FAQ Directory: HEDIS

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11.15.2018 Transitions of Care When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?

Yes. When the PCP or ongoing care provider is the discharging provider, they must document the required discharge information specified in the measure. This must be done in the patient's outpatient medical record on the day of discharge or on the following day.

HEDIS 2019

10.15.2018 Standardized Healthcare-Associated Infection Ration The HEDIS® 2019 Volume 2 Technical Specifications Update announced the suspension of the Standardized Healthcare-Associated Infection Ration (HAI) measure for all product lines. This change causes a discrepancy between the CMS Reporting Memo and HEDIS 2019 Volume 2 Technical Specifications. Will CMS clarify what must be reported for HEDIS 2019 for Medicare?

Yes. CMS released a clarification, through Health Plan Management System (HPMS) on October 12, 2018, that HAI has been suspended and is not required for HEDIS 2019 reporting. If you have additional questions about CMS requirements, contact HEDISquestions@cms.hhs.gov.

HEDIS 2019

10.15.2018 Rules for Allowable Adjustments The General Guidelines in the Rules for Allowable Adjustments states, “use the separate HEDIS Adjustments VSD to calculate measure rates stemming from adjusted measure specification.” Does this mean that ONLY the HEDIS Adjustments VSD must be used?

No. The Allowable Adjustments VSD does not contain the standard HEDIS value sets; standard HEDIS value sets are in the HEDIS 2019 Volume 2 VSD. The Allowable Adjustments VSD includes only SNOMED and LOINC codes that are not in the Volume 2 VSD. Organizations collecting data using the rules for allowable adjustments can elect (but are not required) to use the value sets in the Allowable Adjustments VSD.

HEDIS 2019

10.15.2018 Follow-Up After ED visit for People With Multiple High-Risk Chronic Conditions In Step 2 (Exclusions), ED visits followed by admission to an inpatient care setting on the date of the visit or within 7 days after the visit are excluded. Should ED visits that result in an inpatient stay (when the ED date of service occurs any time during the admission [admission date through discharge date]) also be excluded?

Yes. Exclude ED visits that result in an inpatient stay.

HEDIS 2019

10.15.2018 Required Exclusions Are members who are excluded because of hospice, advanced illness, frailty, Institutional SNP (I-SNP) or living long-term in an institution (LTI) included in the “Number of required exclusions” data element?

No. Only members who meet the criteria in the section of the measure labeled “Required exclusions” are included when reporting the “Number of required exclusions” data element.

HEDIS 2019

10.15.2018 Plan All-Cause Readmissions In General Guideline 15: Members With Dual Enrollment, the Medicare-Medicaid (MMP) subhead indicates that these members must be in both the Medicaid and Medicare HEDIS reports. Does this apply to Plan All-Cause Readmissions (PCR)?

No. For PCR, MMP members are removed from Medicaid reporting and are included in only Medicare reporting.

HEDIS 2019

10.15.2018 Plan All-Cause Readmissions Organizations are instructed to use the file run date to determine the member’s SES stratification in the last 3 months of the continuous enrollment period. For the PCR measure, the continuous enrollment period is 365 days prior to the Index Discharge Date through 30 days after that date. How is a member’s SES stratification determined if the run date falls after the end of the continuous enrollment period?

When determining the SES stratification for PCR, use the last month of the continuous enrollment period, regardless of the run date. For example, if the continuous enrollment period ends July 1, use May, June and July to assess the member’s SES stratification, regardless of the run date of the July Monthly Membership Detail Data File.

HEDIS 2019

10.15.2018 Total Membership How should organizations handle dually enrolled members for the Total Membership (TLM) measure? Should organizations follow the "total unduplicated membership" rule, or should they follow General Guideline 15 and count the member twice (where applicable)?

Organizations should refer to General Guideline 15 in the HEDIS 2019 Volume 2 publication for guidance on reporting members with dual enrollment for the TLM measure. However, when General Guideline 15 allows members to be included in more than one product line deduplicate and count members only once in the measure as follows:

-Report members with dual Medicaid/Medicare enrollment in the Medicare product line.

–For other dual enrolled members report the members in the primary product line.

HEDIS 2019

9.14.2018 Risk of Continued Opioid Use In the HEDIS 2019 Volume 2 Technical Specifications, the Risk of Continued Opioid Use (COU) measure includes the Medicare product line; however, this measure was not included in the CMS Reporting Requirements memo for HEDIS 2019. Given this discrepancy, is the COU measure reported by Medicare plans?

The COU measure does include the Medicare product line, and it will be collected in IDSS by NCQA from Medicare plans; however, because it was not included in the CMS Reporting Requirements memo, it is not required to be reported to CMS for HEDIS 2019.

HEDIS 2019

7.16.2018 Use of Opioids at High Dosage Why is buprenorphine included in the Use of Opioids From Multiple Providers (UOP) and Risk of Continued Opioid Use (COU) measures, but not in the Use of Opioids at High Dosage (UOD) measure?

Unlike UOP and COU, UOD requires the conversion of all dispensed opioids into morphine milligram equivalents (MME). The most current MME conversion file, published by the Centers for Disease Control and Prevention, removes buprenorphine, a partial opioid agonist, and states that the drug is not likely to be associated with overdose in the same dose-dependent manner as pure opioid agonists. NCQA removed it from the UOD measure in HEDIS 2019. This change aligns with the decision made by the Pharmacy Quality Alliance, the organization that developed the measure from which UOD was adapted for use in HEDIS.

HEDIS 2019

7.16.2018 General Guidelines Does a member enrolled in palliative care meet criteria for the hospice exclusion outlined in General Guideline 17?

Palliative care is not the same as hospice care because it can begin when a patient is diagnosed or is undergoing treatment and may not indicate being near end of life. The hospice exclusion requires evidence that the member is receiving hospices services. Documentation that a member is in palliative care is not part of the exclusion.

HEDIS 2019

5.15.2018 ECDS How do ECDS measures differ from the eMeasures in Meaningful Use (eCQMs)?

HEDIS ECDS measures are similar to eCQMs in structure, but although eCQMs are reported at the provider level, using data from an EHR, ECDS measures are reported at the health-plan level, using data from multiple sources to form a complete picture of the patient’s experience across the care continuum.

HEDIS 2018