: such as, “6 week check”, “postpartum” visit/care, PP care, or preprinted postpartum care form
CPT®: 57170, 58300, 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622, 88141-88143, 88147, 88148, 88150, 88152-88154, 88164- 88167, 88174, 88175, 99501 CPT®Cat II: 0503F UB Revenue: 0923
ICD-9-CM Diagnosis: V24.1, V24.2,, V25.11-V25.13, V72.31, V72.32, V76.2
ICD-9-CM Procedure: 89.26
HCPCS: G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
Use of Appropriate Medications for People With Asthma (ASM)
5–64 year old members Evidence of appropriately prescribed medication during the measurement year for members with persistence asthma. Asthma medications: Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Long- acting, inhaled beta-2 agonists, Mast cell stabilizers, Methylxanthines, Short-acting, inhaled beta-2 agonists
Asthma ICD-9-CM: 493.00-493.02, 493.10- 493.12, 493.81-493.82, 493.90-493.92
Codes to Identify Acute Inpatient Visits:
CPT ®: 99221-99223, 99231-99233, 99238-99239, 99251-99255, 99291 UB Revenue: 0100-0101, 0110-0114, 0119-0124, 0129-0134, 0139-0144, 0149-0154, 0159-0160, 0164, 0167, 0169, 0200-0204, 0206-0214, 0219, 0720-0724, 0729, 0987
Codes to Identify Observation Visits: CPT ®: 99217-99220
Codes to Identify ED Visits: CPT ®: 99281- 99285
UB Revenue: 0450-0452, 0456, 0459, 0981
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HEDIS Measure Member Description
Documentation Requirements Codes
Use of Imaging Studies for Low Back Pain (LBP)
18–50 year old members
The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Low Back Pain Codes
ICD-9-CM: 721.3, 722.10, 722.32, 722.52, 722.93, 724.02-724.03, 724.2, 724.3, 724.5, 724.6, 724.70-724.71,724.79, 738.5, 739.3-739.4, 846.0-846.3, 846.8- 846.9, 847.2
Codes to Identify Observation Visits: CPT®: 99217-99220
Codes to Identify Outpatient Visits: CPT® : 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347- 99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 HCPCS: G0402, G0438, G0439, G0463 UB Revenue: 051x, 0520-0523, 0526- 0529, 0982, 0983 Codes to Identify ED Visits: CPT®: 99281-99285 UB Revenue: 0450-0452, 0456, 0459, 0981 Codes to Identify Osteopathic Manipulative Treatment: CPT® : 98925-98929, 98940-98942
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Documentation Requirements Codes
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC)
3-17 year old members Evidence of outpatient visit with PCP or OB/GYN containing the following during the measurement year: 1. BMI percentile (may be a BMI value for adolescents
16-17) • BMI date and percentile value ( BMI percentile
plotted on age-growth chart OK) • Weight date and value • Height date and value
2. Counseling for Nutrition (diet) 3. Counseling for Physical Activity (sports
participation/exercise)
BMI:
ICD-9-CM: V85.0-V85.54
Nutrition:
ICD-9-CM: V65.3 CPT®: 97802-97804 HCPCS: G0447, G0270, G0271, S9449, S9452, S9470
Activity:
ICD-9-CM: V65.41 HCPCS: G0447, S9451
Codes to Identify Outpatient Visits: CPT® : 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347- 99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
HCPCS: G0402, G0438, G0439, G0463
UB Revenue: 0510-0517, 0519-0523, 0526-0529, 0982, 0983
Well Child Visits in the First 15 Months of Life (W15)
0-15 month old infants Well-child visits to a PCP with date of visit and ALL of the following: • Health Education/Anticipatory Guidance (i.e. address safety
issues such as infant car seat, sleep on back) AND • Health & Developmental History (i.e. coos, grasps, follows to
midline) AND • Physical Exam (height, weight, heart, lungs, abdomen)
CPT®: 99381-99385, 99391- 99395, and 99461
ICD-9-CM: V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8 and V70.9
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HEDIS Measure Member Description
Documentation Requirements Codes
Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
3-6 year old children Well-child visits with a PCP during the measurement year with the following: • Health Education/Anticipatory Guidance (i.e. address
safety issues bike helmet, pool fences, window guards) AND
• Health & Developmental History (number of words spoken, plays with peers, goes up and down stairs) AND
• Physical Exam (height, weight, BMI, heart, lungs, abdomen)
Codes to Identify Well-Child Visits: CPT®: 99381-99385, 99391-99395, and 99461
ICD- 9-CM: V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8 and V70.9
HCPCS: G0438, G0439
Aspirin Use and Discussion (ASP) CAHPS Survey
Women 56–79 years of age Men 46–79 years of age
Assessing average aspirin use and management in members with risk factors for cardiovascular disease and discussing aspirin risks and benefits with their doctor or health provider.
