FAQ Directory: HEDIS

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11.15.2013 General Guidelines If a member is included in a measure's denominator due to an incorrect code, may a corrected claim be submitted to remove the member from the measure?

It is not NCQA's policy to dictate an organization's claims submission process. Claims may be corrected or updated as necessary before the HEDIS reporting process begins. However, once the HEDIS reporting process has begun (i.e., the measures' eligible populations are identified and samples are drawn for hybrid reporting), the requirements specified in Volume 2 General Guidelines and Technical Specifications must be followed.

For administrative-only measures, members who meet the eligible population criteria for the measure should remain in the measure. If an organization refreshes data for administrative-only measures, the most accurate and current information must be used for reporting. Additionally, the organization must apply the refresh to all applicable measures.

For hybrid measures, members who are in the denominator due to inaccurate claims data may meet criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review and may not be identified using supplemental data. In order to categorize a member as a valid data error (and replace the member with another member from the sample), the chart must show no evidence of the diagnosis and must include evidence to explain or substantiate the data error. As described in General Guideline 40, organizations that elect to refresh data for the sample may not use the refreshed data to change the hybrid sample after it has been selected. The auditor reviews all valid data error exclusions during Medical Record Review Validation.

HEDIS 2014

11.15.2013 Value Set Directory The Summary of Changes spreadsheet in the HEDIS 2014 Volume 2 Value Set Directory lists LOINC code 72732-0 as added to the Sexual Activity Value Set, but that code is not in the Volume 2 Value Sets to Codes spreadsheet.

LOINC code 73732-0 was added to the Sexual Activity Value Set; it was entered incorrectly (as 72732-0) in the Summary of Changes spreadsheet. We apologize for the inconvenience.

HEDIS 2014

11.15.2013 Volume 2 Technical Update In the Volume 2 Technical Update memo, the term "discharged alive" was replaced with "discharged" in measures that include discharges for AMI or CABG. Does this mean that members who died prior to discharge should be included in the measures?

No. Removal of the language "discharged alive" does not mean that deceased members should be included in measures. As with other HEDIS measures, deceased members who do not meet continuous enrollment or anchor date criteria should not be included in the measures Eligible Population. The term "discharged alive" was removed in order to make language consistent across AMI, CABG and PCI (the term had been removed from PCI in the July 1 release of the publication; NCQA received questions about why it was removed from PCI but not from AMI or CABG). In 2015, NCQA intends to remove the term "discharged alive" from all remaining references (i.e., PBH, FUH and all measure descriptions).

HEDIS 2014

11.15.2013 General Guidelines Have the dates been extended for primary source verification (PSV) and final approval of supplemental data for HEDIS 2014?

Yes. Data collection and entry of all nonstandard and member-reported supplemental data must stop on March 3. PSV and final approval must be completed by March 14, for member-reported supplemental data, and by March 28, for nonstandard supplemental data. PSV may not occur before March 3 unless all supplemental data processes, collection and entry have stopped. Supplemental data approval and PSV may not occur, under any circumstances, before January 1 and receipt of the Roadmap.

HEDIS 2014

10.15.2013 Identification of Alcohol and Other Drug Services On page 298 of HEDIS 2014 Volume 2, in the Outpatient and ED section, the 5th bullet states "where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (POS 53 is not specific to setting)." Should the language be changed to reference an "outpatient" setting?

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

10.15.2013 Mental Health Utilization On page 302 of HEDIS 2014 Volume 2, in the Outpatient and ED section, the 5th bullet states "where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (POS 53 is not specific to setting)." Should the language be changed to reference an "outpatient" setting?

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

8.16.2013 Childhood Immunization Status On May 16, 2013, the Centers for Disease Control and Prevention (CDC) National Center for Immunization and Respiratory Diseases released a document based on Sanofi Pasteurs Pentacel (DTaP-IPV/Hib) and Daptacel (DTaP) vaccine shortage. Because these vaccines are expected to be in short supply through summer 2013, does NCQA plan any changes to the CIS measure for HEDIS 2014?

No. NCQA will not make any changes to the vaccine requirements for HEDIS 2014. As indicated by the CDC, "Single-component DTaP, IPV, HepB, and Hib vaccines and other age-appropriate licensed combination vaccines are available to complete series begun with Pentacel or Pediarix. Currently, there is a sufficient supply of these products to meet the anticipated demand." You can find additional information in the Guidance for Vaccinating Children during the 2013 Pentacel, Daptacel and Pediarix Shortage article at http://www.cdc.gov/vaccines/vac-gen/shortages/downloads/pentacel-guidance.pdf.

HEDIS 2014

7.15.2013 Care for Older Adults If there is a list of medications in the progress note, is a prescribing practitioner or clinical pharmacist's signature alone considered evidence that the list was reviewed for the medication review indicator?

The medication review indicator requires both a medication list and evidence that it was reviewed by the appropriate practitioner. The presence of a medication list with the appropriate practitioner's signature is compliant if it is dated during the measurement year. The practitioner's signature is considered evidence that the medications were reviewed.

HEDIS 2014

7.15.2013 General Guidelines Where can customers find additional information about the supplemental data changes for HEDIS 2014?

7.15.2013 Prenatal and Postpartum Care For the PPC measure, a Pap test alone is acceptable for the Postpartum Care rate. Is documentation of a Pap test compliant for women under the age of 21?

NCQA is aware that recent guidelines recommend pap tests NOT be performed for women under 21 years of age under general circumstances. However, for the PPC measure, a pap test will remain in the specifications as a way to determine that postpartum care occurred. NCQA allows documentation of only a Pap test because this test indicates that a pelvic exam was performed. This measure includes deliveries in any age group.

NCQA is re-evaluating the PPC measure based on clinical practice guideline updates. Any changes will be included in future HEDIS specifications.

HEDIS 2014

2.16.2013 Comprehensive Diabetes Care If no result is documented for an eye exam in the year prior to the measurement year, can the organization infer that the exam was negative for retinopathy?

No. Documentation of an eye exam that does not include a result does not count as a negative result and is not eligible for use in HEDIS reporting.

HEDIS 2013

2.16.2013 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents If height and weight are documented in the medical record during the measurement year, may the organization calculate BMI percentile at a later date?

Yes. The BMI percentile may be calculated by the organization at a later date. It must be calculated and documented in the medical record during the measurement year to be eligible for use in HEDIS reporting.

HEDIS 2013