FAQ Directory: HEDIS

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12.02.2019 Use of High-Risk Medications in Older Adults Why is NDC code 50090096201 included on both the Digoxin .25 mg Medications List and the Digoxin .125 mg Medications List?

NDC codes can be used to identify different medications at different points in time. The NDC code 50090096201 identified digoxin .125 mg until July 2017 and was reassigned to digoxin .25 mg in 2019. The code is included in both lists because of the time frame NCQA used for removing obsolete NDC codes (the look-back period for the measure plus two additional years).
Because it is likely that the code on a claim during the calendar year indicates digoxin .25 mg and because this issue may impose confusion when programming the measure, organizations may elect to remove the NDC code from the Digoxin .125 mg Medications List for HEDIS 2020 reporting. Measure Certification will only test this code as part of the Digoxin .25 mg Medications List.

HEDIS 2020

12.02.2019 General Guideline 50: Mapping Proprietary or Other Codes Organizations may map NDC or RxNorm codes based on generic name (or brand name), strength/dose and route. What information is used to map “dose” or “route”?

For mapping purposes, the organization must demonstrate that the medication being mapped is the same as a medication listed in the Medication List Directory (MLD). For example, the route for “benralizumab” is listed as “subcutaneous” in the Asthma Controller Medications table (p. 153 HEDIS 2020 Volume 2).
The MLD contains two generic products for benralizumab: “1 ML benralizumab 30 MG/ML Prefilled Syringe” and “benralizumab 30 MG/ML Prefilled Syringe,” where the Route is listed as “injection.” Therefore, it would be appropriate to map a code with the generic name “benralizumab” and strength “30 MG/ML and dose form or route of either “syringe” or “prefilled syringe” or “injection.”
Another example is fluticasone, which is listed as “inhalation” in the Asthma Controller Medications table. The MLD (Generic Product Name) identifies appropriate dose/forms as “metered dose inhaler” or “dry powder inhaler,” and lists the route as “inhalation.” Therefore, it would be appropriate to map codes for fluticasone if the strength/dose matches one in the MLD and if the dose form or route is “inhaler” or “metered dose inhaler” or “powder inhaler” or “inhalation.” It would not be appropriate to map codes for fluticasone with dose form or route of “nasal spray.”

HEDIS 2020

11.15.2019 Transitions of Care - Receipt of Discharge Information The Note in the medication record specification states, “Evidence that the PCP or ongoing care provider communicated with the ED about the admission meets criteria.” Should the reference to “admission” in this sentence be changed to “discharge”?

Yes. The sentence should be changed to read, “Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of discharge or the following day meets criteria.”

HEDIS 2020

11.15.2019 General Guideline 37 General Guideline 37 states that if organizations use both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, they should deduplicate and count an NDC code and an RxNorm code for the same drug on the same date of service as only one dispensing event, to avoid double counting. How should organizations handle this where different drugs are included in the same medication list with no variable to differentiate between “same or different”?

For measures where different drugs are included in the same medication list with no variable to differentiate between “same or different,” the organization develops its own method. It is appropriate for the organization to assume that an NDC code and an RxNorm code on the same date of service are for the “same drug” and count as one dispensing event; however, this will not be tested as part of measure certification.

HEDIS 2020

11.15.2019 Mental Health Taxonomy Codes Why did NCQA include Mental Health taxonomy codes in the HEDIS 2020 Value Set Directory? Must we use those codes for transactional data?

The Mental Health Taxonomy Value Set was added in HEDIS 2020 to be used by organizations that report HEDIS using clinical (non-transactional) data. An organization that has taxonomy codes in transactional data may continue to map taxonomy codes not included in the VSD to taxonomy codes in the VSD, with auditor approval.

HEDIS 2020

11.15.2019 Transitions of Care - Notification of Inpatient Admission The medical record specification states, “Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of discharge or the following day meets criteria.” Should the reference to “discharge” in this sentence be changed to “admission”?

Yes. The sentence should be changed to read, “Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of admission or the following day meets criteria.”

HEDIS 2020

11.15.2019 System Generated Dates If during data collection an EHR system generates a date of the medical record report, may the system-generated date be used for medical record abstraction?

No. System generated dates during the data collection/abstraction process may not be used Organizations should use the documentation in the EHR to determine the date of service.

HEDIS 2020

11.15.2019 Comprehensive Diabetes Care Does documentation of “HB1c” meet criteria when reporting the HbA1c testing indicator?

Yes, documentation of " HB1c " is considered evidence of a HbA1c test and may be used when reporting the HbA1c testing indicator.

HEDIS 2020

11.15.2019 Plan All-Cause Readmissions The PCR measure indicates that for commercial and Medicaid, organizations report only members 18–64 years of age. This is inconsistent with Table PCR-1/2/3: Plan Population and Outlier Rate (Medicaid, Commercial and Medicare, 18+) and Table PCR-A-1/2/3 : Plan All-Cause Readmissions Rates Among Nonoutlier Members by Age (Medicaid, Commercial and Medicare, 18+), which indicate that members ages 18 and older are reported for all product lines. Are these data element tables incorrect for commercial and Medicaid reporting?

Yes, the tables are incorrect. When reporting the PCR measure for the commercial and Medicaid product lines, only include members 18–64 years of age. The age ranges 65–74, 75–84, 85+ and 65+ Total included in the data element tables are only collected for Medicare reporting.
For commercial and Medicaid reporting, collect 18–44, 45–54, 55–64 and 18–64 Total. 

HEDIS 2020

11.15.2019 Prenatal and Postpartum Care The Postpartum Care indicator states that documentation of “Resumption of physical activity and attainment of healthy weight” meets criteria. Does documentation need to include both resumption of physical activity AND attainment of healthy weight to meet criteria?

No. Documentation of either resumption of physical activity or attainment of healthy weight alone meets criteria.

HEDIS 2020

10.15.2019 Organization Responsibility for Chart Review HEDIS 2020 clarified that chart pursuit is recommended but is determined by the organization. Does this mean that chart pursuit is up to the organization?

Yes. Although NCQA recommends that organizations using the Hybrid Method pursue charts for all noncompliant members in the systematic sample, ultimately, the decision is the organization’s.

HEDIS 2020

10.15.2019 “Unknown” SES Category The SES stratification guidance in HEDIS 2020 Volume 2 indicates that the “Unknown” category may be used for only Puerto Rico plans or if the auditor approves a small number of unassigned members. Is there a specific number of Unknown members a plan is allowed to report?

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be at or below 1%. If more than 1% of eligible members are assigned to the “Unknown” category, the plan must work with the auditor to identify why members are being categorized as “Unknown.”

HEDIS 2020