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TECHNICAL SPECIFICATIONS
Adult BMI Assessment (ABA)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 99341–99345, 99347–99350 to Table ABA-A.
Added ICD-9-CM Diagnosis codes 678, 679 to Table ABA-C.
Description
The percentage of members 18–74 years of age who had an outpatient visit and who had their body mass
index (BMI) documented during the measurement year or the year prior the measurement year.
Definitions
BMI
Body mass index. A statistical measure of the weight of a person scaled according to
height.
BMI percentile
The percentile ranking based on the Centers for Disease Control and Prevention’s
(CDC) BMI-for-age growth charts, which indicates the relative position of the
patient’s BMI number among those of the same sex and age.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18 years as of January 1 of the year prior to the measurement year to 74 years as of
December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in continuous enrollment of up to 45 days during each year of
continuous enrollment. To determine continuous enrollment for a Medicaid
beneficiary for whom enrollment is verified monthly, the member may not have more
than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2
months [60 days] is not considered continuously enrolled).
Anchor date
None.
Benefit
Medical.
Event/diagnosis
Members who had an outpatient visit (Table ABA-A) during the measurement year or
the year prior to the measurement year.
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
Table ABA-A: Codes to Identify Outpatient Visits
CPT
HCPCS
99201-99205, 99211-99215, 99217-99220, 99241-99245,
99341-99345, 99347-99350, 99385-99387, 99395-99397,
99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
G0344
ICD-9-CM Diagnosis
UB Revenue
V70.0, V70.3, V70.5, V70.6,
V70.8, V70.9
051x, 0520-0523, 05260529, 077x, 0982, 0983
Administrative Specification
Denominator
The eligible population.
Numerator
BMI (Table ABA-B) during the measurement year or year prior to the measurement
year.
Table ABA-B: Codes to Identify BMI
HCPCS
ICD-9-CM Diagnosis
G8417-G8420
V85.0-V85.5
Exclusions (optional)
Members who have a diagnosis of pregnancy (Table ABA-C) during the measurement year or the year prior
to the measurement year.
Table ABA-C: Codes to Identify Exclusions
Description
ICD-9-CM Diagnosis
Pregnancy
630-679, V22, V23, V28
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population. The organization may
reduce the sample size using the current year’s administrative rate or the prior year’s
audited, product line-specific rate. Refer to the Guidelines for Calculations and
Sampling for information on reducing the sample size.
Numerator
BMI during the measurement year or year prior to the measurement year as
documented through either administrative data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from the
administrative data.
Medical record
Documentation in the medical record must indicate the date of the BMI and the BMI
value.
For members younger than 19 years on the date of service, documentation of BMI
percentile also meets criteria:
BMI percentile documented as a value (e.g., 85th percentile)
BMI percentile plotted on an age-growth chart.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Exclusions (optional)
Refer to Administrative Specification for exclusion criteria. Exclusionary evidence in the medical record must
include a note indicating a diagnosis of pregnancy. The diagnosis must have occurred during the
measurement year or the year prior to the measurement year.
Note
The following notations or examples of documentation are considered “negative findings” and do not count as
numerator compliant.
No BMI or BMI percentile documented in medical record or plotted on age-growth chart
Notation of height and weight only
BMI or BMI percentile noted before the look-back period or after the measurement year
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table ABA-1/2/3: Data Elements for Adult BMI Assessment
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population
Administrative
Hybrid
Number of numerator events by administrative data in eligible population (before
exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of administrative data records excluded
Number of medical records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Breast Cancer Screening (BCS)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
Women 42–69 years as of December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of
continuous enrollment. To determine continuous enrollment for a Medicaid
beneficiary for whom enrollment is verified monthly, the member may not have
more than a 1-month gap in coverage during each year of continuous enrollment.
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.
Administrative Specification
Denominator
The eligible population.
Numerator
One or more mammograms during the measurement year or the year prior to the
measurement year. A woman had a mammogram if a submitted claim/encounter
contains any code in Table BCS-A.
Table BCS-A: Codes to Identify Breast Cancer Screening
CPT
HCPCS
ICD-9-CM Diagnosis
ICD-9-CM Procedure
UB Revenue
76090-76092, 77055-77057
G0202, G0204, G0206
V76.11, V76.12
87.36, 87.37
0401, 0403
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Exclusion (optional)
Women who had a bilateral mastectomy. Look for evidence of a bilateral mastectomy as far back as possible
in the member’s history through December 31 of the measurement year. Exclude members for whom there
is evidence of two unilateral mastectomies. Refer to Table BCS-B for codes to identify exclusions.
Table BCS-B: Codes to Identify Exclusions
Description
CPT
ICD-9-CM Procedure
Bilateral mastectomy
19180, 19200, 19220, 19240, 19303-19307
WITH
Modifier .50 or modifier code 09950*
85.42, 85.44, 85.46, 85.48
Unilateral mastectomy (members must have
2 separate occurrences on 2 different dates of
service)
19180, 19200, 19220, 19240, 19303-19307
85.41, 85.43, 85.45, 85.47
*.50 and 09950 modifier codes indicate the procedure was bilateral and performed during the same operative session.
Note
The purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or
MRIs for this measure because they are not appropriate methods for primary breast cancer screening.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table BCS-1/2/3: Data Elements for Breast Cancer Screening
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Colorectal Cancer Screening (COL)
SUMMARY OF CHANGES TO HEDIS 2010
Lowered the upper age limit from 80 to 75 years of age.
Removed double contrast barium enema (DCBE) from the numerator criteria.
Clarified requirements for medical record documentation for the FOBT.
Deleted HCPCS code G0107 from Table COL-A.
Deleted LOINC code 50196-5 from Table COL-A ―FOBT‖ description.
Description
The percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.
Eligible Population
Product lines
Commercial, Medicare (report each product line separately).
Ages
51–75 years as of December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in continuous enrollment of up to 45 days during each year
of continuous enrollment.
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.
Administrative Specification
Denominator
The eligible population.
Numerator
One or more screenings for colorectal cancer. Appropriate screenings are defined
by any one of the following criteria.
Fecal occult blood test (FOBT) during the measurement year. Regardless of
FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the
required number of samples was returned.
Flexible sigmoidoscopy during the measurement year or the four years prior to
the measurement year
Colonoscopy during the measurement year or the nine years prior to the
measurement year
A member had an appropriate screening if a submitted claim/encounter contains
any code in Table COL-A.
HEDIS 2010, Volume 2
Table COL-A: Codes to Identify Colorectal Cancer Screening
Description
CPT
HCPCS
ICD-9-CM
Diagnosis
ICD-9-CM
Procedure
LOINC
FOBT
82270, 82274
G0328, G0394
V76.51
2335-8, 12503-9,
12504-7, 14563-1,
14564-9, 14565-6,
27396-1, 27401-9,
27925-7, 27926-5,
29771-3
Flexible
sigmoidoscopy
45330-45335, 4533745342, 45345
G0104
45.24
Colonoscopy
44388-44394, 44397,
45355, 45378-45387,
45391, 45392
G0105, G0121
45.22, 45.23, 45.25,
45.42, 45.43
Exclusion (optional)
Members with a diagnosis of colorectal cancer or total colectomy. Look for evidence of colorectal cancer or
total colectomy as far back as possible in the member’s history. Refer to Table COL-B for codes to identify
exclusions.
Table COL-B: Codes to Identify Exclusions
Description
CPT
Colorectal cancer
Total colectomy
HCPCS
G0213-G0215, G0231
ICD-9-CM Diagnosis
ICD-9-CM Procedure
153, 154.0, 154.1, 197.5,
V10.05
44150-44153, 4415544158, 44210-44212
45.8
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population for each product line. The
organization may reduce the sample size using the current year’s administrative rate or
the prior year’s audited, product line-specific rate. Refer to the Guidelines for
Calculations and Sampling for information on reducing the sample size.
Numerator
One or more screenings for colorectal cancer. Appropriate screenings are defined by
any one of the following criteria.
FOBT during the measurement year
Flexible sigmoidoscopy during the measurement year or the four years prior to the
measurement year
Colonoscopy during the measurement year or the nine years prior to the
measurement year
Administrative
Refer to Administrative Specification to identify positive numerator hits from the
administrative data.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Medical record
Documentation in the medical record must include a note indicating the date the
colorectal cancer screening was performed. A result is not required if the
documentation is clearly part of the ―medical history‖ section of the record. If it is
unclear whether the documentation is part of the medical history, then the result or
finding must also be present (this ensures that the screening was performed and not
merely ordered).
There are two types of FOBT tests: guaiac (gFOBT) and immunochemical (iFOBT).
Depending on the type of FOBT test, a certain number of samples are required for
numerator compliance. Follow the instructions below to determine member
compliance.
If the medical record does not indicate the type of test and there is no indication as
to how many samples were returned, assume the required number was
returned. The member meets the screening criteria for inclusion in the
numerator.
If the medical record does not indicate the type of test and the number of returned
samples is specified, the member would only meet the screening criteria if the
number of samples specified is greater than or equal to three samples. If the
number of samples is less than three, the member does not meet the screening
criteria for inclusion in the numerator.
iFOBT tests may require fewer than three samples. If the medical record indicates
that an iFOBT was done, the member meets the screening criteria for inclusion
in the numerator regardless of the number of returned samples.
If the medical record indicates that a gFOBT was done, follow the scenarios below.
If the medical record does not indicate the number of returned samples, assume
the required number was returned. The member meets the screening criteria
for inclusion in the numerator.
If the medical record indicates that three or more samples were returned, the
member meets the screening criteria for inclusion in the numerator.
If the medical record indicates that fewer than three samples were returned, the
member does not meet the screening criteria.
Do not count digital rectal exam as evidence of a colorectal screening because it is not
specific or comprehensive enough to screen for colorectal cancer.
Exclusion (optional)
Refer to Administrative Specification for exclusion criteria. Exclusionary evidence in the medical record must
include a note indicating a diagnosis of colorectal cancer or total colectomy. The diagnosis must have
occurred by December 31 of the measurement year. Use the codes in Table COL-B as synonyms for a
diagnosis of colorectal cancer or total colectomy.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table COL-2/3: Data Elements for Colorectal Cancer Screening
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population
Administrative
Hybrid
Number of numerator events by administrative data in eligible population (before exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of administrative data records excluded
Number of medical records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Glaucoma Screening in Older Adults (GSO)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of Medicare members 65 years and older, without a prior diagnosis of glaucoma or glaucoma
suspect, who received a glaucoma eye exam by an eye care professional for early identification of
glaucomatous conditions.
Eligible Population
Product line
Medicare.
Age
67 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment.
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.
Administrative Specification
Denominator
The eligible population.
Numerator
One or more eye exams for glaucoma by an eye care professional (i.e.,
ophthalmologist, optometrist) during the measurement year or the year prior to the
measurement year. A member is considered to have had an eye exam for glaucoma
if a submitted claim/encounter contains any code in Table GSO-A.
Table GSO-A: Codes to Identify Glaucoma Screening Eye Exams
CPT
92002, 92004, 92012, 92014, 92081-92083, 92135,
92140, 99202-99205, 99213-99215, 99242-99245
HCPCS
G0117, G0118, S0620,
S0621
ICD-9-CM Diagnosis
V80.1
ICD-9-CM Procedure
95.02, 95.03, 95.26
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Exclusion (optional)
Members who had a prior diagnosis of glaucoma or glaucoma suspect. Look for evidence of glaucoma as far
back as possible in the member’s history through December 31 of the measurement year. Refer to Table
GSO-B for codes to identify exclusions.
Table GSO-B: Codes to Identify Exclusions
Description
Glaucoma suspect
Glaucoma
ICD-9-CM Diagnosis
365.0
365.1-365.9
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table GSO-3: Data Elements for Glaucoma Screening in Older Adults
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Care for Older Adults (COA)
SUMMARY OF CHANGES TO HEDIS 2010
Added HCPCS G8427, G8428 to Table COA-C.
Clarified that a complete physical functional status assessment is required.
Clarified that a comprehensive pain assessment is required.
Description
The percentage of adults 65 years and older who had each of the following during the measurement year.
Advance care planning
Medication review
Functional status assessment
Pain screening
Definitions
Medication list
A list of the member’s medications in the medical record, which may include
prescriptions, over-the-counter (OTC) medications and herbal or supplemental
therapies.
Medication review
A review of all a member’s medications, including prescription medications, OTC
medications and herbal or supplemental therapies.
Eligible Population
Product line
Medicare SNP.
Ages
66 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in continuous enrollment of up to 45 days during the
measurement year.
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.
Administrative Specification
Denominator
The eligible population.
Numerators
Advance care
planning
Evidence of advance care planning during the measurement year (Table COA-A).
HEDIS 2010, Volume 2
Table COA-A: Codes to Identify Advance Care Planning
Description
CPT Category II
HCPCS
Advance care planning
1157F, 1158F
S0257
Medication
review
At least one medication review (Table COA-B) conducted by a prescribing practitioner
or clinical pharmacist during the measurement year and the presence of a medication
list in the medical record (Table COA-C), as documented through administrative data.
The claim/encounter for a member’s medication review and medication list must be on
the same date of service.
Table COA-B: Codes to Identify Medication Review
Description
CPT
CPT Category II
HCPCS*
Medication review
90862, 99605, 99606
1160F
G8427, G8428
Table COA-C: Code to Identify Medication List
Description
CPT Category II
HCPCS*
Medication list
1159F
G8427, G8428
*The HCPCS codes meet criteria for both medication review and medication list.
Functional status
assessment
At least one functional status assessment during the measurement year (Table COA-D).
Table COA-D: Codes to Identify Functional Status Assessment
Description
Functional status
assessment
CPT Category II
Functional evaluation
Pain screening
ICD-9-CM Procedure
1170F
93.01
At least one pain screening or pain management plan during the measurement year.
A member had a pain screening if a submitted claim/encounter contains any code in
Table COA-E.
Table COA-E: Codes to Identify Pain Screening
Description
CPT Category II
Pain screening
0521F, 1125F, 1126F
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population. The organization may reduce
the sample size using the current year’s administrative rate or the prior year’s audited,
product line-specific rate. Refer to the Guidelines for Calculations and Sampling for
information on reducing the sample size.
Numerators
Advance care
Planning
Evidence of advance care planning as documented through either administrative data
or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Advanced care planning is a discussion about preferences for resuscitation, lifesustaining treatment and end of life care. Evidence of advance care planning must
include either:
The presence of an advanced care plan in the medical record, or
Documentation of an advance care planning discussion with the provider and the
date on which it was discussed. The documentation of discussion must be
notated in the measurement year. Notation that the member has previously
executed an advance care plan meets criteria.
Examples of advance care plans include:
Advance directives. Directives pertaining to treatment preferences and the
designation of a surrogate decision maker in the event that a person should
become unable to make medical decisions on their own behalf. (e.g., living will,
power of attorney, health care proxy).
Actionable medical orders. Written instructions regarding initiation, continuation,
withholding or withdrawal of particular forms of life-sustaining treatment.
Living wills. Legal documents denoting preferences for life-sustaining treatment
and end-of-life care.
Surrogate decision maker. A written document designating someone else to
make future medical treatment choices.
Examples of an advance care planning discussion include either:
Notation in the medical record of a discussion with a provider or the initiation of a
discussion by a provider during the measurement year, or
Oral statements. Conversations with relatives or friends about life-sustaining
treatment and end-of-life care, documented in the medical record. Patient
designation of an individual who can make decisions on their behalf. Evidence of
oral statements must be noted in the medical record during the measurement
year.
Medication
Review
At least one medication review conducted by a prescribing practitioner or clinical
pharmacist during the measurement year and the presence of a medication list in the
medical record, as documented through either administrative data or medical record
review.
HEDIS 2010, Volume 2
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation must come from the same medical record and must include the
following.
A medication list in the medical record, and evidence of a medication review by a
prescribing practitioner or clinical pharmacist and the date on which it was
performed
Notation that the member is not taking any medication and the date on which it
was noted
A review of side effects for a single medication at the time of prescription alone is not
sufficient.
An outpatient visit is not required to meet criteria.
Functional
Status
Assessment
At least one functional status assessment during the measurement year, as
documented through either administrative data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation in the medical record must include evidence of a complete physical
functional status assessment and the date on which it was performed.
Notations for a complete physical functional status assessment may include the
following.
Functional independence
Loss of independent performance, Activities of Daily Living (ADL), social activities,
or Instrumental Activities of Daily Living (IADL)
The level of assistance needed to accomplish daily activities
Result of assessment using a standardized functional status assessment tool, not
limited to:
SF-36®
ADL list
Assessment of Living Skills and Resources (ALSAR)
Barthel ADL Index Physical Self-Maintenance (ADLS) Scale
Bayer Activities of Daily Living (B-ADL) Scale
Barthel Index
Extended Activities of Daily Living (EADL) Scale
Independent Living Scale (ILS)
Katz Index of Independence in Activities of Daily Living
Kenny Self-Care Evaluation
Klein-Bell Activities of Daily Living Scale
Kohlman Evaluation of Living Skills (KELS)
Lawton & Brody’s IADL scales
Pain Screening
At least one pain screening or a pain management plan during the measurement year,
as documented through either administrative data or medical record review.
HEDIS 2010, Volume 2
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation in the medical record must include evidence of a comprehensive pain
screening or a pain management plan and the date on which it was performed.
Evidence of a comprehensive pain screening may include the following.
Notation of a comprehensive pain assessment. Pain assessment associated with
an acute event (e.g., toothache, earache, localized pain from trauma) does not
meet criteria for a comprehensive pain assessment.
Results of a screening using a standardized pain screening tool, as in but not
limited to:
Multidimensional Pain Inventory
Faces Pain Scale
0–10 Numeric Rating Scales, verbal or visual
Verbal Descriptor Scale
Brief Pain Inventory (Short Form)
Evidence of a pain management plan may include the following.
Notation of no pain intervention and the rationale
Notation of plan for treatment of pain, which may include use of pain medications,
psychological support and patient/family education
Notation of plan for reassessment of pain, including reassessment time interval
Note
Refer to Appendix 3 for the definition of clinical pharmacist.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table COA-3: Data Elements for Care for Older Adults
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population
Administrative
Hybrid
Number of numerator events by administrative data in eligible population (before
exclusions)
Each of the 4 rates
Current year’s administrative rate (before exclusions)
Each of the 4 rates
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Each of the 4 rates
Administrative rate on FSS
Each of the 4 rates
Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Each of the 4 rates
Numerator events by medical records
Each of the 4 rates
Each of the 4 rates
Reported rate
Each of the 4 rates
Each of the 4 rates
Lower 95% confidence interval
Each of the 4 rates
Each of the 4 rates
Upper 95% confidence interval
Each of the 4 rates
Each of the 4 rates
HEDIS 2010, Volume 2
Use of Spirometry Testing in the Assessment
and Diagnosis of COPD (SPR)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of members 40 years of age and older with a new diagnosis or newly active COPD who
received appropriate spirometry testing to confirm the diagnosis.
Definitions
Intake Period
A 12-month window that begins on July 1 of the year prior to the measurement year
and ends on June 30 of the measurement year. The Intake Period captures the first
COPD diagnosis.
IESD
Index Episode Start Date. The earliest date of service for any encounter during the
Intake Period with any diagnosis of COPD (Table SPR-A).
For an outpatient claim/encounter, the IESD is the date of service.
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of discharge.
For a transfer or readmission, the IESD is the discharge date of the original admission.
Negative
Diagnosis
History
A period of 730 days (2 years) prior to the IESD (inclusive), during which the member
had no claims/encounters containing any diagnosis of COPD (Table SPR-A). For an
inpatient (acute or nonacute) IESD, use the date of admission to determine the
Negative Diagnosis History.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
42 years or older as of December 31 of the measurement year.
Continuous
enrollment
730 days (2 years) prior to the IESD through 180 days after the IESD.
Allowable gap
One gap in enrollment of up to 45 days is allowed in each of the 12-month periods
prior to the IESD or in the 6-month period after the IESD, for a maximum of two gaps
total. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
Anchor date
IESD.
Benefit
Medical.
HEDIS 2010, Volume 2
Event/
diagnosis
Step 1
The first COPD diagnosis. Follow the steps below to identify the eligible population for
the measure.
Identify all members who had any diagnosis of COPD (Table SPR-A) during the Intake
Period. If the member had more than one diagnosis of COPD, include only the first one.
Table SPR-A: Codes to Identify COPD
Description
ICD-9-CM Diagnosis
Chronic bronchitis
491
Emphysema
492
COPD
496
Step 2
Test for Negative Diagnosis History. Exclude members who had a claim/encounter with a
COPD diagnosis during the 730 days (2 years) prior to the IESD. For an inpatient (acute
or nonacute) IESD, use the date of admission to determine the Negative Diagnosis
History.
