Follow‑up After Emergency Department Visit for Patients With Multiple High‑Risk Chronic Conditions (FMC) 2025

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS measure

This HEDIS measure evaluates the percentage of emergency department (ED) visits, on or between January 1 and December 24, for members 18 years of age and older who have multiple high‑risk chronic conditions and who had a follow‑up service within seven days of the ED visit.

Numerator

Members 18 years and older with two or more high‑risk, chronic conditions who had a follow‑up service within seven days after an emergency department (ED) visit (eight days total) between January 1 and December 24 of the measurement year. This includes visits that occur on the date of the ED visit.

Denominator (eligible patients)

Patients 18 and older with two or more high risk chronic conditions who went to the emergency department (ED) between January 1 and December 24 of the measurement year for one of those high‑risk conditions

Note: Patients may have more than one ED visit. Identify all ED visits between January 1 and December 24 of the measurement year. If a member has more than one ED visit in an eight‑day period, include only the first eligible ED visit.

Exclusions

• Patients who use hospice services or elect to use a hospice benefit any time during the measurement year
• Patients who die any time during the measurement year

Eligible chronic conditions

Patients who had any of the following eligible chronic condition diagnoses prior to the ED visit:

• COPD, asthma, and unspecified bronchitis
• Alzheimer’s disease and related disorders
• Chronic kidney disease
• Depression
• Heart failure
• Acute myocardial infarction
• Atrial fibrillation
• Stroke and transient ischemic attack

Eligible events

Patients who had any of the following events with an eligible chronic condition diagnosis on different dates of service during the measurement year or the year prior to the measurement year, but prior to the ED visit:

• At least two outpatient visits, observation visits, ED visits, telephone visits,
  e‑visits, or virtual check‑ins, non‑acute inpatient encounters, or non‑acute inpatient discharges for the same eligible chronic condition
• At least one acute inpatient encounter with an eligible chronic condition
• At least one acute inpatient discharge with an eligible chronic condition on the discharge claim

Services needed for compliance:

• A follow‑up service within seven days of an ED visit. Include visits that occur on the date of the ED visit. The following meet criteria for follow‑up:
• An outpatient visit:
• Office visits. New patient: 99202–99205; Established patient: 99211–99215
• Preventative medicine services. New patient: 99381–99387; Established patient: 99391–99397
• Consultations for new or established patients: 99242–99245
• Patient home visits. New patient: 99341, 99342, 99344, 99345; Established patient: 99347–99350
• Cognitive assessment and care plan services: 99483
• Non‑face-to-face nonphysician services: 98966–98968
• Non‑face-to-face physician telephone services: 99441–99443
• Outpatient and telehealth value set
• Transitional care management services: 99495, 99496
• Visit setting unspecified value set
• Complex care management services: G0506

Best practices

• Schedule post‑ED follow‑up visit within three to five days after discharge.
• Encourage regular office visits with PCP to monitor and manage chronic disease conditions.
• Develop and implement a case management program that monitors utilization and assures appropriate follow‑up care.
• Provide a visit summary with clear instructions on changes that need immediate attention.
• Encourage patients to call PCP’s office/after‑hours line when condition changes (weight gain, medication changes, high/low blood sugar readings).
• Develop a process to schedule patients who have been discharged from ED or an inpatient stay.
• Establish relationships with area hospitals to develop notification processes for ED visits.

Let’s work together

Measure is closed via the following:

• Claims
• Consolidated Clinical Document Architecture (CCDA)
• SFTP/flat files
• Cotiviti

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