HEDIS MY2025 Highlights

New measures

The newest additions to HEDIS address the use of Breast Imaging Reporting and Data System (BI-RADS) assessments, abnormal breast cancer assessment follow-up and blood pressure control. All these measures are reported using the ECDS reporting method.

• Documented Assessment After Mammogram (DBM-E). The percentage of episodes for members 40–74 years of age with mammograms documented in the form of a BI-RADS assessment within 14 days of the mammogram.
  • Intent: This measure addresses the need for timely documentation of breast cancer screening results using the American College of Radiology’s BI-RADS assessment categories. BI-RADS standardizes reporting of findings into six assessment categories for further management.
• Follow-Up After Abnormal Breast Cancer Assessment (FMA-E). The percentage of episodes for members 40–74 years of age with inconclusive or high-risk BI-RADS assessments that received appropriate follow-up within 90 days of the assessment.
  • Intent: This measure assesses for timely follow-up after inconclusive or high-risk assessments. Successful identification of cancer relies on appropriate follow-up of abnormal results. Failure to complete timely diagnostic testing can undermine the significance of screening. It is estimated that up to 30% of women fail to attend recommended immediate follow-up for high-risk mammograms.[1] Studies have found that delayed time to follow-up after abnormal mammography plays a role in decreased survival rates among underserved minority women.[2] Thus, an opportunity exists to improve breast cancer screening follow-up and reduce the public health burden of this illness.
• Blood Pressure Control for Patients With Hypertension (BPC-E). The percentage of members 18–85 years of age who had a diagnosis of hypertension and whose most recent blood pressure was <140/90 mm Hg during the measurement period.
  • Intent: This new measure has two key modifications from the Controlling High Blood Pressure (CBP) HEDIS measure, which uses the Hybrid reporting method (including medical record review) and a denominator that may miss many people with hypertension who should be included in the measure:
    1. It uses the ECDS reporting method.
    2. The denominator includes a pharmacy data method with a hypertension diagnosis.
  • This measure is stratified by race and ethnicity.

Retired measures

• Childhood Immunization Status (CIS)*.
• Immunizations for Adolescents (IMA)*.
• Cervical Cancer Screening (CCS)*.
• Antidepressant Medication Management (AMM).

*Only the CIS-E, IMA-E and CCS-E measures will be reported.

Overall Changes

• Measure Specifications and Measure Codes are subject to change by NCQA until the measures and codes are frozen by NCQA on March 31, 2025. NCQA will release an update noting any measure or code changes at that time.
• Added FI-SNPs, HI-SNPs and IE-SNPs as types of Institutional SNPs in General Guideline: Reporting HEDIS for Medicare.
• Eye Exam for Patients With Diabetes (EED). NCQA retired the Hybrid Method; this measure is now reported using the Administrative Method only.
• Follow-Up After Emergency Department Visit for Mental Illness and Follow-Up After Hospitalization for Mental Illness (FUM). NCQA updated denominator criteria to include phobia diagnoses, anxiety diagnoses, intentional self-harm X-chapter codes and the R45.851 suicidal ideation code. These measures expanded the numerator criteria with additional follow-up options, including expansion of provider-type options, inclusion of psychiatric residential treatment and peer support services for mental health.
• Use of High-Risk Medications in Older Adults (DAE). NCQA is removing and adding medications to this measure, and is regrouping some medications into different “drug classes” in the specifications to align with the updated American Geriatrics Society (AGS) Beers Criteria®.
• Well-Child Visits in the First 30 Months of Life (W30); Child and Adolescent Well-Care Visits (WCV). NCQA is removing telehealth visits; these were added temporarily in response to the COVID-19 pandemic. Removing telehealth well-care visits aligns the measures with updated guideline recommendations.
• Acute Hospital Utilization (AHU). NCQA expanded this measure to include the Medicaid product line for members 18–64 years of age. This initiative was motivated by the retirement of the Inpatient Utilization measure in MY 2024, and by NCQA’s commitment to improving quality across diverse populations.
• Adult Immunization Status (AIS-E). NCQA added an indicator assessing hepatitis B immunization for adults 19–59 years of age. NCQA removed the herpes zoster live vaccine from the existing herpes zoster immunization indicator, and revised the numerator criteria to assess receipt of the recombinant zoster vaccine on or after October 1, 2017. For the existing pneumococcal immunization indicator, NCQA updated the denominator age range to assess immunization for adults 65 and older.
• Chlamydia Screening (CHL). As part of a cross-cutting project to ensure that HEDIS measures appropriately acknowledge and affirm members’ gender identity, NCQA updated the Chlamydia Screening in Women measure to include transgender members recommended for routine chlamydia screening, and renamed the measure “Chlamydia Screening”.
• Care for Older Adults (COA). NCQA retired the Pain Assessment indicator because it did not differentiate between acute and chronic pain, require comprehensive assessment or assess for follow-up after assessment. NCQA will monitor the field for evolving evidence, and will consider new measures of pain assessment for older adults in the future.