Step 3
Calculate continuous enrollment. Members must be continuously enrolled in the
organization 730 days (2 years) prior to the IESD through 180 days after the IESD.
Administrative Specification
Denominator
The eligible population.
Numerator
At least one claim/encounter with any code listed in Table SPR-B for spirometry in the
730 days (2 years) before the IESD to 180 days after the IESD.
Table SPR-B: Codes to Identify Spirometry Testing
Description
Spirometry
CPT
94010, 94014-94016, 94060, 94070, 94375, 94620
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table SPR-1/2/3: Data Elements for Use of Spirometry Testing in the Assessment
and Diagnosis of COPD
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Pharmacotherapy Management of COPD Exacerbation (PCE)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified in Step 2 that for ED visits resulting in an inpatient stay only the inpatient stay should be included.
Clarified that an ED visit for any diagnosis on or seven days after the Episode Date should be excluded in
step 4.
Description
The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient
discharge or ED encounter between January 1–November 30 of the measurement year and who were
dispensed appropriate medications. Two rates are reported.
1. Dispensed a systemic corticosteroid within 14 days of the event
2. Dispensed a bronchodilator within 30 days of the event
Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on
members. It is possible for the denominator to include multiple events for the same individual.
Definitions
Intake Period
An 11-month period that begins on January 1 of the measurement year and ends on
November 30 of the measurement year. The Intake Period captures eligible episodes of
treatment.
Episode Date
The date of service for any acute inpatient discharge or ED claim/encounter during the
Intake Period with a principal diagnosis of COPD.
For an acute inpatient claim/encounter, the Episode Date is the date of discharge.
For an ED claim/encounter, the Episode Date is the date of service.
Active
prescription
A prescription is considered active if the ―days supply‖ indicated on the date the
member filled the prescription is the number of days or more between that date and the
relevant Episode Date.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
40 years or older as of January 1 of the measurement year.
Continuous
enrollment
Episode Date through 30 days after the Episode Date.
Allowable gap
None.
Anchor date
Episode Date.
Benefits
Medical and pharmacy.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Event/
diagnosis
A COPD exacerbation as indicated by an acute inpatient discharge or ED encounter with a
principal diagnosis of COPD.
Follow the steps below to identify the eligible population.
Step 1
Identify all members who during the Intake Period had an acute inpatient discharge or an
ED visit with a primary diagnosis of COPD (Table PCE-A). Use Table PCE-B to identify
acute inpatient discharges and ED visits.
Table PCE-A: Codes to Identify COPD
Description
ICD-9-CM Diagnosis
Chronic bronchitis
491
Emphysema
492
COPD
496
Table PCE-B: Codes to Identify Visit Type
Description
CPT
Acute inpatient
UB Revenue
010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 0150-0154,
0159, 016x, 020x-022x, 072x, 0987
ED*
99281-99285
045x, 0981
*Do not include ED visits that result in an inpatient admission.
Step 2
Determine all COPD Episode Dates. For each member identified in step 1, identify all
acute inpatient discharges and ED visits. Do not include ED visits that result in an inpatient
admission.
Step 3
Test for transfers. Exclude Episode Dates on which the member was transferred directly to
an acute or nonacute care facility for any diagnosis.
Step 4
Test for readmission and additional ED visits. Exclude Episode Dates for which the
member was readmitted to an acute or nonacute care facility for any diagnosis on or within
seven days after the Episode Date. Exclude Episode Dates for which the member had an
ED visit for any diagnosis on or seven days after the Episode Date.
Step 5
Calculate continuous enrollment. The member must be continuously enrolled without any
gaps in coverage from the Episode Date through 30 days after the Episode Date.
Note: All Episode Dates that were not excluded should remain in the denominator. The
denominator for this measure is based on acute inpatient discharges and ED visits, not
members.
Administrative Specification
Denominator
The eligible population.
Numerators
Systemic
corticosteroid
Dispensed prescription for systemic corticosteroid (Table PCE-C) on or 14 days after
the Episode Date. The organization may count systemic corticosteroids that are active
on the Episode Date.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table PCE-C: Systemic Corticosteroids
Description
Glucocorticoids
Prescription
betamethasone
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
triamcinolone
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Bronchodilator
Dispensed prescription for a bronchodilator (Table PCE-D) on or 30 days after the
Episode Date. The organization may count bronchodilators that are active on
the Episode Date.
Table PCE-D: Bronchodilators
Description
Prescription
Anticholinergic agents
albuterol-ipratropium
ipratropium
tiotropium
Beta 2-agonists
albuterol
arformoterol
budesonide-formoterol
fluticasone-salmeterol
formoterol
levalbuterol
metaproterenol
pirbuterol
salmeterol
Methylxanthines
dyphylline-guaifenesin
guaifenesin-theophylline
potassium iodide-theophylline
aminophylline
dyphylline
theophylline
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table PCE-1/2/3: Data Elements for Pharmacotherapy Management of
COPD Exacerbation
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Exclusions based on direct transfers to another facility*
Exclusions based on readmissions*
Numerator events by administrative data
Each of the 2 rates
Reported rate
Each of the 2 rates
Lower 95% confidence interval
Each of the 2 rates
Upper 95% confidence interval
Each of the 2 rates
*Reporting this additional data element is optional in IDSS.
HEDIS 2010, Volume 2
Cholesterol Management for Patients With Cardiovascular Conditions
(CMC)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that a calculated or direct LDL may be used for LDL-C screening and control.
Deleted CPT codes 99261–99263 from Table CMC-C.
Deleted LOINC code 24331-1 from Table CMC-D.
Description
The percentage of members 18–75 years of age who were discharged alive for AMI, coronary artery bypass
graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the
year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the
measurement year and the year prior to measurement year, who had each of the following during the
measurement year.
LDL-C screening
LDL-C control (<100 mg/dL)
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18–75 years as of December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/
diagnosis
Members are identified for the eligible population in two ways: by event or by
diagnosis. The organization must use both to identify the eligible population, but a
member only needs to be identified in one to be included in the measure.
Event. Discharged alive for AMI, CABG or PTCA on or between January 1 and
November 1 of the year prior to the measurement year. Refer to Table CMC-A for
codes to identify AMI, PTCA and CABG. The organization should include AMI and
CABG from inpatient claims/encounters only. All cases of PTCA should be included,
regardless of setting (e.g., inpatient, outpatient, ED).
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table CMC-A: Codes to Identify AMI, PTCA and CABG
Description
CPT
HCPCS
AMI (include only
inpatient claims)
ICD-9-CM Diagnosis
ICD-9-CM Procedure
410.x1
CABG (include only
inpatient claims)
33510-33514, 33516-33519,
33521-33523, 33533-33536
PTCA
33140, 92980, 92982, 92995
S2205-S2209
36.1, 36.2
00.66, 36.06, 36.07, 36.09
Diagnosis. Identify members as having IVD who met at least one of the following criteria
during both the measurement year and the year prior to the measurement year. Criteria
need not be the same across both years.
At least one outpatient visit (Table CMC-C) with any IVD diagnosis (Table
CMC-B), or
At least one acute inpatient claim/encounter (Table CMC-C) with any IVD diagnosis
(Table CMC-B)
Table CMC-B: Codes to Identify IVD
Description
IVD
ICD-9-CM Diagnosis
411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434, 440.1, 440.2, 440.4, 444, 445
Table CMC-C: Codes to Identify Visit Type
Description
CPT
UB Revenue
Outpatient
99201-99205, 99211-99215, 99217-99220, 99241-99245,
99341-99345, 99347-99350, 99384-99387, 99394-99397,
99401-99404, 99411, 99412, 99420, 99429, 99455, 99456
051x, 0520-0523, 0526-0529, 057x-059x, 077x,
0982, 0983
Acute inpatient
99221-99223, 99231-99233, 99238, 99239, 99251-99255,
99291
010x, 0110-0114, 0119, 0120-0124, 0129,
0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x-022x, 072x, 0987
Administrative Specification
Denominator
The eligible population.
Numerators
LDL-C
Screening
An LDL-C test performed any time during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in Table CMC-D.
The organization may use a calculated or direct LDL for LDL-C screening and control
indicators.
Table CMC-D: Codes to Identify LDL-C Screening
CPT
80061, 83700, 83701, 83704, 83721
CPT Category II
3048F, 3049F, 3050F
LOINC
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2,
49132-4
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
LDL-C Level
<100 mg/dL
Using automated laboratory data, the member is numerator compliant if the most
recent LDL-C level during the measurement year is <100 mg/dL. The member is
noncompliant if the automated result for the most recent LDL-C test is ≥100 mg/dL or
is missing, or if an LDL-C test was not done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-I and use the most recent code
during the measurement year to evaluate whether the member is numerator compliant.
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population for each product line. The
organization may reduce its sample size using the current year’s lowest administrative
rate or the prior year’s audited, product line-specific results for the two rates. Refer to
the Guidelines for Calculations and Sampling for information about sampling.
Numerators
LDL-C
Screening
An LDL-C test performed during the measurement year as determined by
administrative data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may use a calculated LDL for LDL-C screening and control
indicators.
LDL-C Level
<100 mg/dL
The most recent LDL-C level performed during the measurement year is <100 mg/dL,
as documented through automatic laboratory data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from the
administrative data.
Medical record
Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may calculate LDL-C levels from total cholesterol, HDL-C and
triglycerides using the Friedewald equation if the triglycerides are ≤400 mg/dL.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5)
If lipoprotein (a) is measured, this calculation is:
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5) – 0.3[lipoprotein (a)]
These formulae are used when all levels are expressed in mg/dL and cannot be used if
triglycerides are >400 mg/dL.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table CMC-1/2/3: Data Elements for Cholesterol Management for Patients With
Cardiovascular Conditions
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population
Administrative
Hybrid
Number of numerator events by administrative data in eligible population (before
exclusions)
Each of the 2 rates
Current year’s administrative rate (before exclusions)
Each of the 2 rates
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Each of the 2 rates
Administrative rate on FSS
Each of the 2 rates
Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Each of the 2 rates
Numerator events by medical records
Each of the 2 rates
Each of the 2 rates
Reported rate
Each of the 2 rates
Each of the 2 rates
Lower 95% confidence interval
Each of the 2 rates
Each of the 2 rates
Upper 95% confidence interval
Each of the 2 rates
Each of the 2 rates
HEDIS 2010, Volume 2
Controlling High Blood Pressure (CBP)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that member-reported BP readings are not acceptable.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CBP-C ―Evidence of ESRD‖
description.
Added ICD-9-CM Diagnosis codes 678, 679 to Table CBP-C ―Pregnancy‖ description.
Deleted CPT code 90939 from Table CBP-C.
Description
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP
was adequately controlled (<140/90) during the measurement year. Use the Hybrid Method for this measure.
Definitions
Adequate control
Both a representative systolic BP <140 mm Hg and a representative diastolic BP
<90 mm Hg (BP in the normal or high-normal range).
Representative
BP
The most recent BP reading during the measurement year (as long as it occurred
after the diagnosis of hypertension was made). If multiple BP measurements occur
on the same date or are notated in the chart on the same date, the lowest systolic
and lowest diastolic BP reading should be used. If no BP is recorded during the
measurement year, assume that the member is ―not controlled.‖
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18–85 years as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in continuous enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a Medicaid beneficiary
for whom enrollment is verified monthly, the member may not have more than a onemonth gap in coverage (i.e., a member whose coverage lapses for 2 months [60
days] is not considered continuously enrolled).
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
Hypertensive. A member is considered hypertensive if there is at least one outpatient
encounter (Table CBP-B) with a diagnosis of hypertension (Table CBP-A) during the
first six months of the measurement year.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table CBP-A: Codes to Identify Hypertension
Description
ICD-9-CM Diagnosis
Hypertension
401
Table CBP-B: Codes to Identify Outpatient Visits
Description
CPT
Outpatient visits
99201-99205, 99211-99215, 99241-99245, 99384-99387, 99394-99397
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population for each product line whose
diagnosis of hypertension is confirmed by chart review. The organization may reduce
the sample size using the prior year’s audited, product line-specific rate. Refer to the
Guidelines for Calculations and Sampling for information on reducing the sample size.
To confirm the diagnosis of hypertension, the organization must find notation of one of
the following in the medical record on or before June 30 of the measurement year.
HTN
History of HTN
High BP (HBP)
Hypertensive vascular disease (HVD)
Elevated BP ( BP)
Hyperpiesia
Borderline HTN
Hyperpiesis
Intermittent HTN
The notation of hypertension may appear anytime on or before June 30 of the
measurement year, including prior to the measurement year. It does not matter if
hypertension was treated or is currently being treated. The notation indicating a
diagnosis of hypertension may be recorded in any of the following documents.
Problem list (this may include a diagnosis prior to June 30 of the measurement year
or an undated diagnosis; see Note at the end of this section)
Office note
Subjective, Objective, Assessment, Plan (SOAP) note
Encounter form
Telephone call record
Diagnostic report
Hospital discharge summary
Statements such as ―rule out HTN,‖ ―possible HTN,‖ ―white-coat HTN,‖ ―questionable
HTN‖ and ―consistent with HTN‖ are not sufficient to confirm the diagnosis if such
statements are the only notations of hypertension in the medical record.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Identifying the
medical record
The organization should use only the medical records of one practitioner or provider
team for both the confirmation of the diagnosis of hypertension and the representative
BP. All eligible BP measurements recorded in the records from one practitioner or
provider team (even if obtained by a different practitioner) should be considered (e.g.,
from a consultation note or other note relating to a BP reading from a health care
practitioner or provider team). If the organization cannot find the medical record, the
member remains in the measure denominator and is considered noncompliant for the
numerator.
The organization should use the following algorithm to find the appropriate medical
record to review.
Step 1
Identify the member’s primary care practitioner (PCP).
If the member had more than one PCP for the time period, identify the PCP who
most recently provided care to the member
If the member did not visit a PCP for the time period or does not have a PCP,
identify the practitioner who most recently provided care to the member
If a practitioner other than the member’s PCP manages the hypertension, the
organization may use the medical record of that practitioner, instead
Step 2
Use one medical record to both confirm the diagnosis for the denominator and identify
the representative BP level for the numerator. There are circumstances in which the
organization may need to go to a second medical record to either confirm the
diagnosis or obtain the BP reading, as in the following two examples.
If a member sees one PCP during the denominator confirmation period (on or before
June 30 of the measurement year) and another PCP after June 30, the diagnosis of
hypertension and BP reading may be identified through two different medical records.
If a member has the same PCP for the entire measurement year, but it is clear from
claims or medical record data that a specialist (e.g., cardiologist) manages the
member’s hypertension after June 30, the organization may use the PCP’s chart to
confirm the diagnosis and use the specialist’s chart to obtain the BP reading. For
example, if all recent claims coded with 401 came from the specialist, the organization
may elect to use this chart for the most recent BP reading. If the member did not have
any visits with the specialist prior to June 30 of the measurement year, the
organization must go to another medical record to confirm the diagnosis.
Numerator
The number of members in the denominator whose most recent BP is adequately
controlled during the measurement year. For a member’s BP to be controlled, both
the systolic and diastolic BP must be <140/90 (adequate control). To determine if a
member’s BP is adequately controlled, the organization must identify the
representative BP.
Administrative
None.
Medical record
Follow the steps below to determine representative BP.
Step 1
Identify the most recent BP reading noted during the measurement year. The reading
must occur after the date on which the diagnosis of hypertension was made or
confirmed. Do not include BP readings that meet the following criteria.
BPs taken during an acute inpatient stay or an ED visit
BPs taken during an outpatient visit which was for the sole purpose of having a
diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal
of a mole)
HEDIS 2010, Volume 2
BPs obtained the same day as a major diagnostic or surgical procedure (e.g., stress test,
administration of IV contrast for a radiology procedure, endoscopy)
BP readings reported by or taken by the member
Step 2
Identify the lowest systolic and lowest diastolic BP reading from the most recent BP notation
in the medical record. If multiple readings were recorded for a single date, use the lowest
systolic and lowest diastolic BP on that date as the representative BP. The systolic and
diastolic results do not need to be from the same reading.
Exclusions (optional)
Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) (Table
CBP-C) on or prior to December 31 of the measurement year. Documentation in the medical record must
include a dated note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets
the criteria for evidence of ESRD.
Exclude from the eligible population all members with a diagnosis of pregnancy (Table CBP-C) during the
measurement year.
Exclude from the eligible population all members who had an admission to a nonacute inpatient setting any
time during the measurement year. Refer to Table FUH-B for codes to identify nonacute care.
Table CBP-C: Codes to Identify Exclusions
Description
Evidence of
ESRD
CPT
36145, 36800, 36810,
36815, 36818, 36819,
36820, 36821, 3683136833, 50300, 50320,
50340, 50360, 50365,
50370, 50380, 90920,
90921, 90924, 90925,
90935, 90937, 90940,
90945, 90947, 9095790962, 90965, 90966,
90969, 90970, 90989,
90993, 90997, 90999,
99512
Pregnancy
HCPCS
G0257, G0308G0319, G0322,
G0323, G0326,
G0327, G0392,
G0393, S9339
ICD-9-CM
Diagnosis
585.5, 585.6,
V42.0, V45.1,
V56
ICD-9-CM
Procedure
UB
Revenue
UB Type
of Bill
POS
38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.6
0367,
080x,
082x-085x,
088x
72x
65
630-679, V22,
V23, V28
Note
The organization may use an undated notation of hypertension on problem lists. Problem lists generally
indicate established conditions; to discount undated entries might hinder confirmation of the denominator.
Organizations generally require an oversample of 10 percent–15 percent to meet the MRSS for confirmed
cases of hypertension.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table CBP-1/2/3: Data Elements for Controlling High Blood Pressure
Hybrid
Measurement year
Data collection methodology (Hybrid)
Eligible population
Number of numerator events by administrative data in eligible population (before exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of records excluded because of false-positive diagnoses
Number of administrative data records excluded
Number of medical record data records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of members 18 years of age and older during the measurement year who were hospitalized
and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement
year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after
discharge.
Definition
Treatment days
(covered days)
The actual number of calendar days covered with prescriptions within the specified
180-day measurement interval (i.e., a prescription of 90 days supply dispensed on
the 100th day will have 80 days counted in the 180-day interval).
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18 years and older as of December 31 of the measurement year.
Continuous
enrollment
Discharge date through 180 days after discharge.
Allowable gap
No more than one gap in enrollment of up to 45 days within the 180 days of the
event. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap
in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
continuously enrolled).
Anchor date
Discharge date.
Benefit
Medical and pharmacy.
Event/diagnosis
Discharged alive from an acute inpatient setting with an AMI (Table PBH-A) from
July 1 of the year prior to the measurement year through June 30 of the
measurement year.
If a member has more than one episode of AMI from July 1 of the year prior to the
measurement year through June 30 of the measurement year, the organization
should only include the first discharge.
Table PBH-A: Codes to Identify AMI
Description
ICD-9-CM Diagnosis
AMI
410.x1*
* An organization that does not have fifth-digit specificity must develop a methodology to ensure that only the first eligible episode of an AMI
is included in the measure.
HEDIS 2010, Volume 2
Transfers to acute facilities. Include hospitalizations in which the member was
transferred directly to another acute inpatient facility for any diagnosis. Count the
discharge from the subsequent acute inpatient facility, not the initial discharge. The
discharge date from the facility to which the member was transferred must occur on or
before June 30 of the measurement year.
Transfers to nonacute facilities. Exclude from the denominator hospitalizations in which
the member was transferred directly to a nonacute care facility for any diagnosis.
Readmissions. If the member was readmitted to an acute or nonacute care facility for
any diagnosis, include the member in the denominator and use the discharge date
from the original hospitalization.
Administrative Specification
Denominator
The eligible population.
Numerator
A 180-day course of treatment with beta-blockers.
Identify all members in the denominator population whose dispensed days supply is
≥135 days in the 180 days following discharge. Persistence of treatment for this
measure is defined as at least 75 percent of the days supply filled.
To determine continuity of treatment during the 180-day period, sum the number of
allowed gap days to the number of treatment days for a maximum of 180 days (i.e.,
135 treatment days + 45 gap days = 180 days); identify all prescriptions filled within
180 days of the Discharge Date.
To account for members who are on beta-blockers prior to admission, the organization
should factor those prescriptions into adherence rates if the actual treatment days fall
within the 180 days following discharge.
