FAQ Directory: HEDIS

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1.16.2013 Medical Record Review Validation If during MRR validation, a plan fails two samples, and informs the auditor they corrected the problem, what follow-up items are required to validate that the corrections were appropriate?

The auditor may use one or more methods to validate the chart error corrections. Follow-up actions should include:
· reviewing the error investigation and results
· reviewing policies and procedures to correct the error
· reviewing the corrected sample to ensure the updated numerator counts are correct and performing final hybrid rate review
· re-sampling charts for a new validation

Examples:

1. For the exclusions or data errors in the diabetes measure records, the auditor identified a pattern: she found two cases where the chart reviewer said the members did not have diabetes, but the chart showed that both members had elevated blood sugars and above average HbA1c results. One member had a PCP diagnosis of metabolic syndrome that placed him in the measure. The other member had a diagnosis of insulin resistance. The auditor required the plan to re-review all CDC exclusions and submitted charts for the remaining correct exclusions from the measure. The auditor approved reporting.
2. For the two MRRV samples, there were two errors found _ one in each sample. The auditor required the plan to do an analysis and demonstrate corrective actions.
The plan reported that one abstractor made the errors by incorrectly identifying the prior years CDC eye exams. The plan re-reviewed 100% of that abstractors hits and reversed 12 hits to misses. The plan had originally reported 100 admin hits and 200 hybrid hits for CDC eye exam. Of the 200 hybrid hits, 160 were measurement year eye exams, and 40 were negative retinopathy cases from the prior year. The auditor pulled another sample of 16, found no errors, and confirmed that the reported rate for the measure dropped from 73% to 70% as a result.
The auditor approved reporting.
3. The auditor found four errors in the first sample for AWC. He notified the plan and required them to do an analysis and demonstrate corrective actions. The plan submitted:
· the error investigation and results
· the policies and procedures that corrected the error
· a new sample of 16 that proved to have zero errors

The auditor approved reporting.

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 General Guidelines Are home-test kits that collect biometric values allowed for HEDIS reporting?

Only tests administered by a qualified provider may be used for HEDIS reporting. Self-administered tests (including home-test kits) where the patient performs the test and obtains the result are not eligible for use in HEDIS reporting.

Results from a home test kit where a qualified provider uses the kit to conduct a test or determine the results in the office are eligible for HEDIS reporting. If any home test is billed by a qualified provider using a code specified in the measure, it is eligible for use in HEDIS reporting; the code alone indicates compliance.

HEDIS 2013

12.16.2012 Guidelines for Relative Resource Use Measures The table under step 9 on page 350 of the HEDIS 2013 Volume 2 should be used when assigning members to a RRU risk group. This year, the final risk score is rounded to 4 decimal places. In the table, Risk Group 1 is between 0.0000 and 0.2490. Risk Group 2 is between 0.2500 and 0.4990. To which risk group should a member be assigned whose risk score is 0.2495? The score does not fall in either group.

All the last digits of "0" in the table should be replaced with "9" for the upper score. For example, Risk Group 1 should be revised so it is between 0.0000 and 0.2499. A score of 0.2495 should be assigned to group 1.

HEDIS 2013

12.16.2012 General Guidelines Some cells in the HEDIS 2013 Pharmacy Standard Pricing Table (SPT-Pharm) include dashes (-) instead of prices. Are the dashes equivalent to $0.00?

11.16.2012 General Guidelines If a member was included in the denominator because of inaccurate claims data, may we remove the member from the measure? How do we do this?

Members who are in the denominator because of inaccurate claims data may meet the criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review. If a member is in the denominator because of a claim with a code specified for the measure, the medical record must contain evidence that the member does not meet measure criteria; a silent chart is not evidence that the member does not have the condition being measured. If the valid data error criteria are met, the member should be removed from the sample and replaced with a member from the oversample.

Finding valid data errors is not intended to be a method of correcting improper billing practices, and they cannot be identified through supplemental data. Additional information and examples of valid data errors can be found in the Substituting Medical Records in the Guidelines for Calculations and Sampling (page 51).

HEDIS 2013

11.16.2012 Medication Reconciliation Post-Discharge If a member's discharge is followed by a readmission or direct transfer to a nursing home or long term care facility, is the discharge included in the measure's denominator?

If there is evidence that the member remained in the nursing home or long-term care facility through December 1 of the measurement year, the discharge must be excluded from the denominator. If there is evidence that the member was discharged from the nursing home or long term care facility by December 1 of the measurement year, the discharge must be included in the denominator. Organizations may not assume that the member remained in a nursing home or long-term care facility through the end of the measurement year, based solely on the discharge status; there must be a method for identifying the members status for the remainder of the measurement year.

HEDIS 2013

11.16.2012 Care for Older Adults May a yes/no checklist be used for the advance care planning indicator?

If "yes" is checked, it may be counted as evidence that the member executed an advance care plan. If "no" is checked, evidence of an advance care planning discussion must be documented. A checklist does not count as evidence of a discussion.

HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia In the Volume 2 Technical Update, the Continuous Enrollment criteria were revised to read "the measurement year and the year prior to the measurement year." Should the Allowable Gap criteria also include the year prior to the measurement year?

Yes. Members should have no more than one gap in enrollment of up to 45 days during each year of continuous enrollment.

HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia The CMC event/diagnosis criteria were revised in the Volume 2 Technical Update to include both facility and professional claims when identifying an AMI or CABG event. Should both facility and professional claims be included when identifying AMI or CABG for the SMC measure?

Yes. Organizations should include AMI and CABG from inpatient claims only, but may use both facility and professional claims to identify these events for HEDIS 2013 reporting.

HEDIS 2013

11.16.2012 Use of High-Risk Medications in the Elderly When calculating the Average Daily Dose for medications in Table DAE-C, should organizations use rounding rules before comparing the dose to the specified threshold? How should organizations calculate average daily dose for elixirs and concentrates?

Organizations should not round when calculating average daily dose. To calculate average daily dose for elixirs and concentrates multiply the volume dispensed by dose and divide by days supply.

HEDIS 2013

11.16.2012 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the Counseling for Nutrition and Counseling for Physical Activity indicators, do educational materials sent to members via mail or e-mail count toward the numerators?

No. The intent of the measure is to identify instances where a member received counseling for nutrition and physical activity; therefore, educational materials sent via mail or e-mail do not indicate that counseling occurred. The intent of including "member received educational materials" in the measure specifications is to allow for occasions where a provider gave educational materials to a patient during a face-to-face visit.

HEDIS 2013