Retiring Codes

NCQA annually tracks codes that are designated obsolete. NCQA does not remove codes in the year in which they receive the designation of obsolete because of the look-back period in many HEDIS measures. Obsolete codes are deleted from the HEDIS specifications after the look-back period has passed.

For example, since the Asthma Medication Ratio measure counts a principal diagnosis of asthma in the measurement year or the year prior to the measurement year, asthma codes, for this measure, have a 2-year look-back period. A code that is designated obsolete effective January 1, 2024, is deleted from the specifications in HEDIS MY 2025 after the 2-year look-back period (2024, 2025) has passed.

Race and Ethnicity (RES) Stratification is now required for the following measures:

• Controlling High Blood Pressure (CBP).
• Prenatal and Postpartum Care (PPC).
• Child and Adolescent Well-Care Visits (WCV).
• Immunization for Adolescents (IMA-E).
• Asthma Medication Ratio (AMR).
• Colorectal Cancer Screening (COL-E).
• Follow-Up After Emergency Department Visit for Substance Use (FUA).
• Pharmacotherapy for Opioid Use Disorder (POD).
• Initiation and Engagement of Substance Use Disorder Treatment (IET).
• Well-Child Visits in the First 30 Months of Life (W30).
• Breast Cancer Screening (BCS-E).
• Adult Immunization Status (AIS-E).
• Eye Exam for Patients With Diabetes (EED).
• Kidney Health Evaluation for Patients With Diabetes (KED).
• Follow-Up After Hospitalization for Mental Illness (FUH).
• Follow-Up After Emergency Department Visit for Mental Illness (FUM).
• Childhood Immunization Status (CIS-E).
• Cervical Cancer Screening (CCS-E).
• Prenatal Immunization Status (PRS-E).
• Prenatal Depression Screening and Follow-Up (PND-E).
• Postpartum Depression Screening and Follow-Up (PDS-E)
• Glycemic Status Assessment for Patients with Diabetes (GSD).

New RES Measures for 2025:

• Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC).
• Adults’ Access to Preventive/Ambulatory Health Services (AAP).
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP).
• Blood Pressure Control for Patients With Hypertension (BPC-E).

Report only one of the 9 categories for race:

• White.
• Black or African American.
• American Indian and Alaska Native.
• Asian.
• Native Hawaiian and Other Pacific Islander.
• Some Other Race.
• Two or More Races.
• Asked but No Answer.
• Unknown

Report only one of the 4 categories for ethnicity:

• Hispanic/Latino.
• Not Hispanic/Latino.
• Asked but No Answer.
• Unknown.

Language Diversity for Members:

• Spoken language preferred for health care. Data collection guidance. This information can be gathered through questions such as:
  • What language do you feel most comfortable speaking with your clinician or health care provider?
  • What language do you feel most comfortable speaking with your doctor or nurse?
  • In what language do you prefer to receive your medical care?
  • In what language do you want us to speak to you?
  • What language do you prefer to speak when you come to the medical center?
  • What language do you feel most comfortable speaking?
• Preferred language for written materials. Data collection guidance. This information can be gathered through questions such as:
  • In which language would you feel most comfortable reading health care information?
  • In which language would you feel most comfortable reading medical or health care instructions?
  • What language should we write [to] you in?
  • What is your preferred written language?
  • In what language do you prefer to read health-related materials?
  • What language do you prefer for written materials?
• Other language needs. Data collection guidance. This category captures data collected from questions that cannot be mapped to any of the categories above, such as:
  • What is the primary language spoken at home?