Table PBH-B: Beta-Blocker Medications
Description
Prescription
Noncardioselective beta-blockers
carteolol
carvedilol
labetalol
nadolol
penbutolol
pindolol
propranolol
timolol
sotalol
Cardioselective beta-blockers
acebutolol
atenolol
betaxolol
bisoprolol
metoprolol
nebivolol
Antihypertensive combinations
atenolol-chlorthalidone
bendroflumethiazide-nadolol
bisoprolol-hydrochlorothiazide
hydrochlorothiazide-metoprolol
hydrochlorothiazide-propranolol
hydrochlorothiazide-timolol
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
HEDIS 2010, Volume 2
Exclusion (optional)
Use administrative data to look as far back as possible in the member’s history through the end of the
continuous enrollment period for evidence of a contraindication to beta-blocker therapy. Refer to Table
PBH-C and Table PBH-D for codes and medications representing contraindications to beta-blocker
therapy.
Table PBH-C: Codes to Identify Exclusions
Description
ICD-9-CM Diagnosis
History of asthma
493
Hypotension
458
Heart block >1 degree
426.0, 426.12, 426.13, 426.2-426.4, 426.51-426.54, 426.7
Sinus bradycardia
427.81
COPD
491.2, 496, 506.4
Table PBH-D: Medications to Identify Exclusions (History of Asthma)
Description
Prescription
Bronchodilator combinations
budesonide-formoterol
Inhaled corticosteroids
beclomethasone
budesonide
flunisolide
fluticasone-salmeterol
fluticasone
mometasone
triamcinolone
fluticasone CFC free
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table PBH-1/2/3: Data Elements for Persistence of Beta-Blocker Treatment
After a Heart Attack
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Comprehensive Diabetes Care (CDC)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that HbA1c control (<7.0%) is only reported for the commercial and Medicaid product lines.
Deleted CPT codes 99261–99263, 99301–99303, 99311–99313, 99321–99323, 99331–99333 from Table
CDC-C.
Deleted CPT Category II code 3047F from Tables CDC-D, CDC-E, CDC-F and CDC-Q.
Clarified that a calculated or direct LDL may be used for LDL-C screening and control.
Deleted LOINC code 24331-1 from Table CDC-H.
Deleted LOINC codes 34535-5, 50561-0, 53525-2 from Table CDC-J.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CDC-K ―Evidence of treatment for
nephropathy‖ description.
Added LOINC code 53525-2 to Table CDC-K.
Deleted LOINC codes 24356-8, 24357-6, 50556-0, 50564-4 from Table CDC-K.
Deleted CPT code 90939 from Tables CDC-K, CDC-P.
Deleted CPT Category II code 3076F from Table CDC-N.
Clarified that member-reported BP readings are not acceptable.
Added ICD-9-CM Diagnosis code 249 to Table CDC-O ―Steroid induced‖ description.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CDC-P ―ESRD‖ description.
Description
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the
following.
Hemoglobin A1c (HbA1c) testing
LDL-C screening
HbA1c poor control (>9.0%)
LDL-C control (<100 mg/dL)
HbA1c control (<8.0%)
Medical attention for nephropathy
HbA1c control (<7.0%) *
BP control (<130/80 mm Hg)
Eye exam (retinal) performed
BP control (<140/90 mm Hg)
* Additional exclusion criteria are required for this indicator. This indicator is only reported for the commercial and Medicaid
product lines.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18–75 years as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during the measurement year. To
determine continuous enrollment for a Medicaid beneficiary for whom enrollment is
verified monthly, the member may not have more than a 1-month gap in coverage (i.e.,
a member whose coverage lapses for 2 months [60 days] is not considered continuously
enrolled).
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/
diagnosis
There are two ways to identify members with diabetes: by pharmacy data and by claim/
encounter data. The organization must use both to identify the eligible population, but a
member only needs to be identified in one to be included in the measure. Members may
be identified as having diabetes during the measurement year or the year prior to the
measurement year.
Pharmacy data. Members who were dispensed insulin or oral hypoglycemics/antihyperglycemics during the measurement year or year prior to the measurement year on an
ambulatory basis (Table CDC-A).
Table CDC-A: Prescriptions to Identify Members With Diabetes
Description
Prescription
Alpha-glucosidase inhibitors
acarbose
miglitol
Amylin analogs
pramlinitide
Antidiabetic combinations
glimepiride-pioglitazone
glimepiride-rosiglitazone
glipizide-metformin
Insulin
insulin aspart
insulin aspart-insulin aspart protamine
insulin detemir
insulin glargine
insulin glulisine
insulin inhalation
insulin isophane beef-pork
insulin isophane human
insulin isophane pork
insulin isophane-insulin regular
Meglitinides
nateglinide
repaglinide
Miscellaneous antidiabetic
agents
exenatide
sitagliptin
Sulfonylureas
acetohexamide
chlorpropamide
glimepiride
glipizide
Thiazolidinediones
pioglitazone
rosiglitazone
glyburide-metformin
metformin-pioglitazone
metformin-rosiglitazone
metformin-sitagliptin
insulin lispro
insulin lispro-insulin lispro protamine
insulin regular beef-pork
insulin regular human
insulin regular pork
insulin zinc beef-pork
insulin zinc extended human
insulin zinc human
insulin zinc pork
glyburide
tolazamide
tolbutamide
HEDIS 2010, Volume 2
Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes;
members with diabetes on these medications are identified through diagnosis codes only. NCQA will post a
complete list of medications and NDC codes to www.ncqa.org by November 16, 2009.
Claim/encounter data. Members who had two face-to-face encounters with a diagnosis
of diabetes (Table CDC-B) on different dates of service in an outpatient setting or
nonacute inpatient setting, or one face-to-face encounter in an acute inpatient or ED
setting during the measurement year or the year prior to the measurement year. The
organization may count services that occur over both years. Refer to Table CDC-C for
codes to identify visit type.
Table CDC-B: Codes to Identify Diabetes
Description
Diabetes
ICD-9-CM Diagnosis
250, 357.2, 362.0, 366.41, 648.0
Table CDC-C: Codes to Identify Visit Type
Description
CPT
UB Revenue
Outpatient
92002, 92004, 92012, 92014, 99201-99205, 9921199215, 99217-99220, 99241-99245, 99341-99345,
99347-99350, 99384-99387, 99394-99397, 9940199404, 99411, 99412, 99420, 99429, 99455, 99456
051x, 0520-0523, 0526-0529, 057x-059x, 077x, 082x085x, 088x, 0982, 0983
Nonacute inpatient
99304-99310, 99315, 99316, 99318, 99324-99328,
99334-99337
0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525,
055x, 066x
Acute inpatient
99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291
010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134,
0139, 0140-0144, 0149, 0150-0154, 0159, 016x,
020x-022x, 072x, 080x, 0987
ED
99281-99285
045x, 0981
Administrative Specification
Denominator
Required
exclusions for
the HbA1c
Control
<7% indicator
The eligible population.
For the HbA1c control <7% indicator, exclude members who meet any of the following
criteria.
65–75 years of age as of December 31 of the measurement year.
CABG or PTCA. Members discharged alive for CABG or PTCA in the
measurement year or the year prior to the measurement year. Refer to Table
CMC-A and use codes for PTCA and CABG only. CABG cases should be from
inpatient claims/encounters only. Include all cases of PTCA, regardless of
setting (e.g., inpatient, outpatient, ED).
IVD. Members who met at least one of the following criteria during both the
measurement year and the year prior to the measurement year. Criteria need
not be the same across both years.
At least one outpatient visit (Table CMC-C) with an IVD diagnosis (Table CMCB), or
At least one acute inpatient claim/encounter (Table CMC-C) with an IVD
diagnosis (Table CMC-B)
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Chronic heart failure (CHF). Members who had at least one encounter, in any
setting, with CHF. Refer to Table RCA-A and use codes for CHF only. Look as
far back as possible in the member’s history through December 31 of the
measurement year.
Prior MI. Members who had at least one encounter, in any setting, with any code
to identify MI (Table CDC-P). Look as far back as possible in the member’s
history through December 31 of the measurement year.
Chronic renal failure (CRF)/ESRD. Members who had at least one encounter, in
any setting, with any code to identify CRF/ESRD (Table CDC-P). Look as far
back as possible in the member’s history through December 31 of the
measurement year.
Dementia. Members who had at least one encounter, in any setting, with any
code to identify dementia (Table DDE-E). Look as far back as possible in the
member’s history through December 31 of the measurement year.
Blindness. Members who had at least one encounter, in any setting, with any
code to identify blindness (Table CDC-P). Look as far back as possible in the
member’s history through December 31 of the measurement year.
Amputation (lower extremity). Members who had at least one encounter, in any
setting, with any code to identify lower extremity amputation (Table CDC-P).
Look as far back as possible in the member’s history through December 31 of
the measurement year.
Table CDC-P: Codes to Identify Required Exclusions
Description
CPT
HCPCS
MI
CRF/ESRD
ICD-9-CM
Procedure
UB Revenue
UB Type
of Bill
POS
410, 412
36145, 36800-36821,
36831-36833, 9091990921, 90923-90925,
90935, 90937, 90940,
90945, 90947, 9095790962, 90965, 90966,
90969, 90970, 90989,
90993, 90997, 90999,
99512
Blindness
Amputation (lower
extremity)
ICD-9-CM
Diagnosis
G0257, G0311G0319, G0321G0323, G0325G0327, G0392,
G0393, S9339
585.4, 585.5,
585.6, V42.0,
V45.1, V56
38.95, 39.27,
39.42, 39.43,
39.53, 39.93,
39.94, 39.95,
54.98
080x, 082x085x, 088x
72x
65
369.0, 369.1,
369.2, 369.4,
369.6, 369.7
27290, 27295, 2759027592, 27594, 27596,
27598, 27880, 27881,
27882, 27884, 27886,
27888, 27889, 28800,
28805, 28810, 28820,
28825
84.1
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Numerators
HbA1c Testing
An HbA1c test performed during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in Table CDC-D.
Table CDC-D: Codes to Identify HbA1c Tests
CPT
CPT Category II
LOINC
83036, 83037
3044F, 3045F, 3046F
4548-4, 4549-2, 17856-6
HbA1c Poor
Control >9%
Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is >9.0% or is missing a result or if an HbA1c test was not done during
the measurement year. The member is not numerator compliant if the automated
result for the most recent HbA1c test during the measurement year is ≤9.0%.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-E and use the most recent code
during the measurement year to evaluate whether the member is numerator
compliant.
Note: For this indicator, a lower rate indicates better performance (i.e., low rates of
poor control indicate better care).
Table CDC-E: Codes to Identify HbA1c Levels >9%
Description
Numerator compliant (HbA1c >9.0%)
Not numerator compliant (HbA1c ≤9.0%)
HbA1c Control
<8%
CPT Category II
3046F
3044F, 3045F
Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is <8.0%. The member is not numerator compliant if the automated result
for the most recent HbA1c test is ≥8.0% or is missing a result, or if an HbA1c test was
not done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-Q and use the most recent code
during the measurement year to evaluate whether the member is numerator
compliant.
Table CDC-Q: Codes to Identify HbA1c Levels <8%
Description
Numerator compliant (HbA1c <8.0%)
Not numerator compliant (HbA1c ≥8.0%)
CPT Category II
3044F
3045F*, 3046F
* CPT Category II code 3045F indicates most recent HbA1c (HbA1c) level 7.0%–9.0% and is not specific enough to denote numerator
compliance for this indicator. For members with this code, the organization may use other sources (laboratory data, hybrid reporting
method) to determine if the HbA1c result was <8%.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
HbA1c
Control <7%
Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is <7.0%. The member is not numerator compliant if the automated result for
the most recent HbA1c test is ≥7.0% or is missing a result, or if an HbA1c test was not
done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for this
indicator must search for all codes in Table CDC-F and use the most recent code during
the measurement year to evaluate whether the member is numerator compliant.
Note: This indicator uses the eligible population with additional eligible population criteria
(e.g., removing members with required exclusions).
Table CDC-F: Codes to Identify HbA1c Levels <7%
Description
Numerator compliant (HbA1c <7.0%)
Not numerator compliant (HbA1c ≥7.0%)
Eye Exam
CPT Category II
3044F
3045F, 3046F
An eye screening for diabetic retinal disease as identified by administrative data. This
includes diabetics who had one of the following.
A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) in the measurement year, or
A negative retinal exam (no evidence of retinopathy) by an eye care professional in
the year prior to the measurement year
Refer to Table CDC-G for codes to identify eye exams. For exams performed in the year
prior to the measurement year, a result must be available.
Table CDC-G: Codes to Identify Eye Exams*
CPT
67028, 67030, 67031, 67036, 67038-67043,
67101, 67105, 67107, 67108, 67110, 67112,
67113, 67121, 67141, 67145, 67208, 67210,
67218, 67220, 67221, 67227, 67228, 92002,
92004, 92012, 92014, 92018, 92019, 92225,
92226, 92230, 92235, 92240, 92250, 92260,
99203-99205, 99213-99215, 99242-99245
CPT Category II**
2022F, 2024F,
2026F, 3072F***
HCPCS
S0620, S0621,
S0625**, S3000
ICD-9-CM
Diagnosis
V72.0
ICD-9-CM
Procedure
14.1-14.5, 14.9,
95.02-95.04, 95.11,
95.12, 95.16
* Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to
determine that a dilated exam was performed.
** The organization does not need to limit CPT Category II codes or HCPCS S0625 to an optometrist or an ophthalmologist. These codes
indicate an eye exam was performed by an eye care professional.
*** CPT Category II code 3072F can only be used if the claim/encounter was during the measurement year because it indicates the member
had ―no evidence of retinopathy in the prior year.‖ Additionally, because the code definition itself indicates results were negative, an
automated result is not required.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
LDL-C
Screening
An LDL-C test performed during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in table CDC-H.
The organization may use a calculated or direct LDL for LDL-C screening and control
indicators.
Table CDC-H: Codes to Identify LDL-C Screening
CPT
CPT Category II
80061, 83700, 83701, 83704, 83721
3048F, 3049F, 3050F
LDL-C Control
<100 mg/dL
LOINC
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8,
39469-2, 49132-4
Use automated laboratory data to identify the most recent LDL-C test during the
measurement year. The member is numerator compliant if the most recent automated
LDL-C level is <100 mg/dL. If the automated result for the most recent LDL-C test
during the measurement year is ≥100 mg/dL or is missing, or if an LDL-C test was not
done during the measurement year, the member is not numerator compliant.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-I and use the most recent code
during the measurement year to evaluate whether the member is numerator compliant.
Use Table CDC-I to determine compliance.
Table CDC-I: Codes to Identify LDL-C Levels
Description
CPT Category II
Numerator compliant (LDL-C <100 mg/dL)
Not numerator compliant (LDL-C ≥100 mg/dL)
Medical
Attention for
Nephropathy
Nephropathy
screening test
3048F
3049F, 3050F
A nephropathy screening test or evidence of nephropathy, as documented through
administrative data.
Note: A process flow diagram is included at the end of this specification to help
implement this specification.
A nephropathy screening test during the measurement year (Table CDC-J).
Table CDC-J: Codes to Identify Nephropathy Screening Tests
Description
Nephropathy screening test
CPT
82042, 82043,
82044, 84156
CPT Category II
3060F, 3061F
LOINC
1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4,
2890-2, 9318-7, 11218-5, 12842-1, 13801-6, 14956-7, 149575, 14958-3, 14959-1, 13705-9, 14585-4, 18373-1, 20621-9,
21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2,
30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4,
40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1,
44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2,
53531-0, 53532-8
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Evidence of
nephropathy
Any of the following meet criteria for evidence of nephropathy.
A claim/encounter with a code to indicate evidence of treatment for nephropathy
(Table CDC-K) during the measurement year.
A nephrologist visit during the measurement year, as identified by the organization’s
specialty provider codes (no restriction on the diagnosis or procedure code
submitted).
A positive urine macroalbumin test in the measurement year, as documented by
claim/encounter or automated laboratory data. Refer to Table CDC-K for codes to
identify urine macroalbumin tests. ―Trace‖ urine macroalbumin test results are not
considered numerator-compliant.
Evidence of ACE inhibitor/ARB therapy during the measurement year. Members who
had a claim indicating therapy (Table CDC-K) or received an ambulatory
prescription or were dispensed an ambulatory prescription for ACE inhibitors or
ARBs during the measurement year are compliant. Table CDC-L lists the ACE
inhibitors/ARBs included in this measure.
HEDIS 2010, Volume 2
Table CDC-K: Codes to Identify Evidence of Nephropathy
Description
CPT
CPT
Category II*
Urine macroalbumin
test*
81000-81003, 81005
3062F
Evidence of treatment
for nephropathy
36145, 36800, 36810, 36815,
36818, 36819-36821, 3683136833, 50300, 50320, 50340,
50360, 50365, 50370, 50380,
90920, 90921, 90924, 90925,
90935, 90937, 90940, 90945,
90947, 90957-90962, 90965,
90966, 90969, 90970, 90989,
90993, 90997, 90999, 99512
3066F
ACE inhibitor/
ARB therapy
ICD-9-CM
Diagnosis
HCPCS
ICD-9-CM
Procedure
UB
Revenue
UB Type
of Bill
POS
LOINC
5804-0, 20454-5,
50561-0, 53525-2
G0257, G0314G0319, G0322,
G0323, G0326,
G0327, G0392,
G0393, S9339
250.4, 403, 404,
405.01, 405.11,
405.91, 580588, 753.0,
753.1, 791.0,
V42.0, V45.1,
V56
38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.4-55.6
0367, 080x,
082x-085x,
088x
72x
65
4009F
* A CPT Category II code indicates a positive result for urine macroalbumin; the organization must use automated laboratory data to confirm a positive result for tests identified by CPT or LOINC
codes.
Table CDC-L: ACE Inhibitors/ARBs
Description
Angiotensin converting
enzyme inhibitors
Angiotensin II
inhibitors
Antihypertensive
combinations
Prescription
benazepril
enalapril
captopril
fosinopril
candesartan
irbesartan
eprosartan
losartan
amlodipine-benazepril
amlodipine-olmesartan
amlodipine-valsartan
benazepril-hydrochlorothiazide
candesartan-hydrochlorothiazide
captopril-hydrochlorothiazide
lisinopril
perindopril
moexipril
quinapril
olmesartan
valsartan
telmisartan
enalapril-hydrochlorothiazide
eprosartan-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide-irbesartan
hydrochlorothiazide-lisinopril
hydrochlorothiazide-losartan
ramipril
trandolapril
hydrochlorothiazide-moexipril
hydrochlorothiazide-olmesartan
hydrochlorothiazide-quinapril
hydrochlorothiazide-telmisartan
hydrochlorothiazide-valsartan
trandolapril-verapamil
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 16, 2009.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
BP Control
<130/80 mm Hg
Use automated data to identify the most recent BP reading during the measurement
year.
The member is numerator compliant if the BP is <130/80 mm Hg. The member is not
compliant if the BP is ≥130/80 mm Hg or if there is no automated BP reading during
the measurement year. If there are multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date as the representative BP.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-M and use the most recent
codes during the measurement year to evaluate whether the member is numerator
compliant for both systolic and diastolic levels.
Table CDC-M: Codes to Identify Systolic and Diastolic BP Levels <130/80
CPT Category II
Systolic
Diastolic
Description
Numerator compliant (BP <130/80 mm Hg)
3074F
3078F
Not numerator compliant (BP ≥130/80 mm Hg)
3075F, 3077F
3079F, 3080F
BP Control
<140/90 mm Hg
Use automated data to identify the most recent BP reading during the measurement
year. Refer to Table CDC-N and use the most recent code to evaluate whether the
member is numerator compliant.
The member is numerator compliant if the BP is <140/90 mm Hg. The member is not
compliant if the BP is ≥140/90 mm Hg or if there is no automated BP reading during
the measurement year. If there are multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date as the representative BP.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-N and use the most recent
codes during the measurement year to evaluate whether the member is numerator
compliant for both systolic and diastolic levels.
Table CDC-N: Codes to Identify Systolic and Diastolic BP Levels <140/90
CPT Category II
Systolic
Diastolic
Description
Numerator compliant (BP <140/90 mm Hg)
3074F, 3075F
3078F, 3079F
Not numerator compliant (BP ≥140/90 mm Hg)
3077F
3080F
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Hybrid Specification
Denominator
A systematic sample of 548 drawn from the eligible population for each product line. A
sample size of 548 is based on the goal of achieving a sample of at least 411 for the
HbA1c <7% denominator after required exclusions.
Members who meet the required exclusion criteria for the HbA1c <7% indicator
should not be substituted with members from the oversample. These members will
only be excluded when reporting the denominator for the HbA1c <7% indicator.
In other words, organizations should report the FSS for the HbA1c <7% indicator as
548 minus the required exclusions.
Required
exclusions for
HbA1c Good
Control <7%
Administrative
Refer to Administrative Specification to identify required exclusions from
administrative data.
Medical record
Exclude members who meet any of the following criteria.
65–75 years of age as of December 31 of the measurement year.
CABG or PTCA. Dated documentation of CABG or PTCA in the measurement
year or the year prior to the measurement year.
