FAQ Directory: HEDIS

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

expand all

3.16.2020 Plan All-Cause Readmissions When an index hospital stay is discharged to skilled nursing care facilities (SNF) which date is used for reporting the measure?

The discharge date from the index hospital stay should be used for reporting. The PCR measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission. SNFs are considered to be nonacute inpatient settings. Therefore, when a member is transferred from an acute inpatient setting to a SNF, only the acute inpatient stay is assessed for reporting.

For example, a member has an acute inpatient stay February 1 – 5 and was discharged to a SNF February 6 – 9 and then transferred back to acute inpatient care February 10 – 14. There are two acute inpatient stays which are assessed for the PCR measure and count as two index hospital stays for the denominator (Stay 1 is February 1 – 5, Stay 2 is February 10 – 14), provided they meet all other measure criteria. Stay 2 is a readmission for Stay 1, provided it meets all numerator criteria because it occurs within 30 days of the discharge date for Stay 1. Stay 1 counts as an index hospital stay discharged to a SNF.
 

HEDIS 2020

3.16.2020 Plan All-Cause Readmissions Which risk weights are assigned to index hospital stays discharged to skilled nursing care when calculating expected readmission rates for the Medicare product line?

For the Medicare product line only, a “Skilled Nursing Care Stratification” was added to highlight the readmission rate among non-outlier Medicare beneficiaries who were discharged from the hospital to skilled nursing care. An index hospital stay discharged to skilled nursing care experienced by a non-outlier Medicare beneficiary is reported in several places and receives two sets of risk weights.

The tables in the PDF (https://www.ncqa.org/wp-content/uploads/2020/03/20200312_2020_PCR_Tables.pdf) illustrate assignment of risk weights for index hospital stays among two hypothetical Medicare beneficiaries meeting all other measure criteria (e.g. non-outlier, continuously enrolled, etc.). Index Hospital Stay #2 for member 1101 and Index Hospital Stays #1 and #2 for member 1202 are discharged to skilled nursing care.

Table 1 shows that these index stays are assigned the standard set of risk weights for reporting in Table PCR-A-1/2/3 and Table PCR-B-3. Do not assign the skilled nursing care risk weights for the stays in Table PCR-A-1/2/3 and Table PCR-B-3.

Table 2 shows that these same index stays are assigned the skilled nursing care risk weights for reporting the “Skilled Nursing Care Stratification” in Table PCR-C-3. Do not assign the standard set of risk weights for the stays in Table PCR-C-3.

Index hospital stays that are not discharged to skilled nursing do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification” in Table PCR-C-3.  Index Hospital Stays #1 and #3 for member 1101 are examples of events that do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification”. The “Skilled Nursing Care Stratification” applies to the Medicare product line only and index hospital stays among other product lines do not use the skilled nursing care risk weights.



 

HEDIS 2020

2.14.2020 Follow-Up After High-Intensity Care for Substance Use Disorder Direct Transfer instructions state, “Identify direct transfers to an acute inpatient care or residential setting during the 30-day follow-up period.” Should readmissions during the 30-day period also be identified?

No. Only direct transfers during the 30-day follow-up period should be identified. A “direct transfer” is when the discharge date from the first acute inpatient or residential care setting precedes the admission date to a second acute inpatient or residential care setting by one calendar day or less.
If a member had a stay from January 1–5, followed by readmission on January 6 and discharge on January 8, this is considered a direct transfer and the January 8 discharge date is used for reporting.
If a member had a stay from January 1–5 and a stay from January 8–10, this is considered a readmission. The “multiple discharges, visits or events during in a 31-day period” rule applies; the January 5 discharge is used for reporting and the January 10 discharge is dropped.

HEDIS 2020

2.14.2020 Prenatal and Postpartum Care For members whose last enrollment start date is less than 42 days prior to delivery, should we include prenatal visits that occur after the delivery date but within 42 days after the enrollment start date?

No. The intent is to only count prenatal visits, which by definition can only occur prior to delivery. Do not count visits that occur on or after the date of delivery for the Timeliness of Prenatal Care indicator.

HEDIS 2020

1.15.2020 Adherence to Antipsychotic Medications for Individuals With Schizophrenia Are the first two bullets below in Step 2: Exclusions of the Event/Diagnosis “required” exclusions?
• A diagnosis of dementia (Dementia Value Set).
• Did not have at least two antipsychotic medication dispensing events. There are two ways to identify dispensing events: by claim/encounter data and by pharmacy data. The organization must use both methods to identify dispensing events, but an event need only be identified by one method to be counted.
– Claim/encounter data. An antipsychotic medication (Long Acting Injections 14 Days Supply Value Set; Long Acting Injections 28 Days Supply Value Set; Long Acting Injections 30 Days Supply Value Set).
– Pharmacy data. Dispensed an antipsychotic medication on an ambulatory basis. Use all the medication lists in the Oral Antipsychotic Medications and Long-Acting Injections tables below to identify antipsychotic medication dispensing events.

