1. Introduction to HEDIS® Presented by the Quality Improvement Department at Gold Coast Health Plan Ventura County’s Medi-Cal Managed Care Plan Serving Ventura County since July 1, 2011

2. Contents
I. What is HEDIS®? II. HEDIS® Measures GCHP Reports III. HEDIS® Measure Definitions III. Reasons for Low HEDIS® Rates IV. How to Improve your HEDIS® Rates

3. What is HEDIS®?

4. What is HEDIS®?
HEDIS® is a standardized set of performance measures called Healthcare Effectiveness Data Information Set which are developed and maintained by the National Committee for Quality Assurance (NCQA).

5. Who participates in HEDIS®?
Over 90% of America’s health plans (Medicare, Medicaid, and commercial) participate in HEDIS® quality reviews.
California’s Medi-Cal Managed Care Plans are mandated by the Department of Health Care Services (DHCS) to report HEDIS® measures annually.

6. Purpose of HEDIS® Health Plans use HEDIS® reviews to:
Evaluate quality of care and services provided to health plan members
Evaluate accessibility of care
Develop performance improvement initiatives
Perform outreach to providers and members
Compare performance with other health plans

7. Reporting HEDIS® Rates
HEDIS® measures evaluate the previous year’s clinical data.
For example, most HEDIS® rates reported in 2016 are based on clinical services performed in 2015.
Some measures, such as Cervical Cancer Screening, look for services performed up to 5 years prior to the reporting year.
Results of HEDIS® reviews are reported to DHCS and NCQA in June each year.
GCHP distributes HEDIS® Provider Report Cards in June & July.

8. Medical Record Retrieval Measure Improvement Projects
HEDIS® Timeline
Month
HEDIS® Meetings
HEDIS ® Training
Data Integration Runs
HEDIS ® Audit Activity
Medical Record Retrieval
Medical Record Review
HEDIS ® Submissions
Measure Improvement Projects
September X
October
Q3 Run
November
December
January
Q4 Run
Roadmap
February
March
Convenience Samples
April
Q1 Run
Preliminary Rates
May
Medical Record Review Validations
June
Final Rates
July
Q2 Run
Audit Results
August

9. What does HEDIS® measure?
HEDIS® consists of 88 measures across the following 7 domains of care:
Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization and Risk Adjusted Utilization
NCQA combined “Utilization” with “Risk Adjusted Utilization” in 2015.
Relative Resource Use
NCQA removed the “Utilization” measures from this domain in Previously this domain was titled “Utilization and Relative Resource Use”.
Health Plan Descriptive Information
Measures Collected Using Electronic Clinical Data Systems
New domain added by NCQA in 2015.

10. Clinical Data Reviewed for HEDIS® Reporting
Claims data
Encounter data
Pharmacy data
Medical records
Member data
Provider data
Supplemental clinic data such as:
Lab
Vision
Immunization
Electronic medical records

11. Two Types of Measures Hybrid measures Admin measures
Population size reviewed: Sample size of up to 411 eligible members randomly selected
Requires reviewing claims, encounter, and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.).
Require reviewing medical record documentation to validate if members received the service or care being measured.
Admin measures
Population sized reviewed: Entire eligible population
Requires reviewing only claims, encounter and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.).
No medical record reviews required.

12. HEDIS® Measures GCHP Reports

13. HEDIS® Measure Type of Measure Domain Sub-Domain 1
Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents
Hybrid
Effectiveness of Care
Prevention & Screening 2
Childhood Immunization Status 3
Immunizations for Adolescents 4
Cervical Cancer Screening 5
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Admin
Overuse/Appropriateness 6
Use of Imaging Studies for Low Back Pain 7
Medication Management for People with Asthma
Respiratory Conditions 8
Controlling High Blood Pressure
Cardiovascular 9
Comprehensive Diabetes Care
Diabetes 10
Annual Monitoring for Patients on Persistent Medications
Medication Management 11
Children & Adolescent Access to PCPs
Access & Availability of Care 12
Prenatal & Postpartum Care 13
Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life
Utilization & Risk Adjusted Utilization
Utilization 14
Ambulatory Care