IVD. Documentation of an IVD diagnosis. Look as far back as possible in the
member’s history through December 31 of the measurement year. Appropriate
diagnoses include:
IVD
Ischemic heart disease
Angina
Coronary atherosclerosis
Coronary artery occlusion
Cardiovascular disease
Occlusion or stenosis of precerebral arteries (including basilar, carotid and
vertebral arteries)
Atherosclerosis of renal artery
Atherosclerosis of native arteries of the extremities
Chronic total occlusion of artery of the extremities
Arterial embolism and thrombosis
Atheroembolism
CHF. Documentation of CHF diagnosis. Look as far back as possible in the
member’s history through December 31 of the measurement year.
Prior MI. Documentation of prior MI. Look as far back as possible in the member’s
history through December 31 of the measurement year.
CRF/ESRD. Documentation of Stage 4 or 5 CRF or ESRD. Look as far back as
possible in the member’s history through December 31 of the measurement
year.
HEDIS 2010, Volume 2
Dementia. Documentation of dementia. Look as far back as possible in the
member’s history through December 31 of the measurement year.
Blindness. Documentation of blindness in one or both eyes. Look as far back as
possible in the member’s history through December 31 of the measurement
year.
Amputation (lower extremity). Documentation of lower extremity amputation. Look
as far back as possible in the member’s history through December 31 of the
measurement year.
Note: The organization must search the medical record for required exclusions before
it searches for a numerator hit.
Numerators
HbA1c Testing
An HbA1c test performed during the measurement year as identified by administrative
data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
At a minimum, documentation in the medical record must include a note indicating the
date on which the HbA1c test was performed and the result. The organization may
count notation of the following in the medical record.
HbA1c Poor
Control >9%
A1c
Hemoglobin A1c
HbA1c
Glycohemoglobin A1c
HgbA1c
The most recent HbA1c level (performed during the measurement year) is >9.0% or is
missing or was not done during the measurement year, as documented through
automated laboratory data or medical record review.
Note: For this indicator, a lower rate indicates better performance (i.e., low rates of
poor control indicate better care).
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
At a minimum, documentation in the medical record must include a note indicating the
date on which the HbA1c test was performed and the result.
HbA1c Control
<8%
The most recent HbA1c level (performed during the measurement year) is <8.0% as
identified by automated laboratory data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
At a minimum, documentation in medical record must include a note indicating the date
on which the HbA1c test was performed and the result.
HbA1c Good
Control <7%
The most recent HbA1c level (performed during the measurement year) is <7.0% as
identified by automated laboratory data or medical record review.
Note: This indicator uses the eligible population with additional eligible population
criteria (i.e., removing members with comorbid conditions.)
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
HEDIS 2010, Volume 2
Medical record
Eye Exam
At a minimum, documentation in medical record must include a note indicating the date
on which the HbA1c test was performed and the result.
An eye screening for diabetic retinal disease as identified by administrative data or
medical record review. This includes diabetics who had one of the following.
A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) in the measurement year, or
A negative retinal exam (no evidence of retinopathy) by an eye care professional in
the year prior to the measurement year
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
At a minimum, documentation in the medical record must include one of the following.
A note or letter prepared by an ophthalmologist, optometrist, PCP or other health
care professional indicating that an ophthalmoscopic exam was completed by an
eye care professional, the date on which the procedure was performed and the
results, or
A chart or photograph of retinal abnormalities indicating the date on which the
fundus photography was performed and evidence that an eye care professional
reviewed the results. Alternatively, results may be read by a qualified reading
center that operates under the direction of a medical director who is a retinal
specialist.
LDL-C
Screening
An LDL-C test performed during the measurement year as identified by claim/
encounter or automated laboratory data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
At a minimum, documentation in the medical record must include a note indicating the
date on which the LDL-C test was performed and the result. The organization may use
a calculated LDL for LDL-C screening and control indicators.
LDL-C Control
<100 mg/dL
The most recent LDL-C level performed during the measurement year is <100 mg/dL,
as documented through automated laboratory data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may calculate LDL-C levels from total cholesterol, HDL-C and
triglycerides using the Friedewald equation if the triglycerides are ≤400 mg/dL.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5)
If lipoprotein (a) is measured, use the following calculation.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5) – 0.3 [lipoprotein (a)]
These formulae are used when all levels are expressed in mg/dL and cannot be used if
triglycerides >400 mg/dL.
HEDIS 2010, Volume 2
Medical
Attention for
Nephropathy
A nephropathy screening test during the measurement year or evidence of
nephropathy during the measurement year as documented through either
administrative data or medical record review.
Note: A process flow diagram is included at the end of this specification to help
implement this specification.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Nephropathy screening test. At a minimum, documentation must include a note
indicating the date on which a urine microalbumin test was performed, and the result.
Any of the following meet the criteria for a urine microalbumin test.
24-hour urine for microalbumin
Timed urine for microalbumin
Spot urine for microalbumin
Urine for microalbumin/creatinine ratio
24-hour urine for total protein
Random urine for protein/creatinine ratio
Evidence of nephropathy. Any of the following meet the criteria for evidence of
nephropathy.
Documentation of a visit to a nephrologist.
Documentation of medical attention for any of the following (no restriction on
provider type).
Diabetic nephropathy
ESRD
CRF
Chronic kidney disease (CKD)
Renal insufficiency
Proteinuria
Albuminuria
Renal dysfunction
Acute renal failure (ARF)
Dialysis, hemodialysis or peritoneal dialysis
A positive urine macroalbumin test. At a minimum, documentation in the medical
record must include a note indicating the date on which the test was performed,
and a positive result. Any of the following meet the criteria for a positive urine
macroalbumin test.
Positive urinalysis (random, spot or timed) for protein
Positive urine (random, spot or timed) for protein
Positive urine dipstick for protein
Positive tablet reagent for urine protein
Positive result for albuminuria
Positive result for macroalbuminuria
Positive result for proteinuria
Positive result for gross proteinuria
HEDIS 2010, Volume 2
Note: “Trace” urine macroalbumin test results are not considered numerator
compliant.
Evidence of ACE inhibitor/ARB therapy. Documentation in medical record must
include, at minimum, a note indicating that the member received an
ambulatory prescription for ACE inhibitors/ARBs within the measurement
year.
BP Control
<130/80 mm Hg
The most recent BP level (taken during the measurement year) is <130/80 mm Hg,
as documented through administrative data or medical record review.
BP Control
<140/90 mm Hg
The most recent BP level (taken during the measurement year) is <140/90 mm Hg,
as documented through administrative data or medical record review.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
To determine if BP is adequately controlled, the organization must identify the
representative BP following the steps below.
Identifying the
medical record
Step 1
The organization should use the medical record from which it abstracts data for the
other CDC indicators. If the organization does not abstract for other indicators, it
should use the medical record of the provider that manages the member’s diabetes.
If that medical record does not contain a BP, the organization may use the medical
record of another PCP or specialist from which the member receives care.
Identify the most recent BP reading notated during the measurement year. Do not
include BP readings that meet the following criteria.
BPs taken during an acute inpatient stay or an ED visit
BPs taken during an outpatient visit which was for the sole purpose of having a
diagnostic test or surgical procedure performed (e.g., sigmoidoscopy,
removal of a mole)
BPs obtained the same day as a major diagnostic or surgical procedure (e.g.,
stress test, administration of IV contrast for a radiology procedure,
endoscopy)
BP readings reported by or taken by the member
Step 2
Identify the lowest systolic and lowest diastolic BP reading from the most recent BP
notation in the medical record. If there are multiple BPs recorded for a single date,
use the lowest systolic and lowest diastolic BP on that date as the representative
BP. The systolic and diastolic results do not need to be from the same reading.
Exclusions (optional)
Members with a diagnosis of polycystic ovaries (Table CDC-O) who did not have any face-to-face encounters
with a diagnosis of diabetes (CDC-B), in any setting, during the measurement year or the year prior to the
measurement year. Diagnosis can occur at any time in the member’s history, but must have occurred by
December 31 of the measurement year.
Members with gestational or steroid-induced diabetes (CDC-O) who did not have any face-to-face encounters
with a diagnosis of diabetes (CDC-B), in any setting, during the measurement year or the year prior to the
measurement year. Diagnosis can occur during the measurement year or the year prior to the
measurement year, but must have occurred by December 31 of the measurement year.
Table CDC-O: Codes to Identify Exclusions
Description
ICD-9-CM Diagnosis
HEDIS 2010, Volume 2
Polycystic ovaries
256.4
Steroid induced
249, 251.8, 962.0
Gestational diabetes
648.8
Note
The organization may select data collection method (Administrative vs. Hybrid) at the indicator level, but the
method for screening and control rates must be consistent, as must the methodology for BP control
indicators.
Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals
who are legally blind but require a retinal exam and those who are completely blind and therefore do not
require an exam.
HEDIS 2010, Volume 2
Monitoring for Diabetic Nephropathy
Step 1
NO
Go to
Step 2
Is there documentation of
ESRD, chronic or acute renal
failure, renal insufficiency,
diabetic nephropathy
or dialysis?
Review for a urinalysis test that
indicates a protein test was run
or a dipstick was performed for
gross protein macroalbuminuria in 2009
Step 2
YES
Is the test
positive for
2009?
STOP!
Member is
compliant
YES
NO
Go to
Step 3
Was the test
done in 2009?
Step 3
STOP!
Member is
compliant
YES
STOP!
Member is
compliant
Review for a microalbumin
lab test
NO
Go to
Step 4
Step 4
Is there
evidence of
therapy in
2009?
Review for evidence of ACE
inhibitor/ARB therapy
YES
STOP!
Member is
compliant
NO
STOP!
Member is
noncompliant
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table CDC-1/2/3: Data Elements for Comprehensive Diabetes Care
Administrative
Hybrid
Measurement year
Each of the 10 rates
Each of the 10 rates
Data collection methodology (Administrative or Hybrid)
Each of the 10 rates
Each of the 10 rates
Eligible population
Each of the 10 rates
Each of the 10 rates
Number of numerator events by administrative data in eligible population
(before exclusions)
Each of the 10 rates
Current year’s administrative rate (before exclusions)
Each of the 10 rates
Minimum required sample size (MRSS) or other sample size
Each of the 10 rates
Oversampling rate
Each of the 10 rates
Final sample size (FSS)
Each of the 10 rates
Number of numerator events by administrative data in FSS
Each of the 10 rates
Administrative rate on FSS
Each of the 10 rates
Number of original sample records excluded because of valid data errors
Each of the 10 rates
Number of administrative data records excluded
Each of the 10 rates
Number of medical records excluded
Each of the 10 rates
Number of employee/dependent medical records excluded
Each of the 10 rates
Number of HbA1c <7 required exclusions
Each of the 10 rates
Records added from the oversample list
Each of the 10 rates
Denominator
Each of the 10 rates
Numerator events by administrative data
Each of the 10 rates
Numerator events by medical records
Each of the 10 rates
Each of the 10 rates
Reported rate
Each of the 10 rates
Each of the 10 rates
Lower 95% confidence interval
Each of the 10 rates
Each of the 10 rates
Upper 95% confidence interval
Each of the 10 rates
Each of the 10 rates
HEDIS 2010, Volume 2
Disease-Modifying Anti-Rheumatic Drug Therapy
for Rheumatoid Arthritis (ART)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 99301–99303, 99311–99313, 99321–99323, 99331–99333 from Table ART-B.
Added J codes J2910 ―Anti-rheumatics‖ description and J9310 ―Immunomodulators‖ description.
Added ICD-9-CM Diagnosis codes 678, 679 to Table ART-D ―Pregnancy‖ description.
Description
The percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least
one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days. To determine continuous
enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the
member may not have more than a 1-month gap in coverage (i.e., a member whose
coverage lapses for 2 months [60 days] is not considered continuously enrolled).
Anchor date
December 31 of the measurement year.
Benefits
Medical and pharmacy.
Event/diagnosis
Two face-to-face physician encounters with different dates of service in an outpatient
or nonacute inpatient setting on or between January 1 and November 30 of the
measurement year with any diagnosis of rheumatoid arthritis. A diagnosis code from
Table ART-A must be in conjunction with a visit type code in Table ART-B.
Table ART-A: Codes to Identify Rheumatoid Arthritis
Description
Rheumatoid arthritis
ICD-9-CM Diagnosis
714.0, 714.1, 714.2, 714.81
Table ART-B: Codes to Identify Visit Type
Description
CPT
UB Revenue
Outpatient
99201-99205, 99211-99215, 99241-99245, 99341-99345,
99347-99350, 99384-99387, 99394-99397, 99401-99404,
99411, 99412, 99420, 99429, 99455, 99456
051x, 0520-0523, 0526-0529, 057x-059x, 077x,
0982, 0983
Nonacute inpatient
99304-99310, 99315, 99316, 99318, 99324-99328,
99334-99337
0118, 0128, 0138, 0148, 0158, 019x, 0524,
0525, 055x, 066x
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Administrative Specification
Denominator
The eligible population.
Numerator
Members who had at least one ambulatory prescription dispensed for a DMARD
during the measurement year. Table ART-C lists the DMARDs included in this
measure.
Table ART-C: DMARDs
Description
Prescription
J Codes
5-Aminosalicylates
sulfasalazine
Alkylating agents
cyclophosphamide
Aminoquinolines
hydroxychloroquine
Anti-rheumatics
auranofin
aurothioglucose
gold sodium thiomalate
leflunomide
methotrexate
penicillamine
J1600, J2910, J9250, J9260
Immunomodulators
abatacept
adalimumab
anakinra
etanercept
golimumab
infliximab
rituximab
J0129, J0135, J1438, J1745,
J9310
Immunosuppressive agents
azathioprine
cyclosporine
Tetracyclines
minocycline
J7502, J7515, J7516
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Exclusions (optional)
Members diagnosed with HIV. Look for evidence of HIV diagnosis as far back as possible in the member’s
history through December 31 of the measurement year.
Members who have a diagnosis of pregnancy during the measurement year.
Table ART-D: Codes to Identify Exclusions
Description
ICD-9-CM Diagnosis
HIV
042, V08
Pregnancy
630-679, V22, V23, V28
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table ART-1/2/3: Data Elements for DMARD Therapy for Rheumatoid Arthritis
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Number of numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Osteoporosis Management in Women Who Had a Fracture (OMW)
SUMMARY OF CHANGES TO HEDIS 2010
Added ICD-9-CM Diagnosis codes 733.93–733.98 to Table OMW-A.
Deleted HCPCS S2362 from Table OMW-A.
Description
The percentage of women 67 years of age and older who suffered a fracture and who had either a bone
mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after
the fracture.
Definitions
Intake Period
A 12-month window that begins on July 1 of the year prior to the measurement year
and ends on June 30 of the measurement year. The Intake Period is used to capture
the first fracture.
IESD
Index Episode Start Date. The earliest date of service for any encounter during the
Intake Period with a diagnosis of fracture (Table OMW-A).
For an outpatient or ED claim/encounter, the IESD is date of service.
For an inpatient claim/encounter, the IESD is the date of discharge.
For direct transfers, the IESD is the discharge date from the second admission.
Negative
Diagnosis
History
A period of 60 days prior to the IESD, during which time the member had no diagnosis
of fracture using Table OMW-A. For fractures requiring an inpatient stay, use the date
of admission to determine Negative Diagnosis History. For direct transfers, use the first
admission to determine the Negative Diagnosis History.
Eligible Population
Product line
Medicare.
Age
Women 67 years and older as of December 31 of the measurement year.
Continuous
enrollment
12 months prior to the IESD through 6 months (180 days) after the IESD.
Allowable gap
No more than one gap in enrollment of up to 45 days during the continuous enrollment
period.
Anchor date
IESD.
Benefits
Medical and pharmacy.
Event/
diagnosis
The earliest fracture during the Intake Period.
Follow the steps below to identify the eligible population.
HEDIS 2010, Volume 2
Step 1
Identify all members who had a fracture (Table OMW-A) during the 12-month Intake Period. If
the member had more than one fracture, include only the first fracture.
Table OMW-A: Codes to Identify Fractures*
CPT
21800-21825, 22305-22328, 22520, 22521, 22523, 22524,
23500-23515, 23570-23630, 23665-23680, 24500-24587,
24620, 24635, 24650-24685, 25500-25652, 25680, 25685,
26600, 26605, 26607, 26608, 26615, 27193-27248, 27254,
27267-27269, 27500-27514, 27520-27540, 27750-27828,
28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436,
28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476,
28485, 29850, 29851, 29855, 29856
HCPCS
S2360
ICD-9-CM
Diagnosis
733.1, 733.93733.98, 805-806,
807.0-807.4,
808-815, 818825, 827, 828
ICD-9-CM Procedure
79.01-79.03, 79.05-79.07, 79.1179.13, 79.15-79.17, 79.21-79.23,
79.25-79.27, 79.31-79.33, 79.3579.37, 79.61- 79.63, 79.65-79.67,
81.65, 81.66
*Fractures of finger, toe, face and skull are not included in this measure.
Step 2
Test for Negative Diagnosis History. Exclude members with a fracture (Table OMW-A) during
the 60 days prior to the IESD. For fractures requiring an inpatient stay, use the admission date
to determine Negative Diagnosis History. For direct transfers, use the first admission to
determine the Negative Diagnosis History.
Step 3
Calculate continuous enrollment. Members must be continuously enrolled during the 12 months
prior to the fracture through 6 months (180 days) post-fracture.
Step 4
Exclude members who had a BMD test (Table OMW-B) or who received any osteoporosis
treatment (Table OMW-C) during the 365 days prior to the IESD.
For an inpatient claim/encounter, use the admission date to determine the 365 days prior to the
IESD.
Administrative Specification
Denominator
The eligible population.
Numerator
Appropriate testing or treatment for osteoporosis after the fracture defined by any of the
following criteria.
A BMD test (Table OMW-B) on the IESD or in the 180-day period after the IESD, or
A BMD test (Table OMW-B) during the inpatient stay for the fracture (applies only to
fractures requiring hospitalization), or
A dispensed prescription (Table OMW-C) to treat osteoporosis on the IESD or in the
180-day period after the IESD
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Comprehensive Diabetes Care
Table OMW-B: Codes to Identify Bone Mineral Density Test
CPT
76070, 76071, 76075-76078, 76977, 77078-77083, 78350, 78351
HCPCS
ICD-9-CM Diagnosis
ICD-9-CM Procedure
G0130
V82.81
88.98
Table OMW-C: FDA-Approved Osteoporosis Therapies
Description
Prescription
J Codes
J3488
Biphosphonates
alendronate
alendronate-cholecalciferol
calcium carbonate-risedronate
ibandronate
risedronate
zoledronic acid
Estrogens
conjugated estrogens
conjugated estrogens synthetic
esterified estrogens
estradiol
estradiol acetate
estradiol cypionate
estradiol valerate
estropipate
ethinyl estradiol
Miscellaneous
hormones
calcitonin
raloxifene
teriparatide
Sex hormone
combinations
conjugated estrogens—
medroxy-progesterone
estradiol-levonorgestrel
estradiol-norethindrone
estradiol-norgestimate
ethinyl estradiol-norethindrone
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table OMW-3: Data Elements for Osteoporosis Management in Women Who Had a Fracture
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Comprehensive Diabetes Care
Antidepressant Medication Management (AMM)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified Negative Diagnosis History for inpatient claims/encounters and transfers.
Deleted CPT codes 90871, 99261–99263 from Table AMM-B.
Description
The percentage of members 18 years of age and older who were diagnosed with a new episode of major
depression, treated with antidepressant medication, and who remained on an antidepressant medication
treatment. Two rates are reported.
Effective Acute Phase Treatment. The percentage of newly diagnosed and treated members who
remained on an antidepressant medication for at least 84 days (12 weeks).
Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated members who
remained on an antidepressant medication for at least 180 days (6 months).
Definitions
Intake Period
The 12-month window starting on May 1 of the year prior to the measurement year
and ending on April 30 of the measurement year.
IESD
Index Episode Start Date. The earliest encounter during the Intake Period with any
diagnosis of major depression (Table AMM-A) that meets the following criteria.
A 120-day Negative Diagnosis History
A 90-day Negative Medication History
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of
discharge.
For a direct transfer, the IESD is the discharge date from the facility to which the
member was transferred.
Negative
Diagnosis History
A period of 120 days (4 months) prior to the IESD, during which time the member
had no claims/encounters with any diagnosis of major depression (Table AMM-A)
or prior episodes of depression (Table AMM-C).
For an inpatient (acute or nonacute) claim/encounter, use the date of admission to
determine Negative Diagnosis History.
For direct transfers, use the first admission to determine Negative Diagnosis
History.
