FAQ Directory: HEDIS for the Quality Rating System

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5.15.2023 Colorectal Cancer Screening (COL-E) Should the Colorectal Cancer Screening-E (COL-E) age stratification be updated?

Yes. Replace the reference to “46-49” with “46-50,” and replace the reference to “50-75” with “51-75” in the age stratification and in Table COL-E-A-4: Data Elements for Colorectal Cancer Screening.

EXCHANGE MY 2023

5.15.2023 Social Need Screening and Intervention (SNS-E) Should the SNS-E measure include exclusion criteria for Medicare members?

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
    • Living long-term in an institution any time during the measurement period, 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 period.

EXCHANGE MY 2023

4.14.2023 Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Should the Follow-Up on Positive Screen numerator include the 12-17 years age stratification?

Yes. The 12-17 years age stratification is reported for the Follow-Up on Positive Screen numerator and should be added to the age stratification on page 240 of MY 2023 HEDIS for QRS Version.

EXCHANGE MY 2023

12.15.2022 General Guideline 28 and International Normalized Ratio Monitoring for Individuals on Warfarin (INR) Should organizations use laboratory claims and data for the INR Test Value Set in the International Normalized Ratio Monitoring for Individuals on Warfarin Pharmacy Quality Alliance measure?

Yes. Although LOINC codes were removed from the INR Test Value Set, organizations should use laboratory claims and data for this value set, in addition to medical claims. This value set should be listed in General Guideline 28 with other value sets that do not contain LOINC codes.

EXCHANGE MY 2023

11.16.2022 General Guideline 28: Identifying Events/Diagnoses Using Laboratory or Pharmacy Data Should organizations use laboratory claims and data for the Drug Test Value Set in the Annual Monitoring for Persons on Long-Term Opioid Therapy Pharmacy Quality Alliance measure?

Yes. Although LOINC codes were removed from the Drug Test Value Set, organizations should use laboratory claims and data for this value set. This value set should be listed in General Guideline 28 with the other value sets that do not contain LOINC codes but should use laboratory claims and data.

**This FAQ applies to QRS MY 2022.

EXCHANGE MY 2022

5.16.2022 Reducing the Sample for CIS for MY 2022 Reporting May organizations reduce the minimum required sample size for the Childhood Immunization Status measure when reporting MY 2022?

Yes. Disregard the “N” in Table 1. Organizations may reduce the sample size for the CIS measure using the prior year’s rate or the current year’s administrative rate.

**This FAQ applies to QRS MY 2022.

EXCHANGE MY 2022

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.

EXCHANGE MY 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.

EXCHANGE MY 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.

EXCHANGE MY 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.

EXCHANGE MY 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.

EXCHANGE MY 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.”

EXCHANGE MY 2020