14. HEDIS® Measure Definitions

15. Domain: Effectiveness of Care Sub-Domain: Prevention & Screening

16. Weight Assessment & Counseling for Nutrition & Physical Activity in Children & Adolescents (WCC)
The percentage of 3 to 17 year old children and adolescents who had an outpatient visit with a PCP or OB/GYN and who received ALL of the following three services during the 2015 measurement year:
BMI percentile assessment
Counseling for nutrition
Counseling for physical activity
Three separate rates are reported for each service
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
Hybrid Measure
NCQA’s Changes to the WCC Measure in 2015
Documentation of BMI value for adolescents aged is no longer accepted – BMI percentile must be documented
Documentation of anticipatory guidance related to safety (e.g. wears helmet or water safety) without specific mention to physical activity recommendations no longer meets criteria for counseling for physical activity.

17. Codes to Identify WCC Description ICD-9-CM Diagnosis
CPT
HCPCS
UB Revenue
BMI Percentile, Pediatric <5%
V85.51
Z68.51
BMI Percentile, Pediatric 5% to <85%
V85.52
Z68.52
BMI Percentile, Pediatric 85% to <95%
V85.53
Z68.53
BMI Percentile, Pediatric ≥ 95%
V85.54
Z68.54
Counseling for Nutrition
V65.3
Z71.3
G0270-G0271, G0447, S9449, S9452, S9470, S9449
Counseling for Physical Activity
V65.41
G0447, S9451
Outpatient Visits
, , , , , , , , , 99420, 99429,
G0402, G4038, G4039, G0463, T1015
, ,

18. Childhood Immunization Status (CIS)
The percentage of 2-year old children who had the following childhood immunizations between 42-days after birth and on or before their 2nd birthday:
4 DTaP (diphtheria, tetanus, and acellular pertussis)
3 IPV (polio)
1 MMR (measles, mumps, rubella)
3 HiB (H influenza type B)
3 Hep B (Hepatitis B) – newborn Hep B vaccine administered during 8-day period after birth is acceptable
1 VZV (chicken pox)
4 PCV (pneumococcal conjugate)
Eight rates reported:
One rate for each of the seven immunizations
One combo rate reported showing the percentage of children who had all seven immunizations
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
CAIR Immunization Registry
Hybrid Measure

19. Codes to Identify CIS Immunization CPT ICD-9-CM Diagnosis
DTaP
90698, 90700, 90721,
IPV
90698, 90713, 90723
MMR
90707, 90710
Measles and rubella
90708
Measles
90705
055.0, 055.1, 055.2, , , 055.8, 055.9
B05.0 – B05.4, B05.81, B05.89, B05.9
Mumps
90704
072.0 – 072.3, , , , 072.8, 072.9
B26.0 – B26.3, B26.81 – B26.85, B26.89, B26.9
Rubella
90706
056.00, , , , , 056.8, 056.9
B06.00-B06.02, B06.09, B06.81-B06.82, B06.89, B06.9

20. Codes to Identify CIS Immunization CPT HCPCS ICD-9-CM Diagnosis
ICD-9-PCS
ICD-10-PCS
HiB
, , , 90748
Hepatitis B
90723, , , , 90748
G0010
, , V02.61
B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51
99.55
3E0234Z
VZV
90710,90716
, , , , , , , , , 053.9
B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B B02.24, B02.29-B02.34, B02.39, B02.7 – B02.9
Pneumococcal Conjugate
90669, 90670
G0009

21. Immunization for Adolescents (IMA)
The percentage of 13-year old adolescents who had the following immunizations:
1 Meningococcal between the member’s 11th and 13th birthday
1 Tdap/Td between the member’s 10th and 13th birthday
Three rates are reported:
One rate for each immunization
One combo rate reported showing the percentage of adolescents who had both immunizations
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
CAIR Immunization Registry
Hybrid Measure

