FAQ Directory: HEDIS

  The optional exclusion criteria may be applied only if the member did not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year. If the member was included in the measure based on claim or encounter data, as described in the event/diagnosis criteria, the optional exclusions do not apply because the member had a diagnosis of diabetes. If the member was included in the measure based on pharmacy data alone, the member may meet criteria for an optional exclusion if no diagnosis of diabetes was found in claim or encounter data or in the medical record.

For example, if a member was included in the measure based on pharmacy data but had a visit with a diagnosis of diabetes, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes, but medical record documentation indicated the member is a diabetic, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes and no evidence of diabetes in the medical record being reviewed, the member may meet optional exclusion criteria if there was a diagnosis of polycystic ovaries any time during the member’s history through December 31 of the measurement year, or a diagnosis of gestational diabetes or steroid-induced diabetes during the measurement year or the year prior to the measurement year.

HEDIS 2015

 Although the two diagnoses are clinically different, hypertensive retinopathy is not treated differently from diabetic retinopathy for the CDC measure. The intent of the eye exam indicator is to ensure that members with evidence of any type of retinopathy have an eye exam annually, while members who remain free of retinopathy (i.e., the retinal exam was negative for retinopathy) are screened every other year. If it is clear that a retinal or dilated eye exam was performed by an eye care professional in the year prior to the measurement year and there is documentation indicating that the member is negative for hypertensive retinopathy, this can count as compliant.

HEDIS 2015

To determine if a stay should be excluded, identify the index hospitalization and the FIRST readmission (if there is one). If the FIRST readmission was planned for, drop the index.

So, for example 2:

Stay 1. Index hospitalization with unplanned readmission (stay 2): Include as index.
Stay 2. Index hospitalization with planned readmission (stay 3): Drop as index.
Stay 3. Index hospitalization with planned readmission (stay 4): Drop as index.
Stay 4. Index hospitalization with no readmission: Include as index.

Stay 1 is the index. Stay 2 is the first readmission to assess, but because it does not meet criteria for a “planned hospital stay,” stay 1 is not excluded.

HEDIS 2015

No, if a problem list is found in an office visit note then it would be considered a dated problem list and the date of the visit must be used. A true problem list is a standalone document in the medical record that records a member’s conditions. It is typically located in a centralized section of the medical record (usually the front of the chart) and lists all diagnoses. In an EHR a problem list is present at all routine office visits.

If the documentation is part of the member’s medical history, progress note or office visit note, the date of the visit must be used as the date of the HTN confirmation and must be on or before June 30 of the measurement year. The representative BP reading must occur after the date when the diagnosis of HTN was confirmed.

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

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

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

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

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

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

HEDIS 2014

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

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