This measure is collected using consumer survey methodology.
Flu Vaccinations for Adults (FVA and FVO)
CAHPS Survey
FVA = 18-64 year old members (Comm and Medicaid)
FVO = 65 years of age and older (Medicare)
The percentage of members who received an influenza vaccination between July 1 of the measurement year and the date when the survey was completed.
This measure is collected using consumer survey methodology.
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HEDIS Measure Member Description
Documentation Requirements Codes
Getting Needed Care CAHPS Survey
All members Members experience getting needed care; appointments with specialists, tests, or treatment.
This measure is collected using consumer survey methodology.
Medical Assistance With Smoking and Tobacco Use Cessation (MSC)
CAHPS Survey
Members 18 years of age and older
Evidence of advising smokers and tobacco users to quit, discussing cessation medications and strategies for current smokers or tobacco users.
This measure is collected using consumer survey methodology.
Pneumococcal Vaccination Status for Older Adults (PNU)
CAHPS Survey
Members 65+ Percentage of members who have ever received a pneumococcal vaccine.
This measure is collected using consumer survey methodology.
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HEDIS Measure Member Description
Documentation Requirements Codes
CAHPS Health Plan Survey Adult Version (CPA)
Commercial and Medicaid Members
Results summarize member experiences through rates, composite and question summary rates:
Four global rating overall satisfaction: 1. Rating of All Health Care 2. Rating of Health Plan 3. Rating of Personal Doctor 4. Rating of Specialist Seen Most Often
Seven Composite scores summarize responses in key areas:
1. Claims Processing (COMM only) 2. Customer Service 3. Getting Care Quickly 4. Getting Needed Care 5. How Well Doctors Communicate 6. Shared Decision Making 7. Plan Information on Costs (COMM only)
These rates are collected using consumer survey methodology.
CAHPS Health Plan Survey Child Version (CPC)
Commercial and Medicaid Members
Results summarize member experiences through rates, composite and question summary rates:
Four global rating overall satisfaction: 1. Rating of All Health Care 2. Rating of Health Plan 3. Rating of Personal Doctor 4. Rating of Specialist Seen Most Often
Seven Composite scores summarize responses in key areas:
1. Customer Service 2. Getting Care Quickly 3. Getting Needed Care 4. How Well Doctors Communicate 5. Shared Decision Making
These rates are collected using consumer survey methodology.
Appendix 4
HEDIS Survey Data
Survey Data There are measures that are
collected using survey methodology.
CAHPS Health Plan Survey 5.0H, Adult Version and Child Version
This measure provides information on the experiences of our members and indicates how well the organization meets their expectations for our commercial and Medicaid populations NOTE: Medicare members are surveyed using the Medicare CAHPS survey administered by CMS on behalf of Medicare Advantage plans.
Medicare Health Outcomes Survey This measure provides a general indication of how well an organization manages the physical and mental health of its Medicare members by measuring their status at the beginning and the end of a two-year period
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CAHPS Surveys
CAHPS surveys represent an effort to accurately and reliably capture information from consumers about their experiences with health plans:
• The surveys include the past year for Commercial plans and the past six months for Medicaid & Medicare plans.
• Health plans report survey results to NCQA who use the results to: • make accreditation decisions, and
• create national benchmarks for care and service
• Health plans also use CAHPS survey data for internal quality improvement purposes.
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Results summarize member experiences through summary rates for:
1. Rating of All Health Care 2. Rating of Health Plan 3. Rating of Personal Doctor 4. Rating of Specialist Seen
Most Often
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CAHPS Health Plan Survey 5.0 H – Adult Version
CAHPS Health Plan Survey 5.0H, Adult Version
There are two areas that are reported individually:
1. Health Promotion and Education
2. Coordination of Care
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Composite scores also summarize responses for these key areas:
1. Claims Processing 2. Customer Service 3. Getting Care Quickly 4. Getting Needed Care 5. How Well Doctors
Communicate 6. Shared Decision
Making 7. Plan Information on
Costs
This survey provides information on parents’ experience with their child’s health plan. The scores are the same as the adult version with the exception that the key areas reported on for this population are:
1. Customer Service 2. Getting Care Quickly 3. Getting Needed Care 4. How Well Doctors
Communicate 5. Shared Decision Making
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CAHPS Health Plan Survey 5.0 H – Child Version
Provides a general indication of how well a Medicare organization manages the physical and mental health of its members at the beginning and the end of a two-year period. Scores are categorized and percentages reported as:
• Better • Same • Worse than expected
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Medicare Health Outcomes Survey