IPSD
Index Prescription Start Date. The earliest prescription dispensing date for an
antidepressant medication during the period of 30 days prior to the IESD (inclusive)
through 14 days after the IESD (inclusive).
Negative
Medication History
A period of 90 days (3 months) prior to the IPSD, during which time the member
had no pharmacy claims for either new or refill prescriptions for an antidepressant
medication (Table AMM-D).
HEDIS 2010, Volume 2
Treatment days
The actual number of calendar days covered with prescriptions within the specified
180-day measurement interval. For Effective Continuation Phase Treatment, a
prescription of 90 days supply dispensed on the 151st day will have 80 days counted
in the 231-day interval.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18 years and older as of April 30 of the measurement year.
Continuous
enrollment
120 days prior to the IESD through 245 days after the IESD.
Allowable gap
One gap in enrollment of up to 45 days. To determine continuous enrollment for a
Medicaid beneficiary for whom enrollment is verified monthly, the member may not
have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for
2 months [60 days] is not considered continuously enrolled).
Anchor date
IESD.
Benefits
Medical, pharmacy and mental health (inpatient and outpatient).
Event/diagnosis
The organization should follow the steps below to identify the eligible population, which
should be used for both rates.
Step 1
Identify all members who met at least one of the following criteria during the Intake
Period.
At least one principal diagnosis of major depression (Table AMM-A) in an
outpatient, ED, intensive outpatient or partial hospitalization setting (Table
AMM-B), or
At least two visits in an outpatient, ED, intensive outpatient or partial hospitalization
setting (Table AMM-B) on different dates of service with any diagnosis of major
depression (Table AMM-A), or
At least one inpatient (acute or nonacute) claim/encounter with any diagnosis of
major depression (Table AMM-A)
Table AMM-A: Codes to Identify Major Depression
Description
Major depression
ICD-9-CM Diagnosis
296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311
* Brief depressive reaction (309.0) is not used for diagnosis, since it includes grief reaction (believed to be the most common use of that
code). Additionally, other possible codes that could indicate a depression diagnosis (296.4–296.9, 309.0, 309.28) are not included in this list
because these codes are less specific in identifying members with major depression.
HEDIS 2010, Volume 2
Table AMM-B: Codes to Identify Visit Type
Description
CPT
HCPCS
ED
99281-99285
Outpatient, intensive
outpatient and partial
hospitalization
90804-90815, 98960-98962,
99078, 99201-99205, 9921199215, 99217-99220, 9924199245, 99341-99345, 9934799350, 99384-99387, 9939499397, 99401-99404, 99411,
99412, 99510
UB Revenue
045x, 0981
G0155, G0176, G0177, H0002,
H0004, H0031, H0034-H0037,
H0039, H0040, H2000, H2001,
H2010-H2020, M0064, S0201,
S9480, S9484, S9485
0510, 0513, 0515-0517, 05190523, 0526-0529, 077x, 0900,
0901, 0902-0905, 0907, 09110917, 0919, 0982, 0983
CPT
90801, 90802, 90816-90819, 90821-90824, 9082690829, 90845, 90847, 90849, 90853, 90857, 90862,
90870, 90875, 90876, 99221-99223, 99231-99233,
99238, 99239, 99251-99255
POS
WITH
03, 05, 07, 09, 11, 12, 13, 14, 15,
20, 22, 33, 49, 50, 52, 53, 71, 72
Step 2
Determine the IESD. For each member identified in step 1, identify the date of the earliest
encounter during the Intake Period with any diagnosis of major depression. If the member had
more than one encounter during the Intake Period, include only the first encounter.
Step 3
Test for Negative Diagnosis History. Exclude members who had a claim/encounter for any
diagnosis of major depression (Table AMM-A) or prior episodes of depression (Table AMM-C)
during the 120 days prior to the IESD.
Table AMM-C: Additional Codes to Identify Depression
Description
Depression
ICD-9-CM Diagnosis
296.26, 296.36, 296.4-296.9, 309.0, 309.28
Step 4
Identify the IPSD. The IPSD is the date of the earliest dispensing event for an antidepressant
medication (Table AMM-D) during the period of 30 days prior to the IESD (inclusive) through
14 days after the IESD (inclusive). Exclude members who did not fill a prescription for an
antidepressant medication during this period.
Step 5
Test for Negative Medication History. Exclude members who filled a prescription for an
antidepressant medication 90 days (3 months) prior to the IPSD.
Step 6
Calculate continuous enrollment. Members must be continuously enrolled for 120 days prior to
the IESD to 245 days after the IESD.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Administrative Specification
Denominator
The eligible population.
Numerators
Effective Acute
Phase Treatment
At least 84 days (12-weeks) of continuous treatment with antidepressant medication
(Table AMM-D) during the 114-day period following the IPSD (inclusive). The
continuous treatment allows gaps in medication treatment up to a total of 30 days
during the 114-day period.
Allowable medication changes or gaps include:
Washout period gaps to change medication
Treatment gaps to refill the same medication
Regardless of the number of gaps, there may be no more than 30 gap days. The
organization may count any combination of gaps (e.g., two washout gaps of 15 days
each, or two washout gaps of 10 days each and one treatment gap of 10 days).
Table AMM-D: Antidepressant Medications
Description
Prescription
Miscellaneous antidepressants
bupropion
Monoamine oxidase inhibitors
isocarboxazid
phenelzine
selegiline
tranylcypromine
Phenylpiperazine antidepressants
nefazodone
trazodone
Psychotherapeutic combinations
amitriptyline-chlordiazepoxide
amitriptyline-perphenazine
fluoxetine-olanzapine
SSNRI antidepressants
desvenlafaxine
duloxetine
venlafaxine
SSRI antidepressants
citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
Tetracyclic antidepressants
maprotiline
mirtazapine
Tricyclic antidepressants
amitriptyline
amoxapine
clomipramine
desipramine
doxepin
imipramine
nortriptyline
protriptyline
trimipramine
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Effective
Continuation
Phase Treatment
At least 180 days (6 months) of continuous treatment with antidepressant
medication (Table AMM-D) during the 231-day period following the IPSD (inclusive).
The continuous treatment allows gaps in medication treatment up to a total of 51
days during the 231-day period.
Allowable medication changes or gaps include the following.
Washout period gaps to change medication
Treatment gaps to refill the same medication
Regardless of the number of gaps, gap days may total no more than 51. The
organization may count any combination of gaps (e.g., two washout gaps, each 25
days or two washout gaps of 10 days each and one treatment gap of 10 days).
HEDIS 2010, Volume 2
Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each
date of service; others may be comparable to inpatient billing, with an admission date, a discharge date
and units of service. Organizations whose billing methods are comparable to inpatient billing may count
each unit of service as an individual visit. The unit of service must have occurred during the time frame
specified (e.g., during the Intake Period).
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table AMM-1/2/3: Data Elements for Antidepressant Medication Management
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Each of the 2 rates
Reported rate
Each of the 2 rates
Lower 95% confidence interval
Each of the 2 rates
Upper 95% confidence interval
Each of the 2 rates
HEDIS 2010, Volume 2
Follow-Up After Hospitalization for Mental Illness (FUH)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 90871, 99261–99263 from Table FUH-C.
Description
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of
selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial
hospitalization with a mental health practitioner. Two rates are reported.
1. The percentage of members who received follow-up within 30 days of discharge
2. The percentage of members who received follow-up within 7 days of discharge
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
6 years and older as of the date of discharge.
Continuous
enrollment
Date of discharge through 30 days after discharge.
Allowable gap
No gaps in enrollment.
Anchor date
None.
Benefits
Medical and mental health (inpatient and outpatient).
Event/
diagnosis
Discharged alive from an acute inpatient setting (including acute care psychiatric
facilities) with a principal mental health diagnosis (Table FUH-A) on or between
January 1 and December 1 of the measurement year.
The denominator for this measure is based on discharges, not members. Include all
discharges for members who have more than one discharge on or between January 1
and December 1 of the measurement year.
Table FUH-A: Codes to Identify Mental Health Diagnosis
ICD-9-CM Diagnosis
295–299, 300.3, 300.4, 301, 308, 309, 311–314
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Mental health
readmission or
direct transfer
If the discharge is followed by readmission or direct transfer to an acute facility for any
mental health principal diagnosis (Tables MPT-A, MPT-B) within the 30-day follow-up
period, count only the readmission discharge or the discharge from the facility to which
the member was transferred. Although rehospitalization might not be for a selected
mental health disorder, it is probably for a related condition.
Exclude both the initial discharge and the readmission/direct transfer discharge if the
readmission/direct transfer discharge occurs after December 1 of the measurement
year.
Exclude discharges followed by readmission or direct transfer to a nonacute facility for
any mental health principal diagnosis (Tables MPT-A, MPT-B) within the 30-day followup period. These discharges are excluded from the measure because readmission or
transfer may prevent an outpatient follow-up visit from taking place. Refer to Table
FUH-B for codes to identify nonacute care.
Non-mental
health
readmission or
direct transfer
Exclude discharges in which the patient was transferred directly or readmitted within
30 days after discharge to an acute or nonacute facility for a non-mental health
principal diagnosis. This includes any ICD-9-CM Diagnosis code or DRG code other
than those in Tables MPT-A and MPT-B. These discharges are excluded from the
measure because rehospitalization or transfer may prevent an outpatient follow-up visit
from taking place.
Table FUH-B: Codes to Identify Nonacute Care
Description
HCPCS
UB Revenue
UB Type of Bill
POS
Hospice
0115, 0125, 0135, 0145, 0155,
0650, 0656, 0658, 0659
81x, 82x
34
SNF
019x
21x, 22x, 28x
31, 32
Hospital transitional care, swing bed
or rehabilitation
18x
Rehabilitation
0118, 0128, 0138, 0148, 0158
Respite
0655
Intermediate care facility
54
Residential substance abuse
treatment facility
Psychiatric residential treatment
center
T2048, H0017-H0019
1002
55
1001
56
Comprehensive inpatient rehabilitation
facility
61
Other nonacute care facilities that do not use the UB revenue or type of bill codes for billing (e.g., ICF, SNF)
HEDIS 2010, Volume 2
Administrative Specification
Denominator
The eligible population.
Numerators
30-Day
Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
FUH-C) with a mental health practitioner within 30 days after discharge. Include
outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on
the date of discharge.
7-Day
Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
FUH-C) with a mental health practitioner within 7 days after discharge. Include
outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on
the date of discharge.
Table FUH-C: Codes to Identify Visits
CPT
HCPCS
Follow-up visits identified by the following CPT or HCPCS codes must be with a mental health practitioner.
90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 9921799220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 9939399397, 99401-99404, 99411, 99412, 99510
G0155, G0176, G0177, H0002, H0004, H0031, H0034H0037, H0039, H0040, H2000, H2001, H2010-H2020,
M0064, S0201, S9480, S9484, S9485
CPT
POS
Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner.
90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847,
90849, 90853, 90857, 90862, 90870, 90875, 90876
WITH
03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33,
49, 50, 52, 53, 71, 72
99221-99223, 99231-99233, 99238, 99239, 99251-99255
WITH
52, 53
UB Revenue
The organization does not need to determine practitioner type for follow-up visits identified by the following UB revenue codes.
0513, 0900-0905, 0907, 0911-0917, 0919
Visits identified by the following revenue codes must be with a mental health practitioner or in conjunction with any diagnosis
code from Table FUH-A.
0510, 0515-0517, 0519-0523, 0526-0529, 077x, 0982, 0983
Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each
date of service; others may be comparable to inpatient billing, with an admission date, a discharge date
and units of service. Organizations whose billing methods are comparable to inpatient billing may count
each unit of service as an individual visit. The unit of service must have occurred during the time frame
required for the rate (e.g., within 30 days after discharge or within 7 days after discharge).
Refer to Appendix 3 for the definition of mental health practitioner.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table FUH-1/2/3: Data Elements for Follow-Up After Hospitalization for Mental Illness
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Each of the 2 rates
Reported rate
Each of the 2 rates
Lower 95% confidence interval
Each of the 2 rates
Upper 95% confidence interval
Each of the 2 rates
HEDIS 2010, Volume 2
Annual Monitoring for Patients on Persistent Medications (MPM)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified numerator criteria for Rates 1–3.
Clarified codes that identified a lab panel in Table MPM-A.
Deleted LOINC codes 24320-4, 24321-2, 24326-1, 24322-0, 24323-8, 24362-6, 34554-6, 34555-3,
45064-3, 45065-0, 45066-8, 50261-7 from Table MPM-A.
Deleted LOINC codes 34540-5, 34545-4 from Table MPM-E.
Description
The percentage of members 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 at least one
therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report
each of the four rates separately and as a total rate.
Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARB)
Annual monitoring for members on digoxin
Annual monitoring for members on diuretics
Annual monitoring for members on anticonvulsants
Total rate (the sum of the four numerators divided by the sum of the four denominators)
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
Anchor date
December 31 of the measurement year.
HEDIS 2010, Volume 2
Benefits
Medical and pharmacy.
Event/
diagnosis
Members on persistent medications—defined as members who received at least 180
treatment days of ambulatory medication in the measurement year. Refer to Additional
Eligible Population Criteria for each rate.
Treatment days are the actual number of calendar days covered with prescriptions
within the measurement year (i.e., a prescription of 90 days supply dispensed on
December 1 of the measurement year counts as 31 treatment days).
Administrative Specification
For each product line, report each of the four rates separately and as a combined rate. The total rate is the
sum of the four numerators divided by the sum of the four denominators.
Rate 1: Annual Monitoring for Members on ACE Inhibitors or ARBs
Additional
eligible
population
criteria
Members who received at least 180 treatment days of ACE inhibitors or ARBs, during the
measurement year. Refer to Table CDC-L to identify ACE inhibitors and ARBs.
Numerator
At least one serum potassium and either a serum creatinine or a blood urea nitrogen
therapeutic monitoring test in the measurement year (Table MPM-A). The member must
meet one of the following criteria to be compliant.
Note: Members may switch therapy with any medication listed in Table CDC-L during the
measurement year and have the days supply for those medications count toward the total
180 treatment days (i.e., a member who received 90 days of ACE inhibitors and 90 days
of ARBs meets the denominator definition for rate 1).
A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The tests do not need to occur on the same service date, only within the
measurement year.
HEDIS 2010, Volume 2
Table MPM-A: Codes to Identify Physiologic Monitoring Tests
Description
Lab panel
Serum potassium
(K+)
Serum creatinine
(SCr)
Blood urea
nitrogen (BUN)
CPT
LOINC
80047, 80048, 80050,
80053, 80069
80051, 84132
82565, 82575
84520, 84525
2824-1, 2823-3, 6298-4, 12812-4, 12813-2, 22760-3, 29349-8, 32713-0, 34548-8, 39789-3,
39790-1, 41656-0, 51618-7
2160-0, 2163-4, 2164-2, 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0,
13447-8, 13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 26752-6, 31045-8,
33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1, 38483-4, 39955-0, 39956-8,
39957-6, 39958-4, 39959-2, 39960-0, 39961-8, 39962-6, 39963-4, 39964-2, 39965-9,
39966-7, 39967-5, 39968-3, 39969-1, 39970-9, 39971-7, 39972-5, 39973-3, 39974-1,
39975-8, 39976-6, 40112-5, 40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2,
40119-0, 40120-8, 40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3,
40128-1, 40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2,
40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5, 40269-3,
40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3, 51619-5, 51620-3
3094-0, 6299-2, 11064-3, 11065-0, 12964-3, 12965-0, 12966-8, 14937-7, 44734-2,
49071-4
Rate 2: Annual Monitoring for Members on Digoxin
Additional eligible
population criteria
Members who received at least 180 treatment days of digoxin (Table MPM-B)
during the measurement year.
Table MPM-B: Drugs to Identify Members on Digoxin
Description
Inotropic agents
Numerator
Prescription
digoxin
At least one serum potassium and either a serum creatinine or a blood urea
nitrogen therapeutic monitoring test in the measurement year (Table MPM-A). The
member must meet one of the following criteria to be compliant.
A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The two tests do not need to occur on the same service date, only within the
measurement year.
Rate 3: Annual Monitoring for Members on Diuretics
Additional eligible
population criteria
Members who received at least 180 treatment days of a diuretic (Table MPM-C),
during the measurement year.
Note: Members may switch therapy with any medication listed in Table MPM-C
during the measurement year and have the days supply for those medications
count toward the total 180 treatment days.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table MPM-C: Drugs to Identify Members on Diuretics
Description
Prescription
Antihypertensive
combinations
aliskiren-hydrochlorothiazide
amiloride-hydrochlorothiazide
amlodipine-hydrochlorothiazidevalsartan
atenolol-chlorthalidone
benazepril-hydrochlorothiazide
bendroflumethiazide-nadolol
bisoprolol-hydrochlorothiazide
candesartan-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorthalidone-clonidine
enalapril-hydrochlorothiazide
eprosartan-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide-irbesartan
Loop diuretics
bumetanide
ethacrynic acid
furosemide
torsemide
Potassium-sparing
diuretics
amiloride
eplerenone
spironolactone
triamterene
Thiazide diuretics
bendroflumethiazide
chlorothiazide
chlorthalidone
hydrochlorothiazide
hydroflumethiazide
indapamide
methyclothiazide
metolazone
Numerator
hydrochlorothiazide-lisinopril
hydrochlorothiazide-losartan
hydrochlorothiazide-methyldopa
hydrochlorothiazide-metoprolol
hydrochlorothiazide-moexipril
hydrochlorothiazide-olmesartan
hydrochlorothiazide-propranolol
hydrochlorothiazide-quinapril
hydrochlorothiazide-spironolactone
hydrochlorothiazide-telmisartan
hydrochlorothiazide-timolol
hydrochlorothiazide-triamterene
hydrochlorothiazide-valsartan
polythiazide-prazosin
polythiazide
trichlormethiazide
At least one serum potassium and either a serum creatinine or a blood urea
nitrogen therapeutic monitoring test in the measurement year (Table MPM-A). The
member must meet one of the following criteria to be compliant.
A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The two tests do not need to occur on the same service date, only within the
measurement year.
HEDIS 2010, Volume 2
Rate 4: Annual Monitoring for Members on Anticonvulsants
Additional eligible
population
criteria
Members who received at least 180 treatment days for an anticonvulsant (Table
MPM-D) during the measurement year.
Note: Members who are on multiple anticonvulsant drugs count toward the
denominator multiple times if they meet the persistent medications criteria for each
drug taken during the measurement year (i.e., a member who received at least 180
days of phenytoin and 180 days of valproic acid is counted twice in the denominator
for Rate 4, once for each drug).
Table MPM-D: Drugs to Identify Members on Anticonvulsants
Description
Drugs
Barbiturate anticonvulsants
phenobarbital
Dibenzazepine anticonvulsants
carbamazepine
Hydantoin anticonvulsants
phenytoin
Miscellaneous anticonvulsants
divalproex sodium
valproic acid
At least one drug serum concentration level monitoring test for the prescribed drug in
the measurement year (Table MPM-E).
Numerator
If a member received only one type of anticonvulsant, the drug serum concentration
level test must be for the specific drug taken as a persistent medication (i.e., a
member on phenytoin received a drug serum test for phenytoin).
If a member persistently received multiple types of anticonvulsants, each
anticonvulsant medication and drug monitoring test combination is counted as a
unique event (i.e., a member on both phenytoin and valproic acid with at least 180
treatment days for each drug in the measurement year must separately show
evidence of receiving drug serum concentration tests for each drug [Table MPM-E]
to be considered numerator-compliant for each drug).
Table MPM-E: Codes to Identify Drug Serum Concentration Monitoring Tests
Description
CPT
LOINC
Drug serum concentration for phenobarbital
80184
3948-7, 3951-1, 10547-8, 14874-2, 34365-7
Drug serum concentration for phenytoin
80185, 80186
3968-5, 3969-3, 14877-5, 32109-1, 40460-8
Drug serum concentration for valproic acid or
divalproex sodium
80164
4086-5, 4087-3, 4088-1, 14946-8, 18489-5, 21590-5, 32119-0,
32283-4
Drug serum concentration for carbamazepine
80156, 80157
3432-2, 3433-0, 9415-1, 14056-6, 14639-9, 18270-9, 29147-6,
29148-4, 32058-0, 32852-6, 47097-1
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Exclusion (optional)
Members from each eligible population rate who had an inpatient (acute or nonacute) claim/encounter during
the measurement year.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table MPM-1/2/3: Data Elements for Annual Monitoring for Patients on Persistent Medications
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
For each of the 4 rates and total
Numerator events by administrative data
For each of the 4 rates and total
Reported rate
For each of the 4 rates and total
Lower 95% confidence interval
For each of the 4 rates and total
Upper 95% confidence interval
For each of the 4 rates and total
HEDIS 2010, Volume 2
Potentially Harmful Drug-Disease Interactions in the Elderly (DDE)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 90960–90962, 90966, 90970 to Table DDE-H ―Chronic renal failure‖ description.
