FAQ Directory: HEDIS

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

HEDIS 2016

Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.

HEDIS 2016

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

HEDIS 2016

When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.

The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).

HEDIS 2016

Yes. Unless the measure specification directs otherwise, use diagnosis and procedure codes from both facility and professional claims to identify an admission or discharge event.

HEDIS 2016

No. For HEDIS 2016 reporting, this new requirement was added to only the Effectiveness of Care (EOC) and EOC-like measures. “EOC-like measures” refers to the Utilization measures that have the same structure as and follow the same guidelines as the measures in the EOC domain (i.e., Frequency of Ongoing Prenatal Care, Well-Child Visits in the First 15 Months of Life, Well-Child visits in the Third, Fourth, Fifth and Sixth Years of Life, Adolescent Well-Care Visits). While supplemental data may be used for other measures, NCQA is not currently collecting this data element for other measures at this time.

HEDIS 2016

The reported rate calculation is the sum of all numerator events by administrative data, medical record data and supplemental data, divided by the eligible population for administrative measures, or by the denominator for hybrid measures (i.e., reported rate = numerator events by administrative data + numerator events by medical record data + numerator events by supplemental data / eligible population or denominator).

HEDIS 2016

Yes. For Medicare reporting, exclude members who elect to use the hospice benefit (i.e., use hospice service) any time during the measurement year. These members must be removed prior to determining the measure’s eligible population and drawing the sample for hybrid measures.

HEDIS 2016

If any data is found in a supplemental data source, it is considered a supplemental data hit because the member would not be compliant for the measure/indicator without the data source.

HEDIS 2016

Customers can find additional information about these topics (including FAQs specific to this data source and the DMS measure) at the following link, http://ncqa.org/ECDS.

HEDIS 2016

Yes. The PCS system will be moved to a new Web site—http://my.ncqa.org—by the end of April. Customers who access the old PCS site will be automatically rerouted to the new site. The new site takes the same login and password; you will not need to change them.

HEDIS 2015

Yes. Starting in reporting year 2015, NCQA requires that all Licensed Organizations apply a password lock to the validated and approved sample frame file used for conducting the commercial and Medicaid Child and Adult CAHPS and the Qualified Health Plan (QHP) Enrollee surveys. Survey vendors may not pull a sample from an unlocked file.

HEDIS 2015