22. Codes to Identify IMA Description CPT Tetanus vaccine 90703 Td vaccine
90714, 90718
Tdap vaccine
90715
Diphtheria vaccine
90719
Meningococcal vaccine
90733, 90734

23. Cervical Cancer Screening (CCS)
Measures the percentage of women, between the ages of 21 to 64, who had one of the following cervical cancer screenings:
Women, aged 21-64, who had a cervical cytology screening within the last 3 years
Women, aged 30-64, who had a cervical cytology/HPV co-screening within the last 5 years
One rate reported
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
Labs
Hybrid Measure

24. Codes to Identify CCS Description CPT HCPCS LOINC UB Revenue
Cervical Cancer Screening
, , , ,
G0123-G0124, G0141- G0145, G0147-G0148, P3000-P3001, Q0091
, , , , , , , , ,
0923
HPV Screening
87620, 87621, 87622
, , , , , ,

25. Domain: Effectiveness of Care Sub-Domain: Respiratory Conditions

26. Medication Management for People with Asthma (MMA)
The percentage of members, 5 to 64 years of age, who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period.
Two rates are reported
The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period
The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period
Data reviewed to identify compliance with measure:
Claims and encounter data
Pharmacy data
Administrative measure

27. Codes to Identify MMA Description ICD-9-CM ICD-10-CM CPT HCPCS
UB Revenue
Asthma
493.00, , , , , , , , , ,
J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J J45.902, J45.909, J45.990, J45.991, J45.998
Outpatient
, , , , , , , , , , , 99429,
G0402, G0438, G0439, G0463, T1015
, , , ED
, 0456, 0459, 0981
Acute Inpatient
, , , ,
, , , , , , , 0164, 0167, 0169, , , 0219, , 0729, 0987

28. Domain: Effectiveness of Care Sub-Domain: Cardiovascular

29. Controlling High Blood Pressure (CBP)
The percentage of 18 to 85 year old adults who had a diagnosis of hypertension and whose blood pressure was adequately controlled in 2015 based in the following criteria:
Members 18 to 59 years of age whose BP was < 140/90
Members 60 to 85 years of age with diabetes whose BP was <140/90
Members 60 to 85 year of age without diabetes whose BP was <150/90
One rate reported for all three groups
Data reviewed to identify compliance with measure:
Medical records
Hybrid Measure

30. Codes to Identify CBP Description ICD-9-CM Diagnosis
CPT
HCPCS
Essential Hypertension
I10
Malignant Hypertension
401.0
Benign Hypertension
401.1
Hypertension, NOS
401.9
Outpatient Visits
, , , , , , , , , 99420, 99429,
G0402, G0438, G0439, G0463

31. Domain: Effectiveness of Care Sub-Domain: Diabetes

32. Comprehensive Diabetes Care (CDC)
The percentage of 18 to 75 year old adults with diabetes (Type 1 & 2) who had the following six screenings:
Six rates reported:
Hemoglobin A1c (HbA1c) testing
HbA1c poor control (>9.0%)
HbA1c control (<8.0%)
Diabetic retinal eye exam
Medical attention for nephropathy that includes a nephropathy screening, monitoring test or evidence of nephropathy.
Blood Pressure control (< mm Hg)
Data reviewed to identify compliance with measure:
Claims and encounter data
Vision claims
Medical records
Labs
Hybrid Measure

33. Codes to Identify Members with Diabetes
Description
ICD-9-CM
ICD-10-CM
Diabetes
, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E413.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, , , , , , , , , , , , , , , , , , , , , ,

34. Codes to Place of Diabetic Services
Description
CPT
CPT Category II
LOINC
Outpatient
, , , , , , , , , 99420, 99429,
G0402, G0438, G0439, G0463, T1015
, , ,
Observation ED
99281, 99282, 99823, 99284,
0450, 0451, 0452, 0456, 0459, 0981
Nonacute Inpatient
, 99315, 99316, , ,
0118, 0128, 0138, 0148, 0158, , 0199, 0524, 0525, , , 0669
Inpatient
99221, 99222, 99223, , , 99233, 99238, 99239, , 99252, 99253, 99254, ,
0100, 0101, , , , , , , 0164, 0167, , 0179, , , , 0219, , 0729, 0987,

