No. Because supplemental data may not be used to identify the eligible population, and the same events are used for the denominator and numerator in APC, supplemental data may not be used for this measure. The data elements table in Volume 2 for APC inadvertently includes the “Numerator events by supplemental data” data element. This field will not be included in the IDSS.
HEDIS 2016
Yes. All members who are numerator compliant for Rate 1 must be used as the eligible population for Rate 2 in both the SPC and SPD measures (regardless of the data source used to capture the Rate 1 numerator). For example, if supplemental data were used to identify compliance for the Rate 1 numerator, then supplemental data will be included in identifying the Rate 2 eligible population.
If pharmacy data are the source data, and are treated similar to encounter data, they could be classified as encounter data rather than as supplemental data. For example, if a pharmacy benefit manager (PBM) offers the pharmacy benefit on behalf of a health plan and regularly sends pharmacy data to the plan in a standard format, the data could be considered to be encounter data. Organizations must work with their auditor to determine how data are classified. The auditor will review the organization’s pharmacy benefit structure and the processes for receiving and using data when determining the classification.
HEDIS 2016
Yes. As a result of changes to the measure, the two example lists were combined into a single list to remove redundancy. All examples that met criteria in HEDIS 2015 meet criteria for HEDIS 2016. Urine dipsticks are considered “spot urine” tests so they meet criteria based on the example, “Spot urine for albumin or protein.”
HEDIS 2016
No. The WHP 2016 Reporting Tool audit designations will not be updated because the tool and specifications were released prior to these changes. Organizations should report WHP measures for 2016 using the existing WHP Reporting Tool. Any updates will be included in the 2017 WHP Reporting Tool, which will be released on March 31, 2016.
HEDIS 2016
No. Because CPT Category II codes and HCPCS are standard codes they are not eligible for mapping (the value sets include all standard codes that have been identified as appropriate for use in HEDIS reporting). The Category II and HCPCS codes included in PQRS measures were created specifically for use in PQRS reporting and are not appropriate for use in reporting HEDIS measures. If a service or procedure was rendered by a provider, the expectation is that the provider will submit a claim to the health plan for the service or procedure; the codes expected to be on the claim are included in the HEDIS value sets and identify the member for the HEDIS measure.
HEDIS 2016
For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.
HEDIS 2016
Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.
HEDIS 2016
When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.
The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).
HEDIS 2016