Deleted CPT code 90939 from Table DDE-H.
Description
The percentage of Medicare members 65 years of age and older who have evidence of an underlying
disease, condition or health concern and who were dispensed an ambulatory prescription for a
contraindicated medication, concurrent with or after the diagnosis.
Report each of the three rates separately and as a total rate.
A history of falls and a prescription for tricyclic antidepressants, antipsychotics or sleep agents
Dementia and a prescription for tricyclic antidepressants or anticholinergic agents
CRF and prescription for nonaspirin NSAIDs or Cox-2 Selective NSAIDs
Total rate (the sum of the three numerators divided by the sum of the three denominators)
Members with more than one disease or condition can appear in the measure multiple times (i.e., in each
indicator for which they qualify). For all three rates, a lower rate represents better performance.
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Definitions
IESD
Index Episode Start Date. The earliest diagnosis, procedure or prescription between
January 1 of the year prior to the measurement year and December 1 of the measurement
year.
For an outpatient claim/encounter, the IESD is the date of service.
For an inpatient claim/encounter, the IESD is the discharge date.
For dispensed prescriptions, the IESD is the dispense date.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Eligible Population
Product line
Medicare.
Age
67 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of
continuous enrollment.
Anchor date
Enrolled as of December 31 of the measurement year.
Benefit
Medical and pharmacy.
Event/diagnosis
Members with at least one disease or condition or procedure in the measurement
year or the year prior to the measurement year. Refer to Additional Eligible
Population Criteria for each rate.
Administrative Specification
Report each rate separately and as a combined rate. The total rate is the sum of the three numerators divided
by the sum of the three denominators.
Rate 1: Drug-Disease Interactions—History of Falls and Tricyclic Antidepressants,
Antipsychotics or Sleep Agents
Additional eligible
population
criteria
Step 1
An accidental fall or hip fracture on or between January 1 of the year prior to the
measurement year and December 1 of the measurement year.
Follow the steps below to identify the eligible population.
Identify members who had an accidental fall or hip fracture (Table DDE-A) on or
between January 1 of the year prior to the measurement year and December 1 of
the measurement year. Identify the IESD for each member.
Table DDE-A: Codes to Identify Falls or Hip Fractures
Description
CPT
Falls
ICD-9-CM Diagnosis
E880, E884, E885.9, E887, E888
Hip fracture*
27230, 27232, 27235, 27236, 27238, 27240, 27244-27246, 27248, 27254,
27267-27269, 27767-27769
820, V54.13
*Hip fracture may be used as a proxy for identifying falls.
Step 2
Exclude members with a diagnosis of psychosis (Table DDE-B) on or between
January 1 of the year prior to the measurement year and December 1 of the
measurement year.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
195
Table DDE-B: Codes to Identify Psychosis
Description
ICD-9-CM Diagnosis
Dementias (with delirium or delusions)
290.11, 290.12, 290.20, 290.3, 290.41, 290.42, 290.8, 290.9
Transient mental disorders due to conditions classified elsewhere
293
Dementia in conditions classified elsewhere with behavioral disturbance
294.11
Schizophrenic disorders
295
Episodic mood disorders with psychotic behavior
296.x4
Delusional disorders
297
Other nonorganic psychoses
298
Numerator
Dispensed an ambulatory prescription for a tricyclic antidepressant (Table DDE-C) or
an antipsychotic or sleep agent (Table DDE-D) on or between the IESD and December
31 of the measurement year.
Table DDE-C: Tricyclic Antidepressants
Description
Prescription
Psychotherapeutic combinations
amitriptyline-chlordiazepoxide
Tricyclic antidepressants
amitriptyline
amoxapine
clomipramine
amitriptyline-perphenazine
desipramine
doxepin
imipramine
nortriptyline
protriptyline
trimipramine
Table DDE-D: Antipsychotics and Sleep Agents
Description
Prescription
Miscellaneous antipsychotic agents
aripiprazole
clozapine
haloperidol
loxapine
molindone
olanzapine
Miscellaneous anxiolytics, sedatives
and hypnotics
eszopiclone
ramelteon
zaleplon
zolpidem
Phenothiazine antipsychotics
prochlorperazine
chlorpromazine
fluphenazine
mesoridazine
Psychotherapeutic combinations
fluoxetine-olanzapine
Thioxanthenes
thiothixene
paliperidone
pimozide
quetiapine
risperidone
ziprasidone
perphenazine
thioridazine
trifluoperazine
HEDIS 2010, Volume 2
196
Rate 2: Drug-Disease Interactions—Dementia and Tricyclic Antidepressants or
Anticholinergic Agents
Additional eligible
population criteria
A diagnosis of dementia (Table DDE-E) or a dispensed dementia medication
(Table DDE-F) on or between January 1 of the year prior to the measurement year
and December 1 of the measurement year. Identify the IESD for each member.
Table DDE-E: Codes to Identify Dementia
ICD-9-CM Diagnosis
290, 291.2, 292.82, 294.0, 294.1, 294.8, 331.0, 331.1, 331.82
Table DDE-F: Medications for Dementia
Description
Prescription
Cholinesterase inhibitors
donepezil
galantamine
Miscellaneous central nervous system agents
memantine
Numerator
rivastigmine
tacrine
Dispensed an ambulatory prescription for a tricyclic antidepressant (Table DDE-C),
or anticholinergic agent (Table DDE-G) on or between the IESD and December 31
of the measurement year.
HEDIS 2010, Volume 2
197
Table DDE-G: Anticholinergic Agents
Description
Prescription
Anticholinergic antiemetics
cyclizine
dimenhydrinate
meclizine
scopolamine
trimethobenzamide
Anticholinergic antiParkinson agents
benztropine
trihexyphenidyl
Anticholinergics/
antispasmodics
belladonna
dicyclomine
hyoscyamine
propantheline
Antihistamines
azatadine
brompheniramine
chlorpheniramine
clemastine
cyproheptadine
dexchlorpheniramine
diphenhydramine
hydroxyzine hydrochloride
hydroxyzine pamoate
triprolidine
Phenothiazine antiemetics
prochlorperazine
promethazine
Skeletal muscle relaxants
carisoprodol
chlorzoxazone
cyclobenzaprine
metaxalone
Upper respiratory
combinations
APAP/diphenhydramine/pseudoephedrine
atropine/CPM/hyoscyamine/PSE/scopolamine
brompheniramine/carbetapentane/
phenylephrine
brompheniramine/dextromethorphphenylephrine
brompheniramine/dextromethorphan/PSE
brompheniramine/DM/guaifenesin/
phenylephrine
brompheniramine/DM/guaifenesin/PSE
brompheniramine/DM/phenylephrine
brompheniramine/hydrocodone/phenylephrine
brompheniramine/hydrocodone/pseudo-ephedrine
brompheniramine-phenylephrine
brompheniramine-pseudoephedrine
carbetapentane/chlorpheniramine/
phenylephrine
carbetapentane/CPM/ephedrine/phenylephrine
carbetapentane/diphenhydramine/
phenylephrine
carbetapentane-chlorpheniramine
carbetapentane-diphenhydramine
chlorpheniramine/codeine/PE/K iodide
chlorpheniramine/codeine/pseudoephedrine
chlorpheniramine/dextromethorp/phenylephrine
chlorpheniramine/dextromethorphan/PSE
chlorpheniramine/dihydrocodeine/phenylephrine
chlorpheniramine/dihydrocodeine/PSE
chlorpheniramine/DM/guaifenesin/
phenylephrine
chlorpheniramine/DM/methscopolamine
chlorpheniramine/DM/phenylephrine
chlorpheniramine/guaifenesin/phenylephrine
chlorpheniramine/hydrocodone/phenylephrine
chlorpheniramine/hydrocodone/PSE
chlorpheniramine/methscopolamine/PE
chlorpheniramine/methscopolamine/PSE
chlorpheniramine/PE/phenyltoloxamine
chlorpheniramine/phenylephrine/pyrilamine
chlorpheniramine-hydrocodone
chlorpheniramine-methscopolamine
chlorpheniramine-phenylephrine
chlorpheniramine-pseudoephedrine
codeine/phenylephrine/promethazine
codeine/pseudoephedrine/triprolidine
codeine-promethazine
dexchlorpheniramine/dextrometho/PE/pyrilamine
dexchlorpheniramine/dextromethorphan/PE
dexchlorpheniramine/dextromethorphan/PSE
dexchlorpheniramine/hydrocodone/phenylephrine
dexchlorpheniramine/methscopolamine/PE
dexchlorpheniramine/methscopolamine/PSE
dexchlorpheniramine-pseudoephedrine
dextromethorphan/diphenhydramine/PE
dextromethorphan-promethazine
diphenhydramine/hydrocodone/phenylephrine
diphenhydramine-phenylephrine
hydrocodone/pseudoephedrine/triprolidine
phenylephrine-promethazine
pseudoephedrine-triprolidine
Urinary antispasmodics
butabarbital/hyoscyamine/phenazopyridine
flavoxate
hyoscyamine/methenam/m-blue/phenyl salicyl
oxybutynin
tolterodine
methocarbamo
orphenadrine
HEDIS 2010, Volume 2
Rate 3: Drug-Disease Interactions—CRF and Nonaspirin NSAIDs or Cox-2 Selective NSAIDs
Additional eligible
population
criteria
A diagnosis of CRF (Table DDE-H) on or between January 1 of the year prior to the
measurement year and December 1 of the measurement year. Identify the IESD for
each member.
Table DDE-H: Codes to Identify CRF
Description
Chronic renal
failure
CPT
HCPCS
36145, 36800, 36810,
36815, 36818, 36819-36821,
36831-36833, 50300, 50320,
50340, 50360, 50365,
50370, 50380, 90921,
90925, 90935, 90937,
90940, 90945, 90947,
90960-90962, 90966, 90970,
90989, 90993, 90997,
90999, 99512
G0257, G0317G0319, G0323,
G0327, G0392,
G0393, S9339
Numerator
ICD-9-CM
Diagnosis
585.5, 585.6,
V42.0, V45.1,
V56
ICD-9-CM
Procedure
UB
Revenue
38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.6
0367,
080x,
082x-085x,
088x
UB
Type
of Bill
72x
POS
65
Dispensed an ambulatory prescription for an NSAID or Cox-2 selective NSAID
(Table DDE-I) on or between the IESD and December 31 of the measurement year.
Table DDE-I: NSAIDs and Cox-2 Selective NSAIDs
Description
Prescription
Cox-2 inhibitors
celecoxib
Nonsteroidal antiinflammatory agents
diclofenac potassium
diclofenac sodium
etodolac
fenoprofen
flurbiprofen
ibuprofen
indomethacin
ketoprofen
ketorolac
meclofenamate
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
sulindac
tolmetin
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table DDE-3: Data Elements for Potentially Harmful Drug-Disease Interactions in the Elderly
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
For each of the 3 rates and total
Numerator events by administrative data
For each of the 3 rates and total
Reported rate
For each of the 3 rates and total
Lower 95% confidence interval
For each of the 3 rates and total
Upper 95% confidence interval
For each of the 3 rates and total
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Use of High-Risk Medications in the Elderly (DAE)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of Medicare members 65 years of age and older who received at least one high risk
medication
The percentage of Medicare members 65 years of age and older who received at least two different high risk
medications
For both rates, a lower rate represents better performance.
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Eligible Population
Product line
Medicare.
Age
65 years and older as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during the measurement year.
Anchor date
Enrolled as of December 31 of the measurement year.
Benefits
Medical and pharmacy.
Event/diagnosis
None.
Administrative Specification
Denominator
The eligible population.
Numerator 1
At least one prescription dispensed for any high-risk medication (Table DAE-A)
during the measurement year.
Numerator 2
At least two prescriptions dispensed for different high risk medications (Table
DAE-A) during the measurement year.
Note: Identify different drugs using the Drug ID field located in the NDC list on
NCQA’s Web site (www.ncqa.org).
HEDIS 2010, Volume 2
200
Table DAE-A: High-Risk Medications
Description
Prescription
Antianxiety (includes
combination drugs)
aspirin-meprobamate
meprobamate
Antiemetics
scopolamine
trimethobenzamide
Analgesics (includes
combination drugs)
acetaminophen-diphenhydramine
diphenhydramine-magnesium salicylate
ketorolac
Antihistamines (includes
combination drugs)
APAP/dextromethorphan/diphenhydramine
APAP/diphenhydramine/phenylephrine
APAP/diphenhydramine/pseudoephedrine
acetaminophen-diphenhydramine
atropine/CPM/hyoscyamine/PE/PPA/scopolamine
carbetapentane/diphenhydramine/phenylephrine
codeine/phenylephrine/promethazine
codeine-promethazine
cyproheptadine
dexchlorpheniramine
dexchlorpheniramine/dextromethorphan/PSE
dexchlorpheniramine/guaifenesin/PSE
dexchlorpheniramine/hydrocodone/phenylephrine
dexchlorpheniramine/methscopolamine/PSE
dexchlorpheniramine-pseudoephedrine
dextromethorphan-promethazine
diphenhydramine
diphenhydramine/hydrocodone/phenylephrine
diphenhydramine-magnesium salicylate
diphenhydramine-phenylephrine
diphenhydramine-pseudoephedrine
hydroxyzine hydrochloride
hydroxyzine pamoate
phenylephrine-promethazine
promethazine
tripelennamine
Antipsychotic, typical
mesoridazine
thioridazine
Amphetamines
amphetaminedextroamphetamine
benzphetamine
dexmethylphenidate
dextroamphetamine
diethylpropion
methamphetamine
methylphenidate
Barbiturates
amobarbital
butabarbital
mephobarbital
pentobarbital
phenobarbital
secobarbital
Long-acting benzodiazepines
(includes combination drugs)
amitriptyline-chlordiazepoxide
chlordiazepoxide
Calcium channel blockers
nifedipine—short-acting only
Gastrointestinal antispasmodics
dicyclomine
Belladonna alkaloids
(includes combination drugs)
atropine
atropine/CPM/hyoscyamine/PE/scopolamine
atropine/hyoscyamine/PB/scopolamine
atropine-difenoxin
atropine-diphenoxylate
atropine-edrophonium
belladonna
belladonna/caffeine/ergotamine/pentobarbital
Skeletal muscle relaxants
(includes combination drugs)
ASA/caffeine/orphenadrine
ASA/carisoprodol/codeine
aspirin-carisoprodol
aspirin-meprobamate
aspirin-methocarbamol
carisoprodol
chlorzoxazone
cyclobenzaprine
metaxalone
methocarbamol
orphenadrine
Oral estrogens (includes
combination drugs)
conjugated estrogen
conjugated estrogenmedroxyprogesterone
esterified estrogen
esterified estrogenmethyltestosterone
estropipate
pemoline
phendimetrazine
phentermine
chlordiazepoxide-clidinium
diazepam
flurazepam
propantheline
belladonna/ergotamine/phenobarbital
butabarbital/hyoscyamine/phenazopyridine
digestive enzymes/hyoscyamine/ phenyltoloxamine
hyoscyamine
hyoscyamine/methenam/m-blue/phenyl salicyl
hyoscyamine-phenobarbital
HEDIS 2010, Volume 2
201
Table DAE-A: High-Risk Medications (continued)
Description
Prescription
Oral hypoglycemics
chlorpropamide
Narcotics (includes combination drugs)
ASA/caffeine/propoxyphene
acetaminophen-pentazocine
acetaminophen-propoxyphene
belladonna-opium
meperidine
meperidine-promethazine
naloxone-pentazocine
pentazocine
propoxyphene hydrochloride
propoxyphene napsylate
Vasodilators
cyclandelate
dipyridamole—short-acting only
ergot mesyloid
isoxsuprine
Others (including androgens and anabolic
steroids, thyroid drugs, urinary antiinfectives)
methyltestosterone
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin macrocrystals-monohydrate
thyroid desiccated
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table DAE-3: Data Elements for Use of High-Risk Medications in the Elderly
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
For each of the 2 rates
Reported rate
For each of the 2 rates
Lower 95% confidence interval
For each of the 2 rates
Upper 95% confidence interval
For each of the 2 rates
HEDIS 2010, Volume 2
202
Medication Reconciliation Post-Discharge (MRP)
SUMMARY OF CHANGES TO HEDIS 2010
Added definition of ―medication reconciliation.‖
Clarified medical record documentation for evidence of medication reconciliation.
Description
The percentage of discharges from January 1–December 1 of the measurement year for members 65 years
of age and older for whom medications were reconciled on or within 30 days of discharge.
Definition
Medication
reconciliation
A type of review in which the discharge medications are reconciled with the current
medication list in the outpatient medical record.
Eligible Population
Product line
Medicare SNP.
Ages
66 years and older as of December 31 of the measurement year.
Continuous
enrollment
Date of discharge through 30 days after discharge.
Allowable gap
None.
Anchor date
Date of discharge.
Benefit
Medical.
Event/diagnosis
An acute or nonacute inpatient discharge on or between January 1 and December 1
of the measurement year.
The denominator for this measure is based on discharges, not members. Include all
discharges for members who have one or more discharges on or between January
1 and December 1 of the measurement year.
Readmission or
direct transfer
If the discharge is followed by a readmission or direct transfer to an acute or
nonacute facility within the 30-day follow-up period, count only the readmission
discharge or the discharge from the facility to which the member was transferred.
Exclude both the initial discharge and the readmission/direct transfer discharge if
the readmission/direct transfer discharge occurs after December 1 of the
measurement year.
HEDIS 2010, Volume 2
203
Administrative Specification
Denominator
The eligible population.
Numerator
Medication reconciliation (Table MRP-A) conducted by a prescribing practitioner or
clinical pharmacists on or within 30 days of discharge. A member had a medication
reconciliation if a claim/encounter contains a code in Table MRP-A.
Table MRP-A: Codes to Identify Medication Reconciliation
Description
CPT Category II
Medication reconciliation
1111F
Hybrid Specification
Denominator
A systematic sample drawn from the eligible population. The organization may
reduce the sample size using the current year’s administrative rate or the prior year’s
audited, product line-specific rate. Refer to the Guidelines for Calculations and
Sampling for information on reducing the sample size.
The denominator is based on episodes, not members. Members may appear more
than once in the sample.
Numerator
Medication reconciliation conducted by a prescribing practitioner or clinical
pharmacist, as documented through either administrative data or medical record
review on or within 30 days of discharge.
Administrative
Refer to Administrative Specification to identify positive numerator hits from
administrative data.
Medical record
Documentation in the medical record must include evidence of medication
reconciliation, and the date on which it was performed. The following evidence meets
criteria.
Notation that the medications prescribed or ordered upon discharge were
reviewed, or
Notation that no medications were prescribed or ordered upon discharge
Only documentation in the outpatient chart meets the intent of the measure, but an
outpatient visit is not required. A medication list in a discharge summary obtained
from the hospital or inpatient chart should not be used as evidence of medication
reconciliation, but the intent of the measure is met if the discharge summary is in the
outpatient chart.
Note
The denominator is based on the discharge date found in administrative/claims data. This date must be used,
regardless of subsequent data errors or corrections found during medical record review.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table MRP-3: Data Elements for Medication Reconciliation Post-Discharge
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population
Administrative
Hybrid
Number of numerator events by administrative data in eligible population (before
exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Medicare Health Outcomes Survey (HOS)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.
Description
This measure provides a general indication of how well a Medicare organization manages the physical and
mental health of its members. The survey measures each member’s physical and mental health status at the
beginning and the end of a two-year period.
A two-year change score is calculated and each member’s physical and mental health status is categorized
as better, the same or worse than expected, taking into account risk adjustment factors. Organization-specific
results are assigned as percentages of members whose health status was better, the same or worse than
expected.
HEDIS 2010, Volume 2
Fall Risk Management (FRM)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.
Description
The following components of this measure assess different facets of fall risk management.
Discussing
Fall Risk
The percentage of Medicare members 75 years of age and older or 65–74 years of age
with balance or walking problems or a fall in the past 12 months, who were seen by a
practitioner in the past 12 months and who discussed falls or problems with balance or
walking with their current practitioner.
Managing
Fall Risk
The percentage of Medicare members 65 years of age and older who had a fall or had
problems with balance or walking in the past 12 months, who were seen by a practitioner
in the past 12 months and who received fall risk intervention from their current
practitioner.
HEDIS 2010, Volume 2
Management of Urinary Incontinence in Older Adults (MUI)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.
Description
The following components of this measure assess the management of urinary incontinence in older adults.
Discussing Urinary
Incontinence
The percentage of Medicare members 65 years of age and older who reported
having a problem with urine leakage in the past six months and who discussed
their urine leakage problem with their current practitioner.