35. Codes to Identify HbA1c Screening for Diabetic Members
Description
CPT
CPT Category II
LOINC
HbA1c Tests
83036, 83037
3044F, 3045F, 3046F
, ,
HbA1c Levels < 7.0 %
3044F
HbA1c Levels 7.0 – 9.0 %
3045F
HbA1c Levels > 9.0 %
3046F

36. Codes to Identify Retinal Eye Exams for Diabetic Members
Description
CPT
CPT Category II
HCPCS
Diabetic Retinal Screening
67028, 67030, 67031, 67036, 67039, 67040, , 67042, 67043, 67101, 67105, 67107, , 67110, 67112, 67113, 67121, 67141, , 67208, 67210, 67218, 67220, 67221, , 67228, 92002, 92004, 92012, 92014, , 92019, 92134, 92225, 92226, 92227, , 92230, 92235, 92240, 92250, 92260, , 99204, 99205, 99213, 99214, 99215, , 99243, 99244, 99245
2022F, 2024F, 2026F,
S0620, S0621, S0625, S3000
Negative Diabetic Retinal Screening
3072F

37. Codes to Identify Screening/Monitoring for Nephropathy
Description
ICD-9-CM
ICD-10-CM
CPT Category II
Evidence of Nephropathy Treatment
, , , , , , , , , , , , , 580.0, , , , 580.9, , , , 581.9, 582.0, 582.1, 582.2, 582.4, , , 582.9, , 583.4, 583.6, 583.7, , , 583.9, , 586, 587, , 588.1, , , 588.9, 753.0, , , 791.0
E08.21, E08.22, E08.29, E09.21, E09.22 E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0-N00.9, N01.0-N01.9, N02.0-N02.9, N03.0-N03.9, N04.0-N04.9, N05.0-N05.9, N06.0-N06.9, N07.0-N07.9, N08, N14.0-N14.4, N17.0, N17.1, N17.2, N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0- Q60.6, Q61.00-Q61.02, Q61.11, Q61.19, Q61.2-Q61.5, Q61.8, Q61.9, R80.0-R80.3, R80.8, R80.9
3066F, 4010F
Description
CPT
CPT Category II
LOINC
Nephropathy Screening Test
81000, 81001, , 81003, , 82042, , 82044,
3060F, 3061F, 3062F
, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

38. Codes to Identify Evidence of Nephropathy
Description
ICD-9-CM
ICD-9-PCS
ICD-10-CM
ICD-10-PCS
CPT
HCPCS
Revenue Codes
CKD Stage 4
585.4
N18.4
ESRD
585.5, 585.6, V45.11, V45.12
38.95, 39.27, , 39.43, , 39.93, , 39.95,
N18.5, N18.6, Z91.15, Z99.2
3E1M39Z, 5A1D00Z, 5A1D60Z
36147, 36800, 36810, , , , 90935, , 90940, 90945, , , , 90966, 90969, , 90989, 90993, , 90999, 99512
G0257, S9339
, 0809, , , , , 0859, , 0889
Kidney Transplant
V42.0
55.61, 55.69
Z94.0
0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY1072
50300, 50320, 50340, , 50365, 50370,
S2065
0367

39. Domain: Effectiveness of Care Sub-Domain: Medication Management

40. Annual Monitoring for Patients on Persistent Medications (MPM)
The percentage of adults, 18 years of age and older, who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent during the measurement year.
Four rates are reported for the following therapeutic agents:
Angiotensin Converting Enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
Digoxin
Diuretics
Total rate
Data reviewed to identify compliance with measure:
Claims and encounter data
Pharmacy Data
Labs
Administrative measure

41. Codes to Identify MPM Description CPT LOINC Lab Panel
80047, 80048, 80050, , 80069
Digoxin Level
80162
3563-4,
Serum Potassium (K+)
80051, 84132
, , , , , , , , , , ,
Serum Creatinine (SCr)
82565, 82575
, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

