Coding spotlight: HEDIS MY 2021

HEDIS overview

The National Committee for Quality Assurance (NCQA) is a non-profit organization that accredits and certifies health care organizations. The NCQA establishes and maintains the Healthcare Effectiveness Data and Information Set (HEDIS^®). HEDIS is a tool comprised of standardized performance measures used to compare managed care plans. The overall goal is to measure the value of health care based on compliance with HEDIS measures. HEDIS also allows stakeholders to evaluate physicians based on health care value rather than cost. This article will outline specific changes to the HEDIS measures as outlined by the NCQA. The changes are effective for the measurement year (MY) 2020 to 2021. It is important to note that the state health agency has the authority to determine which measures and rates managed care organizations should capture.

 

HEDIS data helps calculate national performance statistics and benchmarks and sets standards for measures in NCQA Accreditation.

 

Health plans use HEDIS performance results to:

• Evaluate the quality of care and services.
• Evaluate provider performance.
• Develop performance improvement initiatives.
• Perform outreach to providers and members.
• Compare performance with other health plans.

 

HEDIS MY 2020 new measures:

• Follow-up After High-Intensity Care for Substance Use Disorder (FUI)
• Pharmacotherapy for Opioid Use Disorder (POD)
• Breast Cancer Screening (BCS-E)
• Follow-up Care for Children Prescribed ADHD Medication (ADD-E)
• Prenatal Depression Screening and Follow-up (PND)
• Postpartum Depression Screening and Follow-up (PDS)

 

HEDIS MY 2020 retired measures:

• Annual Monitoring for Patients on Persistent Medications (MPM)
• Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
• Standardized Healthcare-Associated Infection Ratio (HAI).

 

Retired measures are no longer maintained by NCQA or included in the HEDIS measurement set. NCQA has determined that specific measures are clinically inappropriate and are no longer in use. Once retired, the measures are not used in any product, program or service, and all use must stop.

 

HEDIS MY 2020 revised hybrid measures:

• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
• Childhood Immunization Status (CIS)
• Immunizations for Adolescents (IMA)
• Cervical Cancer Screening (CCS)
• Colorectal Cancer Screening (COL)
• Care for Older Adults (COA)
• Controlling High Blood Pressure (CBP)
• Medication Reconciliation Post-Discharge (MRP)
• Transitions of Care (TRC)
• Prenatal and Postpartum Care (PPC)
• Well-Child Visits in the First 15 Months of Life (W15)
• Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
• Adolescent Well-Care Visits (AWC)

HEDIS MY 2020 revised administrative measures:

• Appropriate Testing for Children with Pharyngitis (CWP)
• Statin Therapy for Patient’s with Cardiovascular Disease (SPC)
• Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
• Osteoporosis Management in Women Who Had a Fracture (OMW)
• Follow-Up After Hospitalization for Mental Illness (FUH)
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
• Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP).

 

HEDIS and telehealth

HEDIS measures include synchronous telehealth (which requires real-time interactive audio and video telecommunications), telephone visits and online assessments, as appropriate. A measure specification will indicate when telephone visits or online assessments are eligible for use in reporting.

 

A measure specification that is silent about telehealth is assumed to include telehealth. Correct coding requires billing telehealth services using standard CPT^® and HCPCS codes for professional services in conjunction with a telehealth modifier and a telehealth POS code. Therefore, the CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present). A measure specification will indicate when telehealth is not eligible for use and is excluded.

 

The future of HEDIS

The future of HEDIS focuses on six core ideas:

• Allowable adjustments: New flexibility lets users modify measures without changing their clinical intent.
• Licensing and certification: Updated requirements ensure the accuracy of the results.
• Digital measures: HEDIS specifications that download directly into users’ data systems bring new ease of use.
• Electronic clinical data systems (ECDS): This new reporting method helps clinical data create insight for managing the health of individuals and groups.
• Schedule change: A new schedule gives users more time by providing the complete measure specifications sooner – 11 months earlier than the traditional timeline
• Telehealth: The access to care that telehealth has brought during COVID-19 is vital to quality now after the pandemic.

 

Resources:

HEDIS^® Measures and Technical Resources. https://www.ncqa.org/HEDIS^®/measures