Medicare Socioeconomic Status (SES) Stratification

The following measures, Medicare members, are categorized by socioeconomic status (SES) stratification:

• Breast Cancer Screening.
• Colorectal Cancer Screening.
• Eye Exam for Patients With Diabetes.
• Plan All-Cause Readmissions.

Report Medicare members in only one of the six stratifications listed below.

• Non-LIS/DE, Non-disability: Member is eligible for Medicare due to age only (does not receive LIS, is not DE for Medicaid, does not have disability status).
• LIS/DE: Member is eligible for Medicare due to age and receives LIS (includes members eligible for Medicare due to DE) and does not have disability status.
• Disability: Member is eligible for Medicare due to disability status only.
• LIS/DE and Disability: Member is eligible for Medicare due to age, receives LIS and has disability status.
• Other: Member has ESRD-only status or is assigned “9—none of the above.”
• Unknown: Member’s SES is unknown. May be >0 only for Puerto Rico plans, or if the auditor approved a small number of unassigned members*.
• Total Medicare: Total of all categories above.

Best Practice and Measure Tips: How can I improve HEDIS scores?

• Maximize use of codes: Only codes will close gaps for Administrative Measures.
• Submit claim/encounter data for every service in an accurate and timely manner.
• Some measures collect more than one data element. Submit codes required for all elements.
• Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not exclude member from CCS Measure).
• Information from the medical record must validate all required measure or exclusion components.
• Each medical record/office note MUST contain:
  • Member Name
  • Date OF Birth (DOB)
  • Date OF Service (DOS)
  • Note regarding Faxes Requests: Information on a fax cover sheet cannot be used.
    • Due to the limited data collection timeframe, a turnaround time of 3‐5 days is appreciated.
    • Under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS® is permitted, and the release of this information requires no special patient consent or authorization.
  • Follow the NCQA Guidelines for Medical Records Documentation.
• Only completed events count toward HEDIS compliance.
• Documentation in a medical record of a diagnosis or procedure code alone does not comply with the numerator criteria.
• A date must be specific enough to determine a test or service was performed within the time frame specified, not merely ordered.
• An undated event on a problem list or history sheet can be used as long as it is specific enough to determine that the event occurred during the timeframe specified in the measure.
• Educate schedulers to review for needed screenings, tests and referrals.
• Assist member with scheduling tests. Follow-up to ensure completes ordered screening.
• Provide member education on disease process and rationale for tests.
• Ask open-ended questions to determine any barriers to care or treatment.
• Collaborate with other providers member receives services from to help ensure care is comprehensive, safe and effective.
• Refer members to a behavioral health professional as indicated.
• Not Acceptable: Documenting terms such as “recent,” “most recent”, “at a prior visit” or “Colonoscopy up to date”. These are not specific enough to know when an event occurred.
• Document any upcoming scheduled screening and name of provider who will be performing.
• Incomplete information will not close gaps.

Improve Medication Adherence:

• Is treatment appropriate? Should therapy continue? Follow-up to assess how the medication is working.
• Use prescription benefit at the pharmacy. Only prescription fills processed with a member’s health plan ID card can be used to measure a member’s adherence.

Talk with members about:

• Why they are on a medication, the importance of taking medication as prescribed and timely refills. Confirm instructions.
• Any barriers? Are there concerns related to health benefits, side effects or cost? Any problems getting medications from pharmacy?
• Develop a medication routine with each patient if they are on multiple medications that require them to be taken at different times.
• Encourage members to utilize pillboxes or organizers.
• Advise members to set up reminders or alarms for when medications are due.
• Adjust the timing, frequency, amount and or dosage when possible to simplify the regimen.

 

Required Enrollment

• To ensure there is enough time for member to receive services, each measure has criteria for:
  • Continuous enrollment: Specifies the minimum amount of time that a member must be enrolled with an organization before becoming eligible for a measure
  • A gap is the time when a member is not covered by the organization. An allowable gap can occur any time during continuous enrollment.
  • Anchor date: If a measure requires a member to be enrolled and to have a benefit on a specific date, the allowable gap must not include that date; the member must also have the benefit on that date.