42. Domain: Effectiveness of Care Sub-Domain: Overuse/Appropriateness NCQA Added New Sub-Domain in 2015

43. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
The percentage of 18 to 64 year old adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.
One rate reported
Data reviewed to identify compliance with measure:
Claims and encounter data
Rx data
Administrative measure
NCQA’s Changes to the AAB Measure in 2015
AAB measure moved from Respiratory Conditions sub-domain to Overuse/Appropriateness sub-domain

44. Codes to Identify AAB Description ICD-9-CM Diagnosis*
CPT
HCPCS
UB Revenue
Acute Bronchitis
466.0
J20.3-J20.9
Outpatient Visits
, , , , , , , , , , , 99429,
G G G0439 G0463 T1015
, , ,
Emergency Department Visits
, 0456, 0459, 0981

45. Use of Imaging Studies for Low Back Pain (LBP)
The percentage of members (any age) with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis.
One rate reported
Data reviewed to identify compliance with measure:
Claims and encounter data
Administrative measure
NCQA’s Changes to the LBP Measure in 2015
LBP measure moved from Musculoskeletal Conditions sub-domain to Overuse/Appropriateness sub-domain

46. Codes to Identify LBP Description ICD-9-CM Diagnosis
Low Back Pain
721.3, , , , , , , , 724.3, 724.5, 724.6, , , , , 739.3, 739.4, 846.0, 846.1, 846.2, 846.3, 846.8, , 847.2
M46.46-M46.48, M47.26-M47.28, M M47.818, M M47.898, M48.06-M48.08, M51.16, M51.17, M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M51.86, M51.87, M53.2X6 - M53.2X8. M53.3, M M53.88, M M54.32, M M54.42, M54.5, M54.89, M54.9, M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A, S33.110D, S33.110S, S33.120A, S33.120D, S33.120S, S A, S33.130D, S33.130S, S33.140A, S33.140D, S33.140S, S33.5XXA, S33.6XXA, S33.8XXA, S33.9XXA, S39.002A, S39.002D, S39.002S, S A, S39.012D, S39.012S, S39.029A, S39.029D, S39.029S, S39.82XA, S39.82XD, S39.82XS, S39.92XA, S39.92XD, S39.92XS

47. Codes to Identify LBP Description CPT HCPCS UB Revenue
Osteopathic Manipulative Study ,
Imaging Study
72010, 72020, 72052, 72100, 72110, , 72120, 72131, 72132, 72133, , 72142, 72146, 72147, 72148, , 72156, 72158, 72200, 72202,
0320, 0329, 0350, 0352 , 0359, 0610, 0612, 0614, 0619, 0972
Outpatient Visits/Observation
, , , , , , , , , , , 99429,
G0402, G0438, G0439. G0463, T1015
, , ,
Emergency Department Visits
0450, 0451, 0452, 0456, 0459, 0981

48. Domain: Access and Availability of Care

49. Children & Adolescents’ Access to PCPs (CAP)
The percentage of members:
12 months to 6 years old who had a visit with a PCP during the measurement year (2015)
7 to 19 years old who had a visit with a PCP during the measurement year (2015) or the year prior to the measurement year (2014)
Four rates are reported for the following age groups:
12 to 24 months
25 months to 6 years
7 to 11 years
12 to 19 years
Data reviewed to identify compliance with measure:
Claims and encounter data
Administrative measure

50. Codes to Identify CAP Description ICD-9-CM Diagnosis
CPT
HCPCS
UB REV
Wellness Exams
V20.2
V70.0
V70.3
V70.5
V70.6
V70.8
V70.9
Z00.00 – Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.81-Z02.83, Z02.89, Z02.9
Ambulatory Visit
, , , , , , , , , , 99429
, , ,
Wellness Visits
G0402, G4038, G4039, G0463, T1015

51. Prenatal & Postpartum Care (PPC)
The percentage of women with live birth deliveries, between November 6, 2014 and November 5, 2015, who had prenatal and postpartum care visits.
Two rates are reported:
Prenatal Care: The percentage of women who had a prenatal care visit during the first trimester or within 42 days of enrollment with their health plan
Postpartum Care: The percentage of women who had a postpartum care visit between 21 and 56 days after delivery
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
Hybrid measure

