FAQ Directory: HEDIS

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11.15.2023 Codes for Race and Ethnicity Stratification (RES) Are LOINC codes used to identify race and ethnicity?

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

  • 2106-3 = “White” (CDC Race and Ethnicity).
  • 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS MY 2024

11.15.2023 HEDIS Roadmap Documentation Requirements for Aggregators What HEDIS Compliance Audit Roadmap documentation is required by health plans for data sources provided from an aggregator (e.g., health information exchange)?

It depends:

  • For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
  • For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS MY 2024

11.15.2023 Excluding Laboratory Claims (Claims with POS Code 81) Will instructions to exclude laboratory claims (claims with POS code 81) be added to additional measures and value sets in the Technical Update memo?

Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR:    Step 2 of the event/diagnosis (Asthma Value Set)
GSD:    Numerators (HbA1c Test Result or Finding Value Set)
EED:     Event/diagnosis (Diabetes Value Set)
OMW:   Step 2 of the event/diagnosis (Fractures Value Set)
SSD:     Numerator (HbA1c Test Result or Finding Value Set)
SMD:    Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC:    Numerator (LDL-C Test Result or Finding Value Set)
IET:      Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E:  Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)

HEDIS MY 2024

11.15.2023 Members Recommended for Routine Cervical Cancer Screening The Cervical Cancer Screening (CCS and CCS-E) measures include the following criteria to identify members recommended for routine cervical cancer screening:
• Administrative Gender of Female (AdministrativeGender code F) any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement year.
What data sources can be used to identify these members?

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS MY 2024

10.16.2023 Explanation of Benefit (EOB) The digital measure packages for MY 2024 include “Explanation of Benefit” (EOB) criteria. What does that mean?

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS MY 2024

10.16.2023 Race and Ethnicity Stratification for Childhood Immunization Status (CIS) and Cervical Cancer Screening (CCS) Race and ethnicity stratification criteria are listed for CIS-E but not for CIS, and for CCS-E but not for CCS. Is this intentional?

Yes. Race and ethnicity stratification is not required for traditional reporting of CIS and CCS. The race and ethnicity stratifications are reported when using the Electronic Clinical Data Systems reporting standard for CIS-E and CCS-E.

HEDIS MY 2024

10.16.2023 Palliative Care Timeframe for Risk of Continued Opioid Use (COU) The time frame for palliative care (bullets 2 and 3 under “Required exclusions”) in the COU measure states to identify palliative care during the measurement period. Is this correct?

No. The correct time frame for identifying palliative care is “at any time during the 365 days prior to the IPSD through 61 days after the IPSD.” This correction will be in the MY 2024 Technical Update.

HEDIS MY 2024

9.15.2023 COL-E Age Stratifications in Characteristics The age stratifications listed under the “Characteristics” section of the COL-E header in Volume 2 are not the same as the age stratifications listed in the Data Elements for Reporting table. What are the correct age strata for the measure?

The age stratifications listed under “Characteristics” are incorrect; they should be 46-50 and 51-75. This correction will be in the MY 2024 Technical Update. The age stratifications listed in the Data Elements for Reporting tables are correct.
 

HEDIS MY 2024

8.16.2023 Required Exclusions and Hybrid Reporting For HEDIS MY 2023, optional exclusions are now required exclusions. For hybrid measures, if a member meets exclusion criteria via medical record review, can the member be removed from the measure and replaced with a member of the oversample?

Yes. If medical records document that the member meets exclusion criteria, the member is excluded from the sample and replaced with a member of the oversample.
 

HEDIS MY 2023

8.16.2023 Kidney Health Evaluation for Patients With Diabetes (KED) What is the intent of removing LOINC code 32294-1 from the Urine Albumin Creatinine Ratio Lab Test Value Set?

The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.

HEDIS MY 2024

8.16.2023 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?

Organizations cannot use PCS responses that are over 3 years old. If your question relates directly to a measure specification or general guideline that was revised from a previous measurement year, submit the question rather than using the answer in PCS.

HEDIS MY 2024

7.27.2023 Cervical Cancer Screening (CCS) In HEDIS MY 2023, the CCS exclusion for hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix is now a required exclusion. Does documentation of a hysterectomy in combination with documentation that the patient no longer needs Pap testing/cervical cancer screening sufficient to meet criteria as a required exclusion for HEDIS MY 2023 reporting?

No. Members with documentation of “hysterectomy” and documentation indicating that they no longer need Pap testing/cervical cancer screening must remain in the measure for MY 2023 reporting. Members with documentation of a “vaginal pap smear” and documentation of “hysterectomy” must also remain in the measure for HEDIS MY 2023 reporting. This is because the documentation must match the clinical specificity of the codes in the value sets and there are no codes that are clinically synonymous with these examples.
There must be evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix in order to meet required exclusion criteria for MY 2023 reporting.
Documented “vaginal hysterectomy” or “complete/total/radical hysterectomy” that matches a definition in applicable value sets may be used to meet criteria, subject to auditor approval.
 

HEDIS MY 2023