Measure Exclusions

An exclusion will remove a member from the measure denominator based on information captured in claims, encounter, pharmacy, and/or enrollment data.

• Required exclusions: Must be applied as part of identifying the denominator.
• Exclusions for hospice, palliative care, advanced illness, frailty and long-term nursing home residence exclusions are specified in HEDIS measures where the services being captured may not be of benefit for this population or may not be in line with patients’ goals of care.
• The below exclusions are calculated by the software based on administrative data. Supplemental or medical record data may not be used for these exclusions.
  • FRAILTY: Members ages 81 and older as of December 31 of the measurement year (all product lines) with at least two indications of frailty (Frailty Device Value Set; Frailty Diagnosis Value Set; Frailty Encounter Value Set; Frailty Symptom Value Set) with different dates of service during the measurement year. Measures with Frailty exclusions are: Controlling High Blood Pressure (CBP), Persistence of Beta-Blocker Treatment After a Heart Attack (PBH), Cardiac Rehabilitation (CRE), Kidney Health Evaluation for Patients With Diabetes (KED), Osteoporosis Management in Women Who Had a Fracture (OMW), Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA).
  • FRAILITY AND ADVANCED ILLNESS: Members 66-80 years of age as of December 31 of the measurement year (all product lines) with frailty and advanced illness. Members must meet BOTH of the following frailty and advanced illness criteria to be excluded:
    • Frailty: At least two indications with different dates of service during the measurement year.
    • Advanced illness: Either of the following during the measurement year or the year prior to the measurement year:
      • Advanced illness on at least two different dates of service
      • Dispensed a dementia medication: Donepezil, Galantamine, Rivastigmine, Memantine or Donepezil-memantine.
• Long Term Care: Medicare members ages 66 and older as of Dec. 31 of the measurement year who are either:
  • Enrolled in an Institutional Special Needs Plan (I-SNP).
  • Living long term in an institution.

Measure Codes

The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure. NCQA uses Current Procedural Terminology (CPT) codes copyright 2024 American Medical Association.

Measure Codes listed for each measure are not all inclusive and subject to change based on the current NCQA Specifications for each measure. Below are common value sets for quick reference:

• Telephone/Telehealth Visits:
  • Telephone Visits CPT: 98966, 98967, 98968, 99441, 99442, 99443
  • Telehealth (E-visit or virtual check-in):
    • CPT: 98970, 98971, 98972, 98980, 98981, 99421, 99422, 99423, 99457, 99458
    • HCPCS: G0071, G2010, G2012, G2250, G2251, G2252
  • Telehealth Place of Service (POS) (Telehealth POS Value Set): 02, 10:
    • 02: Telehealth Provided Other than in Patient’s Home
    • 10: Telehealth Provided in Patient’s Home
• Outpatient Visit (Outpatient Value Set):
  • CPT: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 9429, 99455, 99456, 99457, 99458, 99483
  • HCPCS: G0402, G0438, G0439, G0463, T1015**.
  • UBREV: 0510, 0511, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0982, 0983
  • Outpatient Place of Service (POS):

• Ambulatory Outpatient Visit Value Set:
  • CPT: 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99421, 99422, 99423, 99429, 99483
  • HCPCS: G0463, G0071, G0402, G0438, G0439, G0463, G2010, G2012, G2250, G2251, G2252, S0620, S0621, T1015**.
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
  • UBREV: 0510, 0511, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0524, 0525, 0526, 0527, 0528, 0529, 0982, 0983
  • Telephone/Telehealth visits codes (listed above) are also part of the Ambulatory Outpatient Visit Value Set.

