FAQ Directory: HEDIS for the Quality Rating System

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1.15.2021 Follow-Up After Hospitalization for Mental Illness (FUH) What value sets can be used to identify community mental health center visits (the fifth bullet in the Numerator)?

The fifth bullet in the Numerator is missing value set references. Replace the bullet text with:
A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value Set; Observation Value Set; Transitional Care Management Services Value Set) with (Community Mental Health Center POS Value Set).

**This FAQ applies to QRS MY 2020.

MARKETPLACE 2020

12.15.2020 Appropriate Testing for Pharyngitis (CWP) Is the denominator for the measure based on episodes or members?

The denominator is based on episodes, not on members. Add the following Note to the event/diagnosis after step 7:
Note: The denominator for this measure is based on episodes, not on members. All eligible episodes that were not excluded remain in the denominator.

**This FAQ applies to QRS MY 2020.

MARKETPLACE 2020

12.15.2020 Use of Imaging Studies for Low Back Pain (LBP) Is a history of a kidney transplant a required exclusion for the measure?

Yes. In the seventh bullet of step 4 of the event/diagnosis, replace the seventh bullet with:
Major organ transplant. Major organ transplant (Organ Transplant Other Than Kidney Value Set; Kidney Transplant Value Set; History of Kidney Transplant Value Set) any time in the member’s history through 28 days after the IESD.

**This FAQ applies to QRS MY 2020.

MARKETPLACE 2020

12.15.2020 Appropriate Testing for Pharyngitis (CWP) Is the episode date excluded if the member does not receive antibiotics on or up to three days after the Episode Date?

Yes, the episode date is excluded. Add the following text to the event/diagnosis after step 3:
Exclude Episode Dates if the member did not receive antibiotics on or up to three days after the Episode Date.

**This FAQ applies to QRS MY 2020.

MARKETPLACE 2020

12.15.2020 Follow-Up After Hospitalization for Mental Illness (FUH) What time frame should be used to identify acute and nonacute readmissions or direct transfers when identifying the event/diagnosis?

Use a 30-day period. Replace the reference to “7-day follow up period” with “30 days after discharge (the denominator event)” in both the “Acute readmission or direct transfer” and “Nonacute readmission or direct transfer” sections of the specification. This ensures that the same Eligible Population criteria are used for all organizations that report the FUH measure (regardless of product line).

**This FAQ applies to QRS MY 2020.

MARKETPLACE 2020

11.16.2020 VSD for the Quality Rating System The same OID is listed for the Systolic Greater Than or Equal To 140 Value Set and the Systolic Less Than 140 Value Set in the QRS Value Set Directory. Is this correct?

No. The value set OID for the Systolic Greater Than or Equal To 140 in the QRS Value Set Directory is incorrect and should be changed to 2.16.840.1.113883.3.464.1004.1242.

MARKETPLACE 2020

11.16.2020 Prenatal and Postpartum Care (PPC) Step 3 of the event/diagnosis states, “Determine if enrollment was continuous 43 days prior to delivery through 56 days after delivery, with no gaps.” Is this correct?

No. Replace this with, “Determine if enrollment was continuous 43 days prior to delivery through 60 days after delivery, with no gaps.”

MARKETPLACE 2020

1.15.2020 Controlling High Blood Pressure The CBP measure lists the following exclusions in the eligible population:

• Medicare members 66 years of age and older as of December 31 of the measurement year who meet either of the following:
– Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.
– Living long-term in an institution any time during the measurement year as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement year.

Should these exclusions be removed from the CBP measure specifications?

 Yes. Remove the bullets that include I-SNP and LTI exclusions for Medicare members from the specifications. They are not intended for the Exchange population.

MARKETPLACE 2020

11.15.2019 Well-Child Visits in the First 15 Months of Life Should the “Number of required exclusions” row be removed from the Data Elements Table in the Well-Child Visits in the First 15 Months of Life (W15) measure?

Yes. Remove the “Number of required exclusions” row in the Data Elements Table.

MARKETPLACE 2020

10.15.2018 Use of Imaging Studies for Low Back Pain Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Use of Imaging Studies for Low Back Pain (LBP) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

MARKETPLACE 2019

10.15.2018 Immunizations for Adolescents Are issuers required to report Combo 1 for the Quality Ratings System in the Immunizations for Adolescents (IMA) measure?

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. Change the reference in the Description from “two combination rates” to “one combination rate.” In the Data Elements Table, change “Each of the 5 rates” to “Each of the 4 rates.”

MARKETPLACE 2019

10.15.2018 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

MARKETPLACE 2019