Yes. Organizations may look back any time during a member’s history to confirm the diagnosis (including when ICD-9 codes were in use). Documentation of ICD-9 diagnosis codes 401.0, 401.1 or 401.9 may also confirm a diagnosis of hypertension.
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12.15.2017 Controlling High Blood Pressure When confirming a hypertension diagnosis, a code from the Essential Hypertension Value Set can be used. This value set includes only ICD-10 codes. May ICD-9 codes be used to confirm the diagnosis?
12.15.2017 Reporting Requirements Last year, NCQA added the IS 3.1 standard in the Roadmap, stipulating that if a facility is mapped to a provider type, all providers at the facility must be of that provider type. Clarify this standard and whether a majority-mapping should be allowed this year. If so, at what level should it be enforced? Should a percentage of providers on the facility roster be of the mapped type, or is it preferable to review for whether a certain percentage of sampled services on claims be those typically received with the provider type? Should all mapped facilities be investigated individually, or is it acceptable to review the two or three with the highest volume?
For HEDIS reporting, NCQA does not allow blanket mapping a facility to a provider type, unless all providers who render services at the facility meet requirements for the provider type.
For HEDIS measures with a provider-type requirement, the information must be present for the service to be counted. For a facility to be mapped to a PCP (or another provider type) the organization must provide evidence that everyone at the facility meets the provider type requirement.
NCQA does not have an acceptable threshold allowance for auditors to audit against. Each facility must be reviewed individually. The auditor determines the impact of each facility's data on measures that require a particular provider type. From there, the auditor must review, with a level of certainty, who practices at the facility, the services they are contracted to perform and the potential impact to measures if an unacceptable provider renders a service that might count for a measure.
This applies to the following Programs and Years:
HEDIS 201812.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update states that documenting preadmission exams and communicating planned admissions are not limited to the time frame criteria as other evidence for the Notification of Inpatient Admission indicator. Are there time frames that must be met?
No. There are no additional time frame requirements for preadmission exams or communicating about planned admissions, other than what is documented in the measure specifications. For example, it may meet the standard time frame (on the day of admission or the following day) or it may occur earlier. To prevent information from "different discharges" from being counted, the measure requires that it "must clearly pertain to the denominator event."
This applies to the following Programs and Years:
HEDIS 201811.15.2017 DEA or CDS Certificates Is a photocopy of a practitioner's DEA certificate acceptable documentation for CR 3, Element A, factor 2?
11.15.2017 Weeks of Pregnancy at Time of Enrollment The HEDIS 2018 Volume 2 Technical Update memo includes a RAND number for the “Weeks of Pregnancy at Time of Enrollment” measure. Is this correct?
11.15.2017
Hospitalization for Potentially Preventable Complications On Page 37 of the HEDIS 2018 Volume 2 Technical Update memo, the “Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers” and “Number of Chronic ACSC Outliers and Acute ACSC Outliers” reporting categories have the same description.
Should the first reporting category listed above state ‘non-outlier’ instead of ‘outlier’?
Yes; the specifications should read “Reporting: Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers:The number of chronic ACSC non-outlier members and the number of acute ACSC non-outliers for each age and gender group and the overall total.”
This applies to the following Programs and Years:
HEDIS 201811.15.2017 Supplemental Data Is it acceptable to flag records in a supplemental data file as paid or denied when there is no payment attached to the records in the file?
No. It is not acceptable to classify a supplemental data source as paid or denied unless it is known whether the data in the data source were paid or denied. This is especially true when the data are being used for measures that require claims payment statuses (e.g. LBP, NCS). Organizations should not assume services were denied services just because there isn't a payment status associated with them. For measures where payment status is required, the auditor must be able to validate that the payment status is accurate.
This applies to the following Programs and Years:
HEDIS 201811.15.2017 Reporting Requirements The HEDIS 2018 Volume 2 Technical Update memo announced the retirement of “Annual Monitoring for Patients on Persistent Medications (MPM)” for Medicare and the name change from “Inpatient Hospital Utilization (IHU)” to “Acute Hospital Utilization (AHU).” This caused a discrepancy between the CMS Reporting Memo and HEDIS 2018 Volume 2 Technical Specifications. Will CMS release a clarification on what must be reported for HEDIS 2018 for Medicare?
Yes. CMS released a clarification on October 11, 2017, through HPMS, announcing that MPM was retired and is not required for HEDIS 2018 reporting; it also clarified that “Inpatient Hospital Utilization” is now “Acute Hospital Utilization” and should be reported as the updated measure. If you have additional questions, contact CMS at HEDISquestions@cms.hhs.gov.
This applies to the following Programs and Years:
HEDIS 201811.15.2017 Use of Opioids at High Dosage In the HEDIS 2018 Volume 2 Technical Update memo Table UOD-A includes a variable ranging from 4-12 for the MED Conversion Factor for methadone based on mg/day of methadone used. However, in the HEDIS 2018 NDC MLD Directory all NDCs for Methadone under the medication list "Opioid Medication" have a MED Conversion Factor (column M) of 3. For performing the MED calculation in UOD, which MED Conversion Factor should be used for methadone?
For HEDIS 2018 reporting, for methadone, the MED conversion factor of "3" should be used as listed in the NDC list; not the factors listed in Table UOD-A. We will reevaluate using the sliding scale conversion factors for HEDIS 2019.
This applies to the following Programs and Years:
HEDIS 201811.15.2017 General Guidelines General Guideline 17 says that "Members with dual commercial and Medicaid coverage must be reported in the commercial HEDIS reports. These members may be excluded from the Medicaid HEDIS reports." If a member has primary insurance in a Medicaid plan and secondary insurance in another Medicaid plan at any time during the measurement year, should the secondary Medicaid plan report the member in their HEDIS report?
To meet criteria for dual coverage, the member should have dual coverage at the end of the continuous enrollment period (dual coverage is assessed on a measure-by-measure basis). For example, if a measure's continuous enrollment period ends on December 31 of the MY and has dual Medicaid and commercial enrollment on that date, then the member may be excluded from the Medicaid HEDIS reports for the measure and only be reported in the commercial product line (General Guideline 23 in HEDIS 2018 Volume 2). In cases where the member is dually enrolled in two Medicaid plans, the secondary Medicaid payer would have the choice to exclude the member if the primary Medicaid coverage was offered through a different organization.