52. Codes to Identify Members for the Prenatal and Postpartum Care Measure
Description
ICD-9-CM
ICD-10 –CM
Pregnancy Diagnosis
640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22.0- V22.2, V23.0- V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81-V23.87, V23.89, V23.9, V28.0-V28.6, V28.81, V28.82, V28.89, V28.9
O09.0x, O09.1x, O09.21x, O09.29x, O09.3x, O09.4x, O09.51x, O09.52x, O09.61x, O09.62x, O09.7x, O09.81x, O09.82x, O09.89x, O09.9x, O10.1x, O10.21x, O10.31x, O10.41x, O10.91x, O11.x, O12.0x, O12.1x, O12.2x, O13.x, O14.0x, O14.1x, O14.2x, O14.9x, O15.0x, O15.1, O15.9, O16.x, O20.x, O21.x, O22.0x, O22.1x, O22.2x, O22.3x, O22.4x, O22.5x, O22.8Xx, O22.9x, O23.0x, O23.1x, O23.2x, O23.3x, O23.4x, O23.51x, O23.52x, O23.59x, O23.9x, O24.01x, O24.11x, O24.31x, O24.41x, O24.81x, O24.91x, O25.1x, O26.0x, O26.1x, O26.2x, O26.3x, O26.4x, O26.5x, O26.61x, O26.71x, O26.81x, O26.82x, O26.83x, O26.84x, O26.85x, O26.86, O26.87x, O26.89x, O26.9x, O28.x, O29.01x, O29.02x, O29.09x, O29.11x, O29.12x, O29.19x, O29.21x, O29.29x, O29.3Xx, O29.4x, O29.5Xx, O29.6x, O29.8Xx, O29.9x, O30.00x, O30.01x, O30.02x, O30.03x, O30.04x, O30.09x, O30.10x, O30.11x, O30.12x, O30.19x, O30.20x, O30.21x, O30.22x, O30.29x, O30.80x, O30.81x, O30.82x, O30.89x, O30.9x, O31.00Xx, O31.01Xx, O31.02Xx, O31.03Xx, O31.10Xx, O31.11Xx, O31.12Xx, O31.13Xx, O31.20Xx, Xx, O31.22Xx, O31.23Xx, O31.30Xx, O31.31Xx, O31.32Xx, O31.33Xx, O31.8X1x, O31.8X2x, O31.8X3x, O31.8X9x, O32.0XXx, O32.1XXx, O32.2XXx, O32.3XXx, O32.4XXx, O32.6XXx, O32.8XXx, O32.9XXx, O O33.2, O33.3XXx, O33.4XXx, O33.5XXx, O33.6XXx, O33.7-O33.9, O34.0x, O34.1x, O34.2x, O34.3x, O34.4x, O34.51x, O34.52x, O34.53x, O34.59x, O34.6x, O34.7x, O34.8x, O34.9x, O35.0XXx, O35.1XXx, O35.2XXx, O35.3XXx, O35.4XXx, O35.5XXx, O35.6XXx, O35.7XXx, O35.8XXx, O35.9XXx, O36.011x, O x, O36.013x, O36.019x, O36.091x, O36.092x, O36.093x, O36.099x, O36.111x, O36.112x, O36.113x, O36.119x, O36.191x, O36.192x, O36.193x, O36.20Xx, O36.21Xx, O36.22Xx, O36.23Xx, O36.4XXx, O36.511x, O36.512x, O36.513x, O36.519x, O36.591x, O36.592x, O36.593x, O36.599x, O36.60Xx, O36.61Xx, O36.62Xx, O36.63Xx, O36.70Xx, O36.71Xx, O36.72Xx, O36.73Xx, O36.80Xx, O36.812x, O36.813x, O36.819x, O36.821x, O36.822x, O36.823X, O36.829x, O36.891x, O36.892x, O36.893x, O36.899x, O36.90Xx, O36.91Xx, O36.92Xx, O36.93Xx, O40.1XXx, O40.2XXx, O40.3XXx, O40.9XXx, O41.00Xx, O41.01Xx, O41.02Xx, O41.03Xx, O41.101x, O41.102x, O41.103x, O41.109x, O41.121x, O41.122x, O41.123x, O41.129x, O41.141x, O41.142x, O41.143x, O41.149x, O41.8X1x, O41.8X2x, O41.8X3x, O41.8X9x, O41.90Xx, O41.91Xx, O41.92Xx, O41.93Xx, O42.00, O42.01x, O42.02, O42.10, O42.11x, O42.12, O42.90, O42.91x, O42.92, O43.01x, O43.02x, O43.10x, O43.11x, O43.12x, O43.19x, O43.21x, O43.22x, O43.23x, O43.81x, O43.89x, O43.9x, O44.0x, O44.1x, O45.00x, O45.01x, O45.02x, O45.09x, O45.8Xx, O45.9x, O46.00x, O46.01x, O46.02x, O46.09x, O46.8Xx, O46.9x, O47.0x, O47.1, O47.9, O48.x, O60.0x, O71.0x, O71.1-O71.7, O71.8x, O71.9, O88.01x, O88.11x, O88.21x, O88.31x, O88.81x, O91.01x, O91.03, O91.11x, O91.03, O91.21x, O91.23, O92.01x, O92.03, O92.11x, O92.13, O92.3-O92.6, O92.7x, O98.01x, O98.11x, O98.21x, O98.31x, O98.41x, O98.51x, O98.61x, O98.71x, O98.81x, O98.91x, O99.01x, O99.11x, O O99.213, O O99.283, O O99.313, O O99.323, O O99.333, O O99.343, O O99.353, O99.41x, O99.51x, O99.61x, O99.71x, O99.810, O99.820, O O99.843, O9A.11x, O9A.21x, O9A.31x, O9A.41x, O9A.51x, Z03.7x, Z33.x, Z34.0x, Z34.8x, Z34.9x, Z36

