FAQ Directory: HEDIS

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

1.15.2019 Is death a valid exclusion for HEDIS measures?

Death as an Exclusion in HEDIS

NCQA expects plans to disenroll deceased members. Members who died during the continuous enrollment period would not meet the measure’s eligible population criteria (e.g., continuous enrollment and anchor date requirements) and would not be included in the measure denominator. However, a member who meets the continuous enrollment criteria remains in the measure. For example, when reporting the MRP measure, a member who was discharged on July 1 and died on August 1, but enrollment data indicates the member is enrolled in the organization during the continuous enrollment period (the date of discharge through 30 days after discharge) must remain in the measure.

Keep in mind that organizations may not use other data sources (e.g., medical record data) when removing deceased members.
 

1.15.2019 When using supplemental data for measures that require a result, does the actual numeric result need to be present in the supplemental data to meet criteria?

Supplemental Data

Yes. For all measures that require a result, the actual numeric value of the result must be present in the supplemental data to meet criteria. For example, when reporting the BP control indicator of the CDC measure, documentation of the code 3078F alone in the supplemental data cannot be used to indicate a diastolic level that is less than 80. The actual diastolic value (e.g., 79) must be present in the supplemental data to meet criteria. It is appropriate for the approved data to be mapped to code 3078F (or applicable codes) to integrate into vendor or internal systems for measure calculation. Mapping would need to be reviewed and approved by the auditor.

The only exceptions to this are described in a General Guideline FAQ posted 11/15/2018. The exceptions described in the 11/15 FAQ are for the ABA and WCC measures. When reporting the BMI indicators for both measures, height and weight do not need to be in the supplemental data, but the actual BMI value or BMI percentile, with the date, must be present. For the counseling for physical activity indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria. For counseling for nutrition indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria.

1.15.2019 There was a change to the ICD-10 coding guidelines, effective October 1, 2018, related to the codes for reporting body mass index (BMI). The change allows providers to bill for BMI codes only if the member has a clinically relevant condition, such as obesity. How does this change affect reporting the BMI percentile documentation indicator of the WCC measure?

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI percentile code only when there is an associated diagnosis (e.g., overweight, obesity) that meets the new requirements.  “Healthy weight” is not considered an associated diagnosis. As a result, members in the denominator, whose only visit is in October, November, or December of 2018, without an appropriate ICD-10 code, due to the lack of an associated diagnosis, will not have claims that meet the current numerator criteria.

NCQA’s analysis shows that, because this measure is reported primarily through the hybrid-reporting option, the effect will be small. This change does not affect organizations using the hybrid method, because the rule pertains to only the use of ICD-10 codes on claims. It does not prohibit providers from measuring and documenting a BMI in the medical record.
 

1.15.2019 There was a change to the ICD-10 coding guidelines, effective October 1, 2018, related to the codes for reporting body mass index (BMI). The change allows providers to bill for BMI codes only if the member has a clinically relevant condition, such as obesity. How does this change affect reporting the ABA measure?

Adult BMI Assessment (ABA)

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI or BMI percentile code only when there is an associated diagnosis (e.g., overweight, obesity) that meets the new requirements. “Healthy weight” is not considered an associated diagnosis. As a result, members in the denominator, whose only visit is in October, November, or December of 2018, without an appropriate ICD-10 code, due to the lack of an associated diagnosis, will not have claims that meet the current numerator criteria.

NCQA’s analysis shows that, because this measure is reported primarily through the hybrid-reporting option, the effect will be small. This change does not affect organizations using the hybrid method, because the rule pertains to only the use of ICD-10 codes on claims. It does not prohibit providers from measuring and documenting a BMI in the medical record.
 

1.15.2019 If documentation in a 2018 visit note indicates “No Diabetic Retinopathy as of Ophtho note on 9/2017,” does this meet criteria as a negative retinal exam?

Comprehensive Diabetes Care (CDC)

Yes. This meets criteria for HEDIS 2019 reporting because the documentation indicates that the eye exam was completed by an eye care professional (optometrist or ophthalmologist), the date when the procedure was performed was within the appropriate time frame and the results are present (a negative retinal exam in the year prior to the measurement year).