Receiving Urinary
Incontinence
Treatment
The percentage of Medicare members 65 years of age and older who reported
having a urine leakage problem in the past six months and who received treatment
for their current urine leakage problem.
HEDIS 2010, Volume 2
Osteoporosis Testing in Older Women (OTO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.
Description
The percentage of Medicare women 65 years of age and older who report ever having received a bone
density test to check for osteoporosis.
HEDIS 2010, Volume 2
Physical Activity in Older Adults (PAO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.
Description
The following components of this measure assess different facets of promoting physical activity in older
adults.
Discussing
Physical Activity
The percentage of Medicare members 65 years of age and older who had a doctor’s
visit in the past 12 months and who spoke with a doctor or other health provider
about their level of exercise or physical activity.
Advising
Physical Activity
The percentage of Medicare members 65 years of age and older who had a doctor’s
visit in the past 12 months and who received advice to start, increase or maintain
their level exercise or physical activity.
HEDIS 2010, Volume 2
Flu Shots for Older Adults (FSO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.
Description
The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year
who received an influenza vaccination between September 1 of the measurement year and the date on which
the Medicare CAHPS survey was completed.
HEDIS 2010, Volume 2
Medical Assistance With Smoking and Tobacco Use Cessation (MSC)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.
Description
The following components of this measure assess different facets of providing medical assistance with
smoking and tobacco use cessation.
Advising Smokers
and Tobacco Users
to Quit
A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users and who received advice to quit
during the measurement year.
Discussing Cessation
Medications
A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users and who discussed or were
recommended medications to quit during the measurement year.
Discussing Cessation
Strategies
A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users who discussed or were provided
cessation methods or strategies during the measurement year.
HEDIS 2010, Volume 2
Pneumonia Vaccination Status for Older Adults (PNU)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.
Description
The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year
who have ever received a pneumococcal vaccine
HEDIS 2010, Volume 2
Adults’ Access to Preventive/Ambulatory Health Services (AAP)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of members 20 years and older who had an ambulatory or preventive care visit. The
organization reports three separate percentages for each product line.
Medicaid and Medicare members who had an ambulatory or preventive care visit during the
measurement year
Commercial members who had an ambulatory or preventive care visit during the measurement year or
the two years prior to the measurement year
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
20–65 years and older as of December 31 of the measurement year. Report three age
stratifications and a total rate.
20–44 years
45–64 years
65 years and older
Total
Total. The total rate is the sum of the three numerators divided by the sum of the three
denominators.
Continuous
enrollment
Medicaid and Medicare: The measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for
whom enrollment is verified monthly, the member may not have more than a 1-month
gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.
Commercial: The measurement year and the two years prior to the measurement year.
HEDIS 2010, Volume 2
Administrative Specification
Denominator
The eligible population (report each age stratification separately).
Numerator
Medicaid and Medicare: One or more ambulatory or preventive care visits (Table
AAP-A) during the measurement year.
Commercial: One or more ambulatory or preventive care visits (Table AAP-A) during
the measurement year or the two years prior to the measurement year.
Table AAP-A: Codes to Identify Preventive/Ambulatory Health Services
Description
CPT
Office or other outpatient
services
99201-99205, 99211-99215,
99241-99245
Home services
99341-99345, 99347-99350
Nursing facility care
99304-99310, 99315, 99316,
99318
Domiciliary, rest home or
custodial care services
99324-99328, 99334-99337
Preventive medicine
99385-99387, 99395-99397,
99401-99404, 99411, 99412,
99420, 99429
Ophthalmology and
optometry
92002, 92004, 92012, 92014
HCPCS
ICD-9-CM Diagnosis
UB Revenue
051x, 052x, 0982,
0983
G0344
077x
General medical
examination
V70.0, V70.3, V70.5,
V70.6, V70.8, V70.9
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table AAP-1/2/3: Data Elements for Adults’ Access to Preventive/Ambulatory
Health Services
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
For each age stratification and total
Numerator events by administrative data
For each age stratification and total
Reported rate
For each age stratification and total
Lower 95% confidence interval
For each age stratification and total
Upper 95% confidence interval
For each age stratification and total
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment (IET)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 99261–99263 from Table IET-B.
Description
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD)
dependence who received the following.
Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD
admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the
diagnosis.
Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or
more additional services with an AOD diagnosis within 30 days of the initiation visit.
Definitions
Intake Period
January 1–November 15 of the measurement year. The Intake Period is used to
capture new episodes of AOD.
Index Episode
The earliest inpatient, intensive outpatient, partial hospitalization, outpatient,
detoxification or ED encounter during the Intake Period with a diagnosis of AOD.
For ED visits that result in an inpatient stay, the inpatient stay is the Index Episode.
IESD
Index Episode Start Date. The earliest date of service for any inpatient, intensive
outpatient, partial hospitalization, outpatient, detoxification or ED encounter during the
Intake Period with any diagnosis of AOD.
For an outpatient, intensive outpatient, partial hospitalization, detoxification or ED (not
resulting in an inpatient stay) claim/encounter, the IESD is the date of service.
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of
discharge.
For an ED visit that results in an inpatient stay, the IESD is the date of the inpatient
discharge.
For direct transfers, the IESD is the discharge date from the second admission.
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Negative
Diagnosis
History
A period of 60 days prior to the IESD, during which the member had no claims/
encounters with any diagnosis of AOD dependence.
For an inpatient claim/encounter, use the admission date to determine the Negative
Diagnosis History.
For ED visits that result in an inpatient stay, use the ED date of service to determine
the Negative Diagnosis History.
For direct transfers, use the first admission to determine the Negative Diagnosis
History.
Eligible Population
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Age
13 years and older as of the December 31 of the measurement year. Report two age
stratifications and a total rate.
13-17 years
18+ years
Total
The total rate is the sum of the two numerators divided by the sum of the two
denominators.
Continuous
enrollment
60 days prior to the IESD through 44 days after the IESD (inclusive).
Allowable gap
None.
Anchor date
None.
Benefits
Medical and chemical dependency (inpatient and outpatient).
Note: Members with detoxification-only chemical dependency benefits do not meet
these criteria.
New episode of AOD during the Intake Period.
Event/
diagnosis
Follow the steps below to identify the eligible population, which is the denominator for
both rates.
Step 1
Identify the Index Episode. Identify all members in the specified age range who during
the Intake Period had one of the following.
An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
IET-B) with a diagnosis of AOD (Table IET-A)
A detoxification visit (Table IET-C)
An ED visit (Table IET-D) with a diagnosis of AOD (Table IET-A)
HEDIS 2010, Volume 2
An inpatient discharge with a diagnosis of AOD as identified by either of the
following.
An inpatient facility code in conjunction with a diagnosis of AOD (IET-A)
An inpatient facility code in conjunction with an AOD procedure code (IET-E)
For members with more than one episode of AOD, use the first episode.
For members whose first episode was an ED visit that resulted in an inpatient stay, use
the inpatient discharge.
Select the IESD.
Table IET-A: Codes to Identify AOD Dependence
ICD-9-CM Diagnosis
291-292, 303.00-303.02, 303.90-303.92, 304.00-304.02, 304.10-304.12, 304.20-304.22, 304.30-304.32, 304.40-304.42, 304.50-304.52,
304.60-304.62, 304.70-304.72, 304.80-304.82, 304.90-304.92, 305.00-305.02, 305.20-305.22, 305.30-305.32, 305.40-305.42, 305.50305.52, 305.60-305.62, 305.70-305.72, 305.80-305.82, 305.90-305.92, 535.3, 571.1
Table IET-B: Codes to Identify Outpatient, Intensive Outpatient and Partial
Hospitalization Visits
CPT
HCPCS
90804-90815, 98960-98962, 99078, 9920199205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 9938499387, 99394-99397, 99401-99404, 99408,
99409, 99411, 99412, 99510
UB Revenue
G0155, G0176, G0177, G0396, G0397, H0001, H0002,
H0004, H0005, H0007, H0015, H0016, H0020, H0022,
H0031, H0034-H0037, H0039, H0040, H2000, H2001,
H2010-H2020, H2035, H2036, M0064, S0201, S9480,
S9484, S9485, T1006, T1012
0510, 0513, 0515-0517,
0519-0523, 0526-0529,
077x, 0900, 0902-0907,
0911-0917, 0919, 0944,
0945, 0982, 0983
CPT
POS
90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876
90816-90819, 90821-90824, 90826-90829, 99221-99223, 99231-99233, 99238, 99239,
99251-99255
WITH
WITH
03, 05, 07, 09, 11, 12, 13,
14, 15, 20, 22, 33, 49, 50,
52, 53, 57, 71, 72
52, 53
Table IET-C: Codes to Identify Detoxification Visits
HCPCS
ICD-9-CM Procedure
UB Revenue
H0008-H0014
94.62, 94.65, 94.68
0116, 0126, 0136, 0146, 0156
Table IET-D: Codes to Identify Emergency Department Visits
CPT
UB Revenue
99281-99285
045x, 0981
Table IET-E: Codes to Identify AOD Procedures
ICD-9-CM Procedure
94.61, 94.63, 94.64, 94.66, 94.67, 94.69
______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Step 2
Test for Negative Diagnosis History. Exclude members who had a claim/encounter with
any diagnosis of AOD (Table IET-A) during the 60 days prior to the IESD.
For an inpatient IESD, use the admission date to determine the Negative Diagnosis
History.
For an ED visit that results in an inpatient stay, use the ED date of service to determine
the Negative Diagnosis History.
Step 3
Calculate continuous enrollment. Members must be continuously enrolled without any
gaps 60 days prior to the IESD through 44 days after the IESD.
Administrative Specification
Denominator
The eligible population.
Numerator
Initiation of
AOD Treatment
Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive
outpatient encounter or partial hospitalization within 14 days of diagnosis.
If the Index Episode was an inpatient discharge, the inpatient stay is considered
initiation of treatment and the member is compliant
If the Index Episode was an outpatient, intensive outpatient, partial hospitalization,
detoxification or ED visit, the member must have an inpatient admission,
outpatient visit, intensive outpatient encounter or partial hospitalization (Table
IET-B) with any AOD diagnosis (Table IET-A) within 14 days of the IESD
(inclusive)
If the initiation encounter is an inpatient admission, the admission date (not the
discharge date) must be within 14 days of the IESD (inclusive)
Do not count Index Episodes that include detoxification codes (including inpatient
detoxification) as being initiation of treatment
Exclude from the denominator members whose initiation encounter is an inpatient stay
with a discharge date after December 1 of the measurement year.
Engagement of
AOD Treatment
Initiation of AOD treatment and two or more inpatient admissions, outpatient visits,
intensive outpatient encounters or partial hospitalizations (Table IET-B) with any AOD
diagnosis (Table IET-A) within 30 days after the date of the Initiation encounter
(inclusive). Multiple engagement visits may occur on the same day, but they must be with
different providers in order to be counted.
For members who initiated treatment via an inpatient stay, use the discharge date as the
start of the 30-day engagement time period.
If the engagement encounter is an inpatient admission, the admission date (not the
discharge date) must be within 30 days of the Initiation encounter (inclusive).
Do not count engagement encounters that include detoxification codes (including
inpatient detoxification)
HEDIS 2010, Volume 2
Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some organizations may bill comparable to outpatient billing, with separate claims for
each date of service; others may bill comparable to inpatient billing, with an admission date, a discharge
date and units of service. Organizations that bill comparable to inpatient billing may count each unit of
service as an individual visit. The unit of service must have occurred during the time frame required for the
rate (e.g., within 14 days of the IESD or within 30 days after the date of the initiation encounter).
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table IET-1/2/3: Data Elements for Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment
Administrative
Measurement year
Data collection methodology (administrative)
Eligible population
For each age stratification and total
Numerator events by administrative data
For each age stratification and total
Reported rate
For each age stratification and total
Lower 95% confidence interval
For each age stratification and total
Upper 95% confidence interval
For each age stratification and total
HEDIS 2010, Volume 2
Call Abandonment (CAB)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of calls received by the organization’s Member Services call centers (during operating hours)
during the measurement year that were abandoned by the caller before being answered by a live voice.
Lower rates represent better performance.
Definitions
Abandonment
The caller dials directly into the organization’s Member Services call center or
selects the Member Services option, is placed in the call queue and hangs up the
phone, disconnecting from the call center before being answered by a Member
Services representative.
Call
Telephone contact initiated by an external caller that connects to the organization
Member Services call center. For calls transferred from other parts of the
organization telephone system, measure time from after the call is transferred into
the call center and the member chooses the option to speak to a Member Services
representative and is placed in the call queue.
Member Services
operating hours
Hours of live call-center operation indicated by membership materials (e.g., ID card,
summary organization descriptions, enrollment materials).
Member Services
representative
An employee at the organization’s Member Services call center responsible for
answering calls regarding enrollment, benefits and claims processing.
Member Services
call center
An entity within the organization or under contract with the organization that is
responsible for handling the organization’s network Member Services inquiries
regarding enrollment, benefits and claims processing.
Queue
A sequence of calls waiting to be handled by a Member Services representative. The
wait time on a queued call is calculated by Automatic Call Distribution (ACD), which
tracks incoming calls.
Calculation
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Note: An organization that uses the same systems, policies and procedures and
staff to answer calls for all product lines may report the same rate for all product lines
if it is not possible for it to report data by individual product line.
Denominator
The number of calls received by the organization’s Member Services call center
(during hours of operation) during the measurement year where the member called
directly into Member Services or selected a Member Services option and was put in
the call queue.
Exclude calls to the organization’s benefit contractor (e.g., mental health, dental,
vision, pharmacy) when the contractor has its own call center.
HEDIS 2010, Volume 2
Numerator
The number of calls abandoned by the caller or the system before being answered
by a live voice.
Note: Calls abandoned within 30 seconds remain in the measure and are compliant
for the numerator. Calls sent directly to voicemail should also remain in the measure
and are considered compliant.
Formulas
For an organization with one call center that answers all the organization’s calls and
has the organization as its only client, report the measure as specified.
For an organization with one call center that answers all the organization’s calls and
also has multiple clients, if the call center is unable to report abandonment data for
the organization, report abandonment for the entire volume of calls the center
handles.
For an organization with multiple call centers, each of which answers a portion of the
total amount of calls for the organization and has the organization as its only client,
report the measure as a weighted average (see the formula below).
Definitions
Let N1
= The total number of Member Services calls received by call center 1.
Let N2
= The total number of Member Services calls received by call center 2.
Let PCAB1 = The rate for the Call Abandonment HEDIS measure for call center 1.
Let PCAB2 = The rate for the Call Abandonment HEDIS measure for call center 2.
Set-up calculations
Pooled analysis
Let W1
= The weight assigned to call center 1. This result is calculated by the
formula W1 = N1/(N1+N2).
Let W2
= The weight assigned to call center 2. This result is calculated by the
formula W2 = N2/(N1+N2).
The pooled result from the two rates is calculated as:
PCA pooled = W1*PCAB1+ W2*PCAB2
Note
If during peak call periods (or any regular business hours), the organization blocks calls by immediately giving
members a busy signal and keeping the calls from reaching the call queue, the auditor assesses the
percentage of blocked calls and its impact on the measure.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table CAB-1/2/3: Data Elements for Call Abandonment
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Call Answer Timeliness (CAT)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The percentage of calls received by the organization’s Member Services call centers (during operating hours)
during the measurement year that were answered by a live voice within 30 seconds.
Definitions
Call
Telephone contact initiated by an external caller connects with the organization’s
Member Services call center. For calls transferred from other parts of the
organization’s telephone system, measure time from after the call is transferred
into the Member Services call center, the member chooses the option to speak to
a Member Services representative and is placed in the call queue.
Member Services
operating hours
Hours of live call-center operation indicated by membership materials (e.g., ID
card, summary organization descriptions, enrollment materials).
Member Services
representative
An employee at the organization’s Member Services call center responsible for
answering calls regarding enrollment, benefits and claims processing.
Member Services
call center
An entity within the organization or under contract with the organization that is
responsible for handling the organization’s network Member Services inquiries
regarding enrollment, benefits and claims processing.
Queue
A sequence of calls waiting to be handled by the Member Services representative.
The wait time on a queued call is calculated by ACD, which tracks incoming calls.
Calculation
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Note: An organization that uses the same systems, policies and procedures and
staff to answer calls for all product lines may report the same rate for all product
lines if it is not possible for it to report data by individual product line.
Denominator
The number of calls received by the Member Services call centers (during hours of
operation) during the measurement year, where the member called directly into
Member Services or selected a Member Services option and was put in the call
queue. Exclude calls to a benefits contractor (e.g., mental health, dental, vision,
pharmacy) that uses its own call center.
Numerator
The number of calls answered by a live voice within 30 seconds.
Time measured begins when the member is placed in the call queue and is waiting
to speak to a Member Services representative.
Note: Calls abandoned within 30 seconds remain in the measure and are
noncompliant for the numerator. Calls sent directly to voicemail should also remain
in the measure and are considered noncompliant.
HEDIS 2010, Volume 2
Formulas
For an organization with one call center that answers all the organization’s calls and
has the organization as its only client, report the measure as specified.
For an organization with one call center that answers all the organization’s calls and
also has multiple clients, if the call center is unable to report timeliness data for the
specific organization, report timeliness for the entire volume of calls the center handles.
For an organization with multiple call centers, each of which answers a portion of the
total calls for the organization and has the organization as its only client, report the
measure as a weighted average (see the formula below).
Definitions
Let N1 = The total number of Member Services calls received by call center 1.
Let N2 = The total number of Member Services calls received by call center 2.
Let PCAT1 = The rate for the Call Answer Timeliness HEDIS measure for call center 1.
Let PCAT2 = The rate for the Call Answer Timeliness HEDIS measure for call center 2.
Set-up
calculations
Pooled analysis
Let W1
= The weight assigned to call center 1. This result is calculated by the
formula W1 = N1/(N1+N2).
Let W2
= The weight assigned to call center 2. This result is calculated by the
formula W2 = N2/(N1+N2).
The pooled result from the two rates is calculated as:
PCAT pooled = W1*PCAT1+ W2*PCAT2
Note
If during peak call periods (or any regular business hours), the organization blocks calls by immediately giving
members a busy signal and keeping the calls from reaching the call queue, the auditor assesses the
percentage of blocked calls and its impact on the measure.
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table CAT-1/2/3: Data Elements for Call Answer Timeliness
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
HEDIS 2010, Volume 2
Total Membership (TLM)
SUMMARY OF CHANGES TO HEDIS 2010
Retired the Years in Business portion of the measure.
Renamed the measure.
Clarified Total Membership count.
Description
The number of members enrolled as of December 31 of the measurement year.
Calculation
For each product line the licensed organization offers (i.e., HMO, POS, PPO or FFS), report the number of
members enrolled as of December 31 of the measurement year by product line (i.e., commercial, Medicaid,
Medicare or other**). The total category should equal the licensed organization’s total membership as of
December 31 of the measurement year. The organization should complete this measure once and report the
information for each HEDIS submission.
Include all products and product lines (i.e., across all books of business), even if they were not included in a
HEDIS submission. Include:
Special Needs Plans (SNP) in the Medicare count
ASO members in either the commercial HMO, POS or PPO count, as appropriate
EPO members in either the HMO, POS or PPO count, as appropriate
CHIP members in the Medicaid product line.
Table TLM-1/2/3: Total Membership*
Organization Name: _____________________________________________
Product/Product Line
HMO
Medicaid
Commercial
Medicare
Other
Total Number of Members
Total HMO:
__________________
__________________
__________________
__________________
__________________
Total PPO:
__________________
__________________
__________________
__________________
__________________
Total:
__________________
PPO
Medicaid
Commercial
Medicare
Other
Product/Product Line
POS
Medicaid
Commercial
Medicare
Other
Total Number of Members
Total POS:
__________________
__________________
__________________
__________________
__________________
Total FFS:
__________________
__________________
__________________
__________________
__________________
FFS
Medicaid
Commercial
Medicare
Other
*Total number of members in each category as of December 31 of the measurement year.
HEDIS 2010, Volume 2
Frequency of Selected Procedures (FSP)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 22856, 22861, 22864, 27267–27269 to Table FSP-A.
Added ICD-9-CM Procedure codes 80.53, 80.54 to table FSP-A (―back surgery‖ description).
Deleted CPT codes 63035, 63043, 63044, 63048, 63057, 63066, 63076, 63078, 63082, 63086, 63088,
63091, 63103 from Table FSP-A.
Removed CMS-DRGs from Table FSP-A.
Description
This measure summarizes the utilization of frequently performed procedures that often show wide regional
variation and have generated concern regarding potentially inappropriate utilization.
Calculations
Product lines
Report the following tables for each applicable product line.