53. Codes to Identify Members for the Prenatal and Postpartum Care Measure
Description
ICD-9-CM
ICD-9-PCS
ICD-10-PCS
CPT
Live Deliveries
640.x1, 641.x1, 642.x1, 642.x2, 643.x1, , 645.x1, 646.x1, 646.x2, 647.x1, 647.x2, 648.x1, 648.x2, 649.x1, 649.x2, 650, x1, 652.x1, 653.x1, 654.x1, 654.x2, 655.x1, , , , , , , , , , , 658.x1, 659.x1, 660.x1, 661.x1, 662.x1, 663.x1, 664.x1, 665.x1, 665.x2, 666.x2, 667.x2, 668.x1, 668.x2, 669.x1, 669.x2, , 671.x1, 671.x2, , 673.x1, 673.x2, 674.x1, 674.x2, 675.x1, 675.x2, 676.x1, 676.x2, 678.x1, 679.x1, 679.x2, V27.0, V27.2, V27.3, V27.5, V27.6
72.0, 72.1, 72.21, 72.29, , 72.39, 72.4, , 72.6, 72.71, 72.79, 72.8, 72.9, 73.01, 73.09, 73.1, 73.21, 73.22, 73.3, 73.4, 73.51, 73.59, 73.6, 73.8, , 73.99, , 74.4, 74.99
10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10D17ZZ, 10D18ZZ, 10D27ZZ, 10D28ZZ, 10E0XZZ
59400, 59409, , 59510, , 59515, , 59612, , 59618, , 59622

54. Codes to Identify Prenatal Office Visits
Description
CPT
CPT Category II
HCPCS
UB Revenue
Prenatal Bundles Visits Billed on date of delivery
59400, 59425, 59426, 59510, , 59618
H1005
Prenatal Visits
80055, , , , 99500
0500F, 0501F, 0502F
G0463, H1000, H1001, H1002, H1003, H1004, T1015
0514