1.15.2019 In HEDIS 2019, step 4 of the numerator calculation was revised to indicate that the ratio should be rounded to the nearest whole number using the .5 rule. Should the value that is calculated using the formula in the measure be multiplied by 100 before rounding to the nearest whole number using the .5 rule?

Medication Management for People With Asthma (MMA) and Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)

Yes. The new rounding directions in step 4 are meant to treat the calculated decimal result as a whole number from 0%–100% for the SAA and MMA measures. For example, if a member has 291 total days covered by a medication during a 365-day treatment period, this calculates to 0.7972. Multiply this number by 100, convert it to 79.72% and round it to 80%, the nearest whole number.

1.15.2019 When calculating the number of days covered for the COU measure’s numerators, must the days be consecutive?

Risk of Continued Opioid Use (COU)

No. The covered days are not required to be consecutive when reporting the numerators of the measure. Review all dispensed opioids on the IPSD through the 30-day or 62-day period and follow the instructions for calculating number of days covered for the numerator. For example, if the IPSD is 1/1/18 and the member has an eligible prescription with a 5-day supply and another eligible prescription with a 10-day supply on 1/10/18, the member meets criteria for the ≥15 Days Covered numerator.
 

12.14.2018 The Controlling High Blood Pressure measure includes optional exclusion criteria under the Hybrid methodology. May organizations apply optional exclusion criteria for both the administrative and hybrid reporting methods?

Controlling High Blood Pressure

Yes. The intent is to allow organizations to apply the optional exclusion for both the administrative and hybrid specifications. When using the administrative specification, organizations must use the codes in the value sets to identify members who meet optional exclusion criteria. When using the hybrid specification, organizations should look for evidence of ESRD, kidney transplant, dialysis, pregnancy or a nonacute inpatient admission during the measurement year in order to identify members who meet optional exclusion criteria.

Keep in mind that all exclusions are subject to auditor review.

12.14.2018 To calculate a member’s SES stratification, the instructions say to use the Monthly Membership Detail Data Files (MMDDF) for the measurement year to assess the member’s LIS, DE payment status. We find that in some months, members have multiple rows of data in the MMDDF, which represent adjustments for previous months. What should we do in this situation; is there a better file to use for determining SES?

SES Guidelines*

Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.

  • Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:

 

MemberRunDateLisPremiumSubsidy
12018 10 120000.00
12018 10 120035.50
12018 11 080035.50
12018 11 08-0035.50
12018 11 080035.50
12018 12 080035.50

This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).

MemberLowIncomePeriodStartDateLowIncomePeriodEndDateLipsPercentagePremiumLisAmountContractYear
12016 09 012016 12 3110036.002016
12017 01 012017 12 3110036.002017
12018 01 01 10035.502018

 
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
 
NOTES:

  1. If the LowIncomePeriodEndDate is blank, the member is still eligible.
  2. Plans should use a copy of this file from December 2018 or later.

 
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
 

12.14.2018 On page 453 of the HPC measure, the language for the first sentence in step 3 under “Chronic ACSC” is different than the language for the first sentence in step 3 under “Acute ACSC”. Is the difference in the language intentional?

Hospitalization for Potentially Preventable Complications

No, the difference in the language is not intentional and the reference to “on the discharge claim” was unintentionally excluded. Step 3 for Acute ACSC should contain the same language as step 3 for chronic ACSC. In step 3 for ACSC, for the remaining acute inpatient and observation stay discharges, organizations should identify discharges with specified criteria on the discharge.

12.14.2018 May rural health centers be mapped to the PCP definition in Appendix 3 of Volume 2, similar to how Federally Qualified Heath Centers are handled?

Appendix 3: PCP Definition

No. Rural Health Clinics are not addressed in the updated PCP definition in Volume 2. All providers billing under the Rural Clinic facility codes must meet the definition of “PCP” in Appendix 3 in order to be included in the PCP-based HEDIS measures.

12.14.2018 When reporting ED or observation visits the measures states to exclude ED/observation visits that result in an inpatient stay. Should the ED/observation visit be excluded if the inpatient stay does not contain a principal mental health diagnosis?

Mental Health Utilization

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.