FAQ Directory: HEDIS

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10.16.2012 General Guidelines What is the difference between "required" exclusions and "optional" exclusions?

Required exclusions identify members who must be excluded from the measure, regardless of numerator compliance. They are listed as part of the eligible population criteria because members who meet the required exclusion criteria are removed when identifying the denominator of the measure. Optional exclusions should only be used to remove members that did not meet the measure's numerator criteria. Organizations may choose to apply optional exclusions, which are listed separately at the end of the measure specification, or may choose not to apply the exclusions.

HEDIS 2013

10.16.2012 Comprehensive Diabetes Care Can CPT Category II code 4010F be used to identify ACE inhibitor/ARB therapy for the Medical Attention for Nephropathy indicator?

Yes, CPT Category II code 4010F (Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken) can be used to identify ACE inhibitor/ARB therapy (Table CDC-K) for the Medical Attention for Nephropathy indicator for HEDIS 2014 reporting.

HEDIS 2013

9.16.2012 General Guidelines Can an organization continue to collect medical records for members in the hybrid sample after the May 15 medical record review deadline and record them in supplemental database for use in the current reporting year?

No, organizations may not continue to collect medical record data past May 15 and enter it into a supplemental database for use in the current HEDIS year.

HEDIS 2013

9.16.2012 Medication Reconciliation Post-Discharge The Medication Therapy Management (MTM) program is required for CMS Parts C and D data validation audits. May we use data from the MTM program to satisfy the "medication reconciliation" requirements in the MRP measure?

Data from the MTM program may be used only if the organization can distinguish a member's discharge medications from the member's current medications. The reconciliation must have occurred on or within 30 days of discharge by a prescribing practitioner, clinical pharmacist or registered nurse to meet the intent of the measure.

HEDIS 2013

9.16.2012 Cervical Cancer Screening The USPSTF released new recommendations for cervical cancer screening in March 2012. It recommends cytology (Pap test) screening every three years for women 21_65 years of age or, for women 30_65 years of age who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every five years. In light of the new recommendations, will NCQA update the CCS measure to account for the lengthened screening for women 30_65 years?

In response to USPSTF recommendations, NCQA has scheduled the CCS measure for reevaluation in 2012. The appropriate staff and panels will review updates and other relevant guidelines and will evaluate potential changes to the measure. Proposed changes, if any, will be posted for Public Comment in February 2013 and, pending final approval by the NCQA Committee on Performance Measurement, will be included in HEDIS 2014.

HEDIS 2013

8.16.2012 Comprehensive Diabetes Care May documentation of the glomerular filtration rate (GFR) test be used when reporting the Medical Attention for Nephropathy indicator?

No. GFR testing is not currently acceptable for the Medical Attention for Nephropathy indicator. Clinical experts determined that certain characteristics, such as age, sex and race, may impact the effectiveness of such tests for monitoring nephropathy. If a member was determined to have impaired kidney function based on a GFR test, it is expected that there would be other documentation in the medical record that would make the member compliant for the nephropathy indicator (e.g., documentation of a visit to a nephrologist or documentation of medical attention for any appropriate conditions listed in the specifications).

HEDIS 2013

8.16.2012 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis What combination of visits with a diagnosis of rheumatoid arthritis may be used to meet the event/diagnosis criteria?

Although the event/diagnosis criteria do not specifically state "and/or," it is implied. As long as there are two outpatient visits or two nonacute inpatient discharges, or one outpatient visit and one nonacute inpatient discharge, with a diagnosis of RA, the member meets the criteria for eligible population.

HEDIS 2013

7.16.2012 Medical Record Review Validation Has NCQA communicated the changes to the MRRV process?

Yes. We sent communication to plans, auditors, vendors, physician groups, purchaser groups and state and federal agencies.

HEDIS 2013

7.16.2012 Medical Record Review Validation Does NCQA expect a decrease in rates with this new policy?

Although NCQA does not anticipate that rates will decrease, plans will need to start early and collect all data by May 15 to ensure that their rates are not affected.

HEDIS 2013

7.16.2012 Medical Record Review Validation Does the audit timeline have a new MRR completion date?

Yes. For HEDIS 2013, NCQA will enforce a medical record review deadline of May 15 (the previous deadline was May 10). No charts will be accepted past this deadline, when auditors will begin to review records. Holding all plans to the same timeline ensures comparability among submissions.

HEDIS 2013

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment In the Initiation of AOD Treatment indicator, the third paragraph states that if the Index Episode was an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit, the member must have an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization with an AOD diagnosis, within 14 days of the IESD (inclusive). What does "inclusive" mean?

"Inclusive" means the IESD is day 1 in the 14-day count for the Initiation of AOD Treatment indicator. The time frame for initiation is the IESD and the next 13 days, for a total of 14 days. For example, if a members IESD was an outpatient visit on August 1, the initiation visit must occur on or between August 1 through August 14.

HEDIS 2013

7.16.2012 Medical Record Review Validation Why was a new statistical test chosen for MRRV?

The new test will reduce the number of errors allowed in the systematic sample collected using the Hybrid Method. Auditors will use the Squeglia Zero-based Sampling Plan, which includes more measures but has a smaller sample of 16 charts.

HEDIS 2013