55. Codes to Identify Prenatal Screenings
Description
ICD-9-PCS
ICD-10-PCS
CPT
LOINC
Prenatal Ultrasound
88.78
BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ
76801, , , , ,
Antibody Screenings: Taxoplasmy, Rubella, Herpes Simplex, or Cytomegalovirus
86644, , , , , ,
, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
ABO Screening
86900
883-9,
Rh Screening
86901
, , , 972-0, 978-7
ABO and Rh Screening
882-1, 884-7

56. Codes to Identify Postpartum Visits
Description
ICD-9-CM
ICD-10-CM
CPT
CPT Category II
HCPCS
LOINC
UB Revenue
ICD-9-PCS
Postpartum Visits
V24.1, V24.2, V25.11, V25.12, V25.13, V72.31, V72.32, V76.2
Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2
57170, 58300, , 99501
0503F
G0101
89.26
Postpartum Bundled Visits
59400, 59410, , 59515, , 59614, , 59622
Cervical Cytology
88141, 88142, , 88147, , 88150, , 88153, , 88164, , 88166, , 88174,
G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091
, , , , , , , , ,
0923

57. Domain: Utilization and Risk Adjusted Utilization NCQA revised domain in 2015 from “Utilization and Relative Resource Use” to “Utilization and Risk Adjusted Utilization”

58. Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34)
The percentage of 3 to 6 year old children who had one or more well-child visit(s) with a PCP in 2015 and the provider of care assessed and documented ALL of the following:
Health history
Physical developmental history
Mental developmental history
Physical Exam
Health education/anticipatory guidance
One rate reported
Data reviewed to identify compliance with measure:
Claims and encounter data
Medical records
Hybrid measure

59. Codes to Identify W34 Description ICD-9-CM Diagnosis
CPT
HCPCS
Well care exam
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02-6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9
Annual Wellness Visit
G0438, G0439
Office Visit
, ,

60. Ambulatory Care (AMB)
This measures summarizes utilization of ambulatory care in 2015 in the outpatient and emergency department.
Two rates reported:
Outpatient utilization
Emergency Department utilization
Data audited to identify compliance with measure:
Claims and encounter data
Administrative measure

61. Codes to Identify AMB Description CPT HCPCS UB Revenue POS
Ambulatory Outpatient Visits
92002, 92004, 92012, 92014, , , , , , 99318, , , , , , , , , , 99429, 99461
G0463, T1015
, ,
Emergency Department
, 0456, 0459, 0981 23

62. Codes to Identify AMB Description CPT UB Revenue POS
Emergency Department Visit
, 0456, 0459, 0981 23
ED Procedure Code
10030, 10040, 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, , , , 11008, , , , 11100, 11101, , 11201, , , , , 11426, , 11450, 11451,

63. Reasons for Low HEDIS® Rates

64. Reason for Low HEDIS® Rates
Clinics did not submit claims or encounter data
No data = No history of services performed
Coding on claims and encounter data is incomplete or inaccurate
Incomplete or inaccurate coding = No history of services performed
Delayed claims & encounter submissions
Medical record documentation is incomplete
Patients did not receive annual screenings
Patients with chronic conditions are not monitored
Patients on persistent medications are not monitored
Clinics are not familiar with HEDIS® measure criteria

65. How to Improve your HEDIS® Rates

66. How to Improve your HEDIS® Rates
Timely submission of all claims and encounter data
Complete and accurate coding of all services performed
Document all services and care provided in the medical record
Include child and adolescent counseling for nutrition and physical activity
Schedule patients for their annual screenings and check-ups
Children are expected to have annual check-ups
Continually monitor patients with chronic conditions
Continually monitor patients on persistent medications
Understand the HEDIS® measure criteria and the standard practice guidelines

67. 2016 Medical Codes for HEDIS® Reporting
To obtain a complete list of the medical codes used by NCQA to identify compliance with HEDIS® measures click on the following link, NCQA’s Quality Rating System HEDIS® Value Set Directory or visit

68. HEDIS® Questions? Please email HEDIS® questions to hedis@goldchp.org