FAQ Directory: HEDIS

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2.16.2013 Care for Older Adults For the functional status assessment indicator, the fourth bullet requires notation of at least three of the four components: cognitive status, ambulation status, sensory ability and other functional independence. For "sensory ability," must all three components (hearing, vision, speech) be documented to meet the criterion?

Yes. All three components must be evaluated to fulfill the sensory ability component.

HEDIS 2013

2.16.2013 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents May a member's height, weight and BMI percentile be noted on different dates of service in the medical record for the BMI Percentile indicator?

Yes. Height, weight and BMI percentile may be noted on different dates of service as long as they are documented in the medical record during the measurement year.

HEDIS 2013

2.16.2013 Adult BMI Assessment If the member's weight is documented in the medical record during the measurement year or year prior to the measurement year, may the organization calculate BMI at a later date?

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

HEDIS 2013

2.16.2013 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 2013

2.16.2013 Adult BMI Assessment May a member's weight and BMI be noted on different dates of service in the medical record?

Yes. Weight and BMI may be noted on different dates of service as long as they are documented in the medical record during the measurement year or year prior to the measurement year.

HEDIS 2013

1.16.2013 General Guidelines Should Medicare Advantage (MA) members who elect the hospice benefit and choose to remain enrolled in the MA plan be excluded from MA HEDIS denominators?

No, not for HEDIS 2013 reporting; however, beginning with HEDIS 2014, exclude MA members who elect the hospice benefit available through original Medicare. This change will be in the HEDIS 2014 Volume 2 specifications.

HEDIS 2013

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

HEDIS 2013

1.16.2013 Medical Record Review Validation Can the plan choose to rotate a measure that failed MRR validation?

The intent of measure rotation is to reduce chart review, not be a means to select the best rate possible. However, NCQA does not specifically prohibit this approach. Please note, if the reason for failing can be seen as possibly affecting other measures in the group, the auditor may elect to review those other measures.

HEDIS 2013

1.16.2013 Medical Record Review Validation What records are included in Group F (Exclusions)?

MRRV Group F (Exclusions) includes all optional and required exclusions and valid data errors found during medical record review. It does not include records excluded through administrative data or that belong to employees or their dependents. Other hybrid medical record exclusions that should not be reviewed in Group F are exclusions for CBP and the HbA1C Less Than 7% indicator. Because of the large volume, auditors review exclusion rates for these indicators separately. See the instructions in Volume 5, page 65 for reviewing CBP and HbA1c<7%.

HEDIS 2013

1.16.2013 Medical Record Review Validation Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?

Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.

The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.

HEDIS 2013

1.16.2013 Medical Record Review Validation What happens if a plan doesnt report any measures in a group?

The auditor selects one measure from each measure group that applies to the health plan, and exclusions from the exclusions group. If the plan doesnt report any measures in a particular group, the auditor will use his discretion, based on past performance and current progress, to determine if an additional measure should be selected from a group already used.

HEDIS 2013

1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?

Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.

HEDIS 2013