Measure Exclusion Code

• Hospice Encounter
  • HCPCS: G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046
  • UBREV: 0115, 0125, 0135, 0145, 0155, 0235, 0650, 0651, 0652, 0655, 0656, 0657, 0658, 0659
• Hospice Intervention:
  • CPT: 99377-99378
  • HCPCS: G0182
• Palliative Care Encounter:
  • G9054 Oncology
  • M1017 Patient admitted to palliative care services
  • Z51.5 Encounter for palliative care
    • Direct Reference Code for the following measure: ACP, BPD, CBP, CCS, COL, COU, CRE, DAE, DDE, EED, HBD, HDO, KED, LBP, OMW, OSW, SPC, SPC, SPD
• Frailty Device:
  • HCPCS: E0261, E0294, E0295, E0265, E0266, E0296, E0297, E0255, E0256, E0292, E0293, E1260, E1240, E1270, E1250, E1161, E0167, E0430, E0431, E0435, E0433, E0434, E0443, E0444, E0472, E0471, E0470, E0462, E1298, E1297, E1296, E1130, E0425, E0424, E0440, E0439, E0441, E0442, E0144, E0135, E0143, E0147, E0149, E0148, E0130, E0141, E0140, E1150, E1140, E1160, E1220
• Frailty Encounter:
  • CPT: 99504, 99509
  • HCPCS: G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031.
• Frailty Diagnosis:
  • [R26.2] Difficulty in walking, not elsewhere classified
  • [R26.89] Other abnormalities of gait and mobility
  • [R26.9] Unspecified abnormalities of gait and mobility
  • [R29.6] Repeated falls
  • [R53.1] Weakness
  • [R53.81] Other malaise
  • [R54] Age-related physical debility
  • [R62.7] Adult failure to thrive
  • [R63.4] Abnormal weight loss
  • [R63.6] Underweight
  • [R64] Cachexia
  • [L89.xxx] Pressure ulcer
  • [M62.50] Muscle wasting and atrophy, not elsewhere classified, unspecified site
  • [M62.81] Muscle weakness (generalized)
  • [M62.84] Sarcopenia
  • [W01.0XXA] Fall
  • [W19.XXXA] Unspecified fall, initial encounter
  • [W19.XXXD] Unspecified fall, subsequent encounter
  • [W19.XXXS] Unspecified fall, sequela
  • [Y92.199] Unspecified place in other specified residential institution as the place of occurrence of the external cause
  • [Z59.3] Problems related to living in residential institution
  • [Z73.6] Limitation of activities due to disability
  • [Z74.01] Bed confinement status
  • [Z74.09] Other reduced mobility
  • [Z74.1] Need for assistance with personal care
  • [Z74.2] Need for assistance at home and no other household member able to render care
  • [Z74.3] Need for continuous supervision
  • [Z74.8] Other problems related to care provider dependency
  • [Z74.9] Problem related to care provider dependency, unspecified
  • [Z91.81] History of falling
  • [Z99.11] Dependence on respirator [ventilator] status
  • [Z99.3] Dependence on wheelchair
  • [Z99.81] Dependence on supplemental oxygen
  • [Z99.89] Dependence on other enabling machines and devices
  • Please refer to the HEDIS MY 2025 Volume 2 Value Set Directory for Frailty Diagnosis Value Set for the complete list of ICD-10-CM codes.
• Advanced Illness:
  • ICD-10-CM: A81.00, A81.01, A81.09, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.63, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C91.00, C91.02, C92.00, C92.02, C93.00, C93.02, C93.90, C93.92, C93.Z0, C93.Z2, C94.30, C94.32, F01.50, F01.51, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.81, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.91, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F04, F10.27, F10.96, F10.97, G10, G12.21, G20, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G35, I09.81, I11.0, I12.0, I13.0, I13.11, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J68.4, J84.10, J84.112, J84.17, J84.170, J84.178, J96.10, J96.11, J96.12, J96.20, J96.21, J96.22, J96.90, J96.91, J96.92, J98.2, J98.3, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K74.0, K74.00, K74.01, K74.02, K74.1, K74.2, K74.4, K74.5, K74.60, K74.69, N18.5, N18.6

 