Yes. The first two bullets in Step 2 of the Event/Diagnosis are required exclusions and supplemental data may be used when reporting them. These exclusions are reported in the “Number of required exclusions” data element in IDSS. The remainder of the bullets in Step 2 are exclusions, but they are not required exclusions and supplemental data may not be used when reporting them.

HEDIS 2020

12.16.2019 Childhood Immunization Status The third bullet in the Rotavirus numerator description references Rotavirus (2 Dose Schedule) Procedure Value Set, which does not exist in the Value Set Directory. Which value set should be used for reporting?

Replace the value set reference with “Rotavirus Vaccine (2 Dose Schedule) Procedure Value Set” and use this value set for reporting.

HEDIS 2020

12.16.2019 Follow-Up Care for Children Prescribed ADHD Medication The third bullet in the Rate 2-C&M Phase numerator description references the Observation Visit Value Set, which does not exist in the Value Set Directory. Which value set should be used for reporting?

Replace the value set reference with “Observation Value Set” and use this value set for reporting.

HEDIS 2020

12.02.2019 Prenatal and Postpartum Care The PPC measure defines an enrollment segment as a period of continuous enrollment with no gaps. The “last enrollment segment” is used in calculating the timelines of prenatal care numerator and is defined as the enrollment segment during the pregnancy with a start date closest to the delivery date. How do organizations identify the last enrollment segment for a member who has multiple enrollment segments?

For HEDIS 2020 reporting, enrollment segments are determined based on enrollment data provided by the health plan. If a plan provides the member's enrollment in different products/product lines as different enrollment segments, or even enrollment in the same product/product lines as different enrollment segments, the start date of the last enrollment segment must be used.

HEDIS 2020

12.02.2019 General Guideline 33: Measures That Require Results From the Most Recent Test or Measurement With General Guideline 33, organizations must use the most recent date when multiple dates of service for the same lab test are provided within a 7-day period. Which test is used in the following example, the September test or the December test?
A HbA1c lab claim on 12/30/2019 had a result date in the medical record on 1/3/2020. The member also had an HbA1c test with both the test and a result on 9/30/19.

Using General Guideline 33, the 12/30/2019 test is used as the most recent test while the 1/3/2020 result is within 7 days of the test, it is after the date threshold in the measure and may not be used. The result is counted as missing and the member is compliant for the HbA1c Testing and HbA1c Poor Control indicators. The member is not compliant for the HbA1c Control <7 for Selected Populations and HbA1c Control <8 indicators.
The 9/30/2019 test cannot be used as it is not the most recent.  

Note: Ensuring results in the year after the measurement year are not counted is not tested in HEDIS 2020 Measure Certification. 

HEDIS 2020

12.02.2019 Potentially Harmful Drug-Disease Interactions in Older Adults In the DDE measure, the IESD definition states, “For an acute inpatient encounter identified only by a professional claim (where the discharge date cannot be determined), the IESD is the date of service.” However, the definition does not specify which date to use as the IESD for nonacute inpatient encounters. Which date should be used?

Use the date of service to identify the IESD for nonacute inpatient encounters.

HEDIS 2020

12.02.2019 General Guideline 37: Measures That Use Medication Lists General Guideline 37 states that if an organization uses both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, to avoid double counting, 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. If a measure specification says, “if multiple prescriptions for the same medication are dispensed on the same day, sum the days supply,” should the days supply from the pharmacy data event and the clinical data event be summed?

The intent of GG 37 is to prevent double-counting when an organization uses both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, because the same dispensing event can have both an NDC code in the pharmacy data and an RxNorm code in the clinical data. Because the two codes identify the same dispensing event (not two dispensing events), count an NDC code and an RxNorm code on the same date of service as one dispensing event and do not sum the days supply.

HEDIS 2020

12.02.2019 The “Route” column in the Asthma Medication Ratio and Medication Management for People With Asthma measures In the Asthma Controller Medications table and the Asthma Reliever Medications table (in the AMR and MMA measure specifications), what is the “Route” column used for?

Use the “Route” information from the tables to apply the “Definitions” for calculating an “inhaler dispensing event” and an “injection or intravenous dispensing event.” For routes listed as “subcutaneous” or “intravenous,” use the “injection or intravenous dispensing event” definition.
Note: In the MLD, the “Route” column lists “subcutaneous” and “intravenous” as “injection.”

HEDIS 2020