FAQ Directory: HEDIS

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4.15.2014 HEDIS and ICD-10 Will the HEDIS 2015 Value Set Directory include invalid codes (codes that are not valid for billing)?

No. The HEDIS 2015 Value Set Directory will not include invalid ICD-9 codes; it will only include ICD-9 codes that are valid for billing. The HEDIS 2014 value sets included invalid ICD-9 codes; these will be removed, effective with HEDIS 2015.

HEDIS 2014

4.15.2014 HEDIS and ICD-10 The ICD-10 implementation date has been delayed. Will NCQA include ICD-10 codes in HEDIS 2015?

No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during the HEDIS 2015 measurement year (the 2014 calendar year) and therefore will not be included in the HEDIS 2015 Value Set Directory.

Purchasers of HEDIS 2015 technical specifications will receive a separate file with ICD-10 codes proposed for inclusion in future releases of HEDIS, but the codes will not be considered part of the 2015 measure specifications.

HEDIS 2014

2.14.2014 Osteoporosis Management in Women Who Had a Fracture When determining the eligible population, step 4 states to exclude members with a dispensed prescription to treat osteoporosis (Table OMW-C) during the 365 days (12 months) prior to the IESD. Does this include only osteoporosis prescriptions dispensed during the 365-day look-back period, or may it include an osteoporosis prescription that was dispensed prior to the look back period but is still “active” during the 365 days?

Members with an “active” prescription for osteoporosis treatment (Table OMW-C) during the 365 days prior to the IESD meet the step 4 exclusion criterion. The prescription does not need to be dispensed during the 365-day look-back period. NCQA does not specify how long organizations must look back prior to the IESD to identify an “active” prescription; organizations determine the look-back period, which should be applied consistently across all members.

HEDIS 2014

2.14.2014 Non-Recommended Cervical Cancer Screening in Adolescent Females In the Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) measure, how should the optional exclusions be handled given that a lower rate indicates better performance?

Based on the current guideline, organizations should look for optional exclusions only where administrative data indicate that the specified numerator service or procedure did not occur. For the NCS measure, the optional exclusions indicate a justification for screening so it is not inappropriate care if these members are screened. Therefore, the optional exclusions in the NCS measure were intended to be required exclusions. In HEDIS 2015, these members must be removed from the eligible population regardless of numerator compliance. NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

HEDIS 2014

2.14.2014 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the BMI percentile indicator, does documentation of >99% or <1% meet criteria?

Yes. Documentation of >99% or <1% may be used when reporting because an exact BMI percentile value is evident (i.e., 100% or 0%). These examples are not considered ranges or thresholds, which are not permitted when reporting the BMI percentile indicator. Examples of non-permitted ranges and thresholds are "75-80th percentile" and ">90th percentile" because the exact BMI percentile value is not evident.

HEDIS 2014

2.14.2014 Inpatient Utilization General Hospital/Acute Care In step 4, the text under the "Medicine" bullet states for the Newborns/Neonates MS-DRG Value Set, "Do not include newborn care rendered from birth to discharge home from delivery; only report newborn care rendered if the baby is discharged home from delivery and is subsequently rehospitalized." In HEDIS 2013, this instruction also applies to "Total Inpatient." Should newborn care rendered from birth to discharge home from delivery also be excluded from Total Inpatient?

Yes. Exclude newborn care rendered from birth to discharge home from delivery before reporting Total Inpatient (step 3).

HEDIS 2014

12.16.2013 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Is a BMI growth chart sufficient for the physical requirement of the developmental history component?

No. Growth charts (height, weight, BMI or BMI percentile) do not meet criteria for physical developmental history for the W34 measure. The intent of the developmental history component (physical and mental) is to determine if the child was assessed for specific age-appropriate physical and mental developmental milestones, which are behaviors or physical skills seen in children as they grow and develop. For the W34 measure, examples of mental developmental milestones include ability to speak understandably, identify colors and define words appropriately. For the W34 measure, examples of physical developmental milestones include the ability to hop, throw a ball, draw and make a block tower. Documentation of "developing appropriately" or "normal development" meets criteria for both physical and mental development. Documentation of "growing appropriately" (without notation about "development") does not meet criteria for physical or mental developmental history.

Additional examples can be found in the Appendices of the Bright Futures Pocket Guide Guidelines for Health Supervision of Infants, Children, and Adolescents (http://brightfutures.aap.org/pdfs/bf3%20pocket%20guide_final.pdf).

HEDIS 2014

12.16.2013 Cervical Cancer Screening In step 2 of the Administrative Specification, organizations identify women 30-64 years of age as of December 31 of the measurement year who had cervical cytology and a human papillomavirus (HPV) test, with service dates four or less days apart during the measurement year. When counting service dates, is the date of the cervical cytology considered day one or day zero of the four-day count?

The date of the cervical cytology is considered day zero. For example, if the service date for cervical cytology was December 1 of the measurement year, the HPV test must include a service date on or between December 1 and December 5 of the measurement year.

HEDIS 2014

12.16.2013 General Guidelines Are HbA1c and LDL-C tests where the member collects a blood sample at home and sends it to a lab for results calculation allowed for HEDIS reporting?

No. Tests where the blood sample is collected by the member are considered self-administered tests and are not eligible for use in HEDIS reporting.

HEDIS 2014

12.16.2013 General Guidelines If an organization finds an undated lab result in a progress note, can the progress note date be used as the lab result date?

No. An undated lab result may not be used for HEDIS reporting. To be eligible for use, the date the test was performed (e.g., the date the sample was drawn) or the result date (e.g., the date the lab calculated the result) must be documented.

HEDIS 2014

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 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment The list of code combinations to identify Initiation and Engagement visits do not include codes to identify inpatient admissions. Do inpatient admissions count as initiation and engagement of AOD treatment?

As stated in the paragraphs prior to the list of code combinations, an inpatient admission with a diagnosis of AOD meets criteria for both initiation and engagement. Because NCQA does not specify codes to identify inpatient admissions, inpatient admissions were not included in the list of code combinations. The lists of code combinations include only visits for which value sets exist (outpatient, intensive outpatient and partial hospitalization). Organizations should use their own methods for identifying inpatient admissions when identifying initiation and engagement visits.

HEDIS 2014