HEDIS Terminology

• Anchor dates: A measure may require a member to be enrolled and to have a benefit on a specific date.
• Continuous enrollment: Specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. It ensures that the organization has enough time to render services. The continuous enrollment period and allowable gaps in coverage are specific to each measure.
• Denominator – Number of members who qualify for measure criteria, based on NCQA technical specifications.
• Element – Measurable way a HEDIS measure is broken down and defined. Also referred to as a sub-measure.
• Eligible Population: all members who satisfy all specified criteria, including age, continuous enrollment, benefit, event and the anchor date enrollment requirement for the measure.
• HEDIS Measure – Term for how each domain of care is further broken down. Specifications outline measure definition and details, which outline the specifications required to evaluate the recommended standards of quality for the element(s) in the measure. (Example: COL, BCS measures). NCQA defines how data can be collected for a measure:
  • Administrative Measures: The total eligible population is used for the denominator. Only data considered “administrative” is allowed. Medical, pharmacy, supplemental data, and / or encounter claims count toward the numerator. Medical record review is not allowed for these measures during the Annual Project.
  • Electronic clinical data systems (ECDS) Measures: Data systems that may be eligible for ECDS reporting include, but are not limited to, administrative claims, clinical registries, health information exchanges, immunization information systems, disease/case management systems and electronic health records. Medical records request (MRR) for these measures is not allowed during the Annual Project.
  • Hybrid Measures: Data is collected during the Annual Project through medical record reviews, but can also be collected Prospectively. Most allow administrative data to be included. For the Annual HEDIS Audit Season, the denominator is a random sample of 411 members. This is created from a health plan’s total eligible population by the software following NCQA requirements. The numerator includes data from medical and pharmacy claims, encounters, medical record review data and supplemental data.
• HEDIS Project – Timeframe during the year when data is collected. There are two Projects:
  • Annual Project – Also referred to as Retrospective. This is required by NCQA as part of Accreditation. For HYBRID Measures, the member population is based on a sample of members from each LOB. Administrative Measures look at the total member population. The Audit timeframe is January to May for data collection.
  • Prospective Project – Involves data collection for all LOB, for all members for the next Annual Project. The QI HEDIS Team data collection timeframe is June to January. However, throughout the year Johns Hopkins Health Plans prepares for the Annual Project in various ways to optimize audit results. Review of NCQA Specifications, and updates to training and educational materials are also performed during this time.
• Line of Business (LOB) – Identifies the reporting population: Commercial (EHP, USFHP), Medicaid (Priority Partners) Medicare (Advantage MD)
• Measurement Year (MY) – Refers to the year prior to the Reporting Year. NCQA Specifications reference in measure requirements and anchor dates.
• Numerator – The number of members who meet compliance criteria based on NCQA technical specifications for appropriate care, treatment or service.
• Ongoing care provider (OCP) – The practitioner who assumes responsibility for the member’s care. You will see this term in the TRC measure.
• Primary Care Practitioner (PCP) – A physician or non-physician (e.g., nurse practitioner, physician assistant, certified nurse midwife) who offers primary care medical services.
• Prior Year (PY) – Year prior to measurement year.
• Primary Source Validation (PSV) – Steps in the data validation process required by NCQA.
• Reporting Year – Calendar year after the end of the MY during which the Annual HEDIS Audit occurs. (e.g., For MY2025, the Report Year is 2026).
• Supplemental Data (Non-Standard) – Data collected prospectively which are not in a standard file layout. Medical record reviews are an example.
• Supplemental Data (Standard) – Standardized file process to collect data from sites to close gaps.
• Sub-measure – A measure can be broken down into more specific data elements of care.
• Telehealth: Telehealth is billed using standard CPT and HCPCS codes for professional services in conjunction with a telehealth modifier and/or a telehealth POS code.
  • Synchronous telehealth requires real-time interactive audio and video telecommunications.
    • Telehealth is billed using standard CPT and HCPCS codes for professional services in conjunction with a telehealth modifier and/or a telehealth POS code.
    • CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present).
• Asynchronous telehealth sometimes referred to as an e-visit or virtual check-in, is not “real-time” but still requires two-way interaction between the member and provider.
  • Asynchronous telehealth can occur using a patient portal, secure text messaging or email.

Compliance

• Elements which require the last result in the Measurement Year may impact member compliance throughout the year. (Example: A1c in March 6.0 = compliant. June A1c test no result reported. System will default to >9 until the result is received.)
• Member ages for each measure are based on different criteria. This may impact the age range to include additional ages. (Example: 18 years of age by December 31 of the measurement year- Consider when member turns 18 and include service performed during the measurement year when member was 17.)

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).