Table FSP-1a
Total Medicaid*
Table FSP-2
Commercial—by Product or Combined HMO/POS
Table FSP-3
Medicare
* Report this measure for Total Medicaid only; reporting by eligibility category will
result in small numbers.
Member months
For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.
Procedures
Use Table FSP-A to identify procedures for reporting. Report counts for the
procedures as specified regardless of the site of care (e.g., inpatient or ambulatory
setting). Report the number of procedures rather than the number of members who
received the procedures. Do not double-count the same procedure. The two
examples below illustrate scenarios counted as one procedure.
Count as one
procedure…
If the date of service for two procedures is the same and both codes indicate
CABG
If the date of service for a procedure falls between the admission and
discharge dates for an inpatient stay where the procedure was performed
For example, if a CABG was billed by a surgeon on March 4 of the
measurement year and the facility bill shows a CABG for an admission
that started on March 2 and lasted until March 7 of the measurement
year, combine these to count one CABG
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Myringotomy
Report myringotomy or myringotomy and adenoidectomy. Report toward both
measures, myringotomy and tonsillectomy occurring on the same date of service.
Report as two separate procedures, two myringotomies performed on the same
date of service by the same provider.
Do not report adenoidectomy performed alone.
Tonsillectomy
Report tonsillectomy or tonsillectomy and adenoidectomy. Report toward both
measures myringotomy and tonsillectomy occurring on the same date of service.
Do not report adenoidectomy performed alone.
Nonobstetric D&C
Report nonobstetric D&C.
Do not report obstetric D&C or termination of pregnancy D&C.
Do not report a nonobstetric D&C performed in conjunction with (i.e., on the same
date of service as) a hysterectomy. These services are reported under
hysterectomy.
Hysterectomy
Cholecystectomy
Back surgery
Report abdominal and vaginal hysterectomy separately.
Report open and closed (laparoscopic) cholecystectomy separately.
Report all spinal fusion and disc surgery, including codes relating to laminectomy
with and without disc removal.
Coronary
angioplasty
(PTCA)
Report all PTCAs performed separately. Do not report angioplasty or cardiac
catheterization performed in conjunction with (i.e., on the same date of service as)
a CABG in the angioplasty or the cardiac catheterization rate; report only the
CABG.
Cardiac
catheterization
Report all cardiac catheterizations performed separately. Do not report a cardiac
catheterization performed in conjunction with (i.e., on the same date of service as)
an angioplasty in the cardiac catheterization rate; report only the angioplasty.
Do not report angioplasty or cardiac catheterization performed in conjunction with
(i.e., on the same date of service as) a CABG in the angioplasty or the cardiac
catheterization rate; report only the CABG.
CABG
Coronary artery bypass graft. Report each CABG only once for each date of
service per patient, regardless of the number of arteries involved or the number or
types of grafts involved.
Do not report angioplasty or cardiac catheterization performed in conjunction with
(i.e., on the same date of service as) a CABG in the angioplasty or the cardiac
catheterization rate; report only the CABG.
Prostatectomy
Reduction of
fracture of femur
Report the number of prostatectomies.
Report the number of reductions of fracture of the femur.
HEDIS 2010, Volume 2
Total hip
replacement
Report the number of total hip replacements.
Total knee
replacement
Report the number of total knee replacements.
Partial excision of
large intestine
Carotid
endarterectomy
Report the number of partial excisions of the large intestine.
Report the number of carotid endarterectomies.
Mastectomy
Report the number of mastectomies. Report bilateral mastectomy procedures as
two procedures, even if performed on the same date.
Lumpectomy
Report the number of lumpectomies. Report multiple lumpectomies on the same
date of service as one lumpectomy procedure per patient.
Table FSP-A: Codes to Identify Selected Procedures
Description
Myringotomy or myringotomy
with adenoidectomy
Tonsillectomy or tonsillectomy
with adenoidectomy
Nonobstetric dilation and
curettage
Hysterectomy (abdominal)
Hysterectomy (vaginal)
Cholecystectomy (open)
Cholecystectomy (closed/
laparoscopic)
CPT
HCPCS
ICD-9-CM
Procedure
69433, 69436
20.01
42820, 42821, 42825, 42826, 42860
28.2-28.4
58120
69.09
51925, 58150, 58152, 58180, 58200, 58210, 58240,
58541-58544, 58548, 58570-58573, 58951, 58953,
58954, 58956, 59135, 59525
58260, 58262, 58263, 58267, 58270, 58275, 58280,
58285, 58290-58294, 58550, 58552-58554
47600, 47605, 47610, 47612, 47620
47562-47564
68.3, 68.4, 68.6,
68.8, 68.9
Back surgery
22220, 22222, 22224, 22532, 22533, 22548, 22554,
22556, 22558, 22590, 22595, 22600, 22610, 22612,
22630, 22830, 22856, 22857, 22861, 22862, 22864,
22865, 63001, 63003, 63005, 63011, 63012, 6301563017, 63020, 63030, 63040, 63042, 63045-63047,
63050, 63051, 63055, 63056, 63064, 63075, 63077,
63081, 63085, 63087, 63090, 63101-63102
Coronary angioplasty (PTCA)
MS—
DRG
68.5, 68.7
51.21, 51.22
51.23, 51.24
S2348,
S2350
03.02, 03.09,
80.5, 81.0, 81.3,
81.6, 84.6, 84.8
453-460
92980, 92982, 92995
00.66, 36.06,
36.07, 36.09
246-251
Cardiac catheterization
93501, 93510, 93511, 93514, 93524, 93526-93529,
93539-93545
37.21-37.23,
88.55-88.57
216-218,
222-225,
286, 287
CABG
33510-33514, 33516-33519, 33521-33523, 3353333536
36.1, 36.2
231-236
S2205S2209
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table FSP-A: Codes to Identify Selected Procedures (continued)
Description
Prostatectomy
Reduction of fracture of
femur
Total hip replacement
Total knee replacement
Partial excision of large
intestine
Carotid endarterectomy
Mastectomy
Lumpectomy
CPT
HCPCS
ICD-9-CM Procedure
52601, 52612, 52614, 52620,
52630, 52647, 52648, 55801,
55810, 55812, 55815, 55821,
55831, 55840, 55842, 55845,
55866
27230, 27232, 27235, 27236,
27238, 27240, 27244-27246,
27248, 27267-27269
27130, 27132, 27134
27446, 27447, 27486, 27487
60.2-60.6
44140, 44141, 44143-44147,
44160, 44204-44208
34001, 35001, 35301, 35501,
35601
Bilateral: 19303-19307 with a
modifier .50 code
Unilateral: 19303-19307
45.7
19120, 19125, 19301, 19302
MS—DRG
665-667
79.05, 79.15, 79.25, 79.35
00.70, 81.51, 81.53
00.80, 81.54, 81.55
38.12
Bilateral: 85.42, 85.44, 85.46,
85.48
Unilateral: 85.41, 85.43, 85.45,
85.47
85.2
NA (no MS-DRGs
are specific to total
mastectomy)
584, 585
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table FSP-1: Frequency of Selected Procedures
Member Months
Age
Male
Female
_____________
0-9
_____________
5-19
_____________
10-19
_____________
15-44
_____________
20-44
_____________
30-64
_____________
45-64
_____________
Procedure
Myringotomy
Tonsillectomy
D&C
Hysterectomy, abdominal
Hysterectomy, vaginal
0-4
5-19
0-9
10-19
15-44
45-64
15-44
45-64
15-44
45-64
15-44
45-64
30-64
Cholecystectomy, closed
(laparoscopic)
15-44
45-64
20-44
Back surgery
45-64
Mastectomy
Lumpectomy
15-44
45-64
15-44
45-64
_____________
_____________
Number of Procedures
Procedures/
1,000 Member Months
Male and Female
___________________
___________________
___________________
___________________
Male and Female
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
Male
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Age
30-64
Cholecystectomy, open
Total
0-4
Sex
Female
Male
Female
Female
HEDIS 2010, Volume 2
Table FSP-2: Frequency of Selected Procedures
Age
Male
Member Months
Female
0-4
___________
0-9
___________
5-19
___________
10-19
___________
_____________
15-44
20-44
_____________
30-64
_____________
45-64
_____________
_____________
65+
_____________
_____________
Procedure
Myringotomy
Tonsillectomy
D&C
Hysterectomy, abdominal
0-4
5-19
0-9
10-19
15-44
45-64
15-44
45-64
15-44
45-64
Procedures/
1,000 Member Years
___________________
___________________
___________________
___________________
Male and Female
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Sex
Male and Female
65+
30-64
15-44
Cholecystectomy, open
45-64
65+
30-64
15-44
Cholecystectomy, closed
(laparoscopic)
45-64
65+
_____________
Number of Procedures
Age
65+
Hysterectomy, vaginal
Total
HEDIS 2010, Volume 2
Table FSP-2: Frequency of Selected Procedures (continued)
Procedure
20-44
Back surgery
45-64
65+
45-64
PTCA
65+
45-64
Cardiac catheterization
65+
45-64
CABG
65+
Prostatectomy
Mastectomy
Number of Procedures
Procedures/
1,000 Member Years
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
Age
45-64
65+
15-44
45-64
Sex
65+
Lumpectomy
15-44
45-64
65+
HEDIS 2010, Volume 2
Table FSP-3: Frequency of Selected Procedures
Member Months
Male
Age
Procedure
Female
<65
_____________
_____________
65-74
_____________
_____________
75-84
_____________
_____________
85+
_____________
_____________
Number of Procedures
Procedures/
1,000 Member Years
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Age
<65
65-74
CABG
75-84
85+
<65
65-74
PTCA
75-84
85+
<65
65-74
Cardiac catheterization
75-84
85+
Sex
HEDIS 2010, Volume 2
Table FSP-3: Frequency of Selected Procedures (continued)
Procedure
Number of Procedures
Procedures/
1,000 Member Years
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Age
<65
65-74
Carotid endarterectomy
75-84
85+
<65
65-74
Cholecystectomy, open
75-84
85+
<65
65-74
Cholecystectomy, closed
(laparoscopic)
75-84
85+
<65
65-74
Back surgery
75-84
85+
Sex
HEDIS 2010, Volume 2
Table FSP-3: Frequency of Selected Procedures (continued)
Procedure
Number of Procedures
Procedures/
1,000 Member Years
___________________
___________________
___________________
___________________
___________________
___________________
85+
___________________
___________________
<65
___________________
___________________
___________________
___________________
___________________
___________________
85+
___________________
___________________
<65
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Age
Sex
<65
Hysterectomy (abdominal)
Hysterectomy (vaginal)
Prostatectomy
65-74
75-84
65-74
75-84
65-74
75-84
Female
Female
Male
85+
<65
65-74
Reduction of fracture of femur
75-84
85+
<65
65-74
Total hip replacement
75-84
85+
<65
65-74
Total knee replacement
75-84
85+
HEDIS 2010, Volume 2
Table FSP-3: Frequency of Selected Procedures (continued)
Procedure
Number of Procedures
Procedures/
1,000 Member Years
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
Male
___________________
___________________
Female
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
85+
___________________
___________________
<65
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Age
<65
65-74
Partial excision of large
intestine
75-84
85+
Sex
<65
Mastectomy
Lumpectomy
65-74
75-84
65-74
75-84
85+
Female
Female
HEDIS 2010, Volume 2
Inpatient Utilization—General Hospital/Acute Care (IPU)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Tables IPU-A and IPU-B.
Added ICD-9-CM Diagnosis codes 678–679 to Table IPU-B ―Maternity‖ description.
Description
This measure summarizes utilization of acute inpatient care and services in the following categories.
Total inpatient
Medicine
Surgery
Maternity
Calculations
Product lines
Member months
Report the following tables for each applicable product line.
Table IPU-1a
Total Medicaid
Table IPU-1b
Medicaid/Medicare Dual-Eligibles
Table IPU-1c
Medicaid—Disabled
Table IPU-1d
Medicaid—Other Low Income
Table IPU-2
Commercial—by Product or Combined HMO/POS
Table IPU-3
Medicare
For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.
Maternity rates are reported per 1,000 male and per 1,000 female total member
months in order to capture deliveries as a percentage of the total inpatient
discharges.
Discharges
Refer to the codes in Table IPU-A to identify total inpatient discharges, then use
Table IPU-B to separate discharges into Maternity, Surgery and Medicine.
HEDIS 2010, Volume 2
Table IPU-A: Codes to Identify Total Inpatient Discharges
Principal ICD-9-CM Diagnosis
MS—DRG
001-289, 317-999, V01-V29, V40-V86
OR
001-013, 020-042, 052-103, 113-117, 121-125, 129-139, 146-159, 163-168,
175-208, 215-264, 280-316, 326-358, 368-395, 405-425, 432-446, 453-517,
533-566, 573-585, 592-607, 614-630, 637-645, 652-675, 682-700, 707-718,
722-730, 734-750, 754-761, 765-770, 774-782, 789-795, 799-804, 808-816,
820-830, 834-849, 853-858, 862-872, 901-909, 913-923, 927-929, 933-935,
939-941, 947-951, 955-959, 963-965, 969-970, 974-977, 981-989, 998, 999
WITH
UB Type of Bill
11x, 12x, 41x, 84x
OR
Any acute inpatient facility code
Days
Count all days associated with the identified discharges. Report days for total inpatient,
maternity, surgery and medicine.
ALOS
Refer to the Specific Instructions for Use of Services Tables for the formula. Calculate
average length of stay for total inpatient, medicine, surgery and maternity.
Total inpatient
Use Table IPU-A to identify acute inpatient discharges.
The Total Inpatient should be the sum of the three categories (Medicine, Surgery,
Maternity) and any MS-DRGs defined as ―principal diagnosis invalid as discharge
diagnosis or ungroupable.‖
Use Table IPU-B to identify maternity, surgery and medicine inpatient discharges.
Medicine
DRGs are the preferred method to identify medical discharges. An organization that
uses ICD-9-CM Diagnosis codes must identify total acute inpatient discharges, remove
maternity related discharges and remove all discharges accompanied by UB revenue
code 036X.
Report MS-DRGs 789–795 under Medicine if newborn care is rendered after the baby
has been discharged home from delivery and is subsequently rehospitalized.
Surgery
DRGs are the preferred method to identify surgical discharges. An organization that
uses ICD-9-CM Diagnosis codes must identify total inpatient, remove maternity-related
discharges and include the remaining discharges accompanied by UB revenue code
036X.
Maternity
Include birthing center deliveries in this measure and count them as one day of stay.
Refer to Table IPU-B for ICD-9-CM Principal Diagnosis codes, UB Revenue, UB Type
of Bill and DRG codes.
HEDIS 2010, Volume 2
Table IPU-B: Codes to Identify Medicine, Surgery and Maternity Inpatient Discharges
Description
Principal ICD-9CM Diagnosis
UB Revenue
Medicine
Total—Maternity—
Surgery
Surgery
Total—Maternity*
036x
Maternity
630-676, 678-679,
V24.0
0112, 0122, 0132,
0142, 0152, 07200722, 0724
UB Type
of Bill
MS—DRG
052-103, 121-125, 146-159, 175-208, 280-316, 368-395,
432-446, 533-566, 592-607, 637-645, 682-700, 722-730,
754-761, 789-795, 808-816, 834-849, 862-872, 913-923,
933-935, 947-951, 963-965, 974-977
001-013, 020-042, 113-117, 129-139, 163-168, 215-264,
326-358, 405-425, 453-517, 573-585, 614-630, 652-675,
707-718, 734-750, 799-804, 820-830, 853-858, 901-909,
927-929, 939-941, 955-959, 969-970, 981-989
84x
765-770, 774-782
* If the organization uses ICD-9-CM Diagnosis codes to report this measure, all discharges reported in the Surgery group must be in
conjunction with UB revenue code 036x.
Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude claims and
encounters that contain any of the following codes.
Table IPU-C: Codes to Identify Exclusions
Principal ICD-9-CM Diagnosis
Secondary ICD-9-CM Diagnosis
WITH
960-979
291-292, 303-305
Table IPU-1: Inpatient Utilization—General Hospital/Acute Care
Age
Member Months
<1
_____________
1-9
_____________
10-19
_____________
20-44
_____________
45-64
_____________
65-74
_____________
75-84
_____________
85+
_____________
Unknown
_____________
Total:
_____________
HEDIS 2010, Volume 2
Table IPU-1: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges
Discharges/1,000
Member Months
Days
Days/1,000 Member
Months
Average Length
of Stay
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Age
Total Inpatient
Total:
_______
___________
___________
___________
_______
___________
___________
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Medicine
Total:
_______
___________
___________
___________
_______
___________
___________
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Surgery
Total:
___________
_______
___________
_______
___________
___________
___________
HEDIS 2010, Volume 2
Table IPU-1: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges
Discharges/1,000
Member Months
Days
Days/1,000 Member
Months
Average Length of
Stay
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
Unknown
___________
Age
Maternity*
Total:
___________
_______
___________
___________
_______
___________
___________
*The maternity category is calculated using member months for members 10–64 years.
Table IPU-2/3: Inpatient Utilization—General Hospital/Acute Care
Age
Member Months
<1
_____________
1-9
_____________
10-19
_____________
20-44
_____________
45-64
_____________
65-74
_____________
75-84
_____________
85+
_____________
Unknown
_____________
Total:
_____________
Discharges
Discharges/1,000
Member Years
Days
Days/1,000 Member
Years
Average Length of
Stay
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Age
Total Inpatient
Total:
___________
_______
___________
_______
___________
___________
___________
HEDIS 2010, Volume 2
Table IPU-2/3: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges
Discharges/1,000
Member Years
Days
Days/1,000 Member
Years
Average Length
of Stay
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Age
Medicine
Total:
_______
___________
___________
___________
_______
___________
___________
<1
___________
___________
_______
___________
___________
1-9
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
65-74
___________
___________
_______
___________
___________
75-84
___________
___________
_______
___________
___________
85+
___________
___________
_______
___________
___________
Unknown
___________
Surgery
Total:
_______
___________
___________
___________
_______
___________
___________
10-19
___________
___________
_______
___________
___________
20-44
___________
___________
_______
___________
___________
45-64
___________
___________
_______
___________
___________
Unknown
___________
Maternity
Total:
___________
_______
___________
_______
___________
___________
___________
HEDIS 2010, Volume 2
Ambulatory Care (AMB)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT code 99461 to Table AMB-A.
Description
This measure summarizes utilization of ambulatory care in the following categories.
Outpatient Visits
ED Visits
Ambulatory Surgery/Procedures
Observation Room Stays
Calculations
Product lines
Report the following tables for each applicable product line.
Table AMB-1a
Total Medicaid
Table AMB-1b
Medicaid/Medicare Dual-Eligibles
Table AMB-1c
Medicaid—Disabled
Table AMB-1d
Medicaid—Other Low Income
Table AMB-2
Commercial—by Product or Combined HMO/POS
Table AMB-3
Medicare
Member months
For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.
Counting multiple
services
For ambulatory surgery/procedures that occur on the same date of service as an
ED visit, report as a single ED visit.
For Observation Room visits that occur on the same date of service as an
ambulatory surgery/procedure, report as a single ambulatory surgery/procedure.
For Observation Room visits that occur on the same date of service as an ED visit,
report as a single ED visit.
For all other combinations of multiple ambulatory services falling in different
categories on the same day, report each service that meets the criteria in the
appropriate category.
____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Outpatient visits
Use Table AMB-A to identify outpatient visits. Count each occurrence of the CPT
codes listed in Table AMB-A if rendered by different practitioners (a CPT code may
count more than once on the same date of service if rendered by different
practitioners).
Report services without regard to practitioner type, training or licensing. Include
office-based surgical procedures (use the Ambulatory Surgery/Procedures codes in
Table AMB-C and include surgeries conducted at the practitioner’s office).
Table AMB-A: Codes to Identify Outpatient Visits
Description
CPT
UB Revenue
Office or other outpatient visits
99201-99205, 99211-99215, 99241-99245
Home visits
Nursing facility care
Domiciliary or rest home care
Preventive medicine
99341-99345, 99347-99350
99304-99310, 99315, 99316, 99318
99324-99328, 99334-99337
99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420,
99429
99432, 99461
92002, 92004, 92012, 92014
Newborn care
Ophthalmology and optometry
ED visits
051x, 052x,
0982, 0983
Use Table AMB-B to identify ED visits. Count once each visit to an ED that does not
result in an inpatient stay, regardless of the intensity or duration of the visit. Count
multiple ED visits on the same date of service as one visit.
Table AMB-B: Codes to Identify ED Visits
CPT
UB Revenue
99281-99285
045x, 0981
OR
CPT
10040-69979
Ambulatory
surgery/
procedures
WITH
POS
23
Use Table AMB-C to identify ambulatory surgeries/procedures. Identify encounters
using Option A or Option B. Option A is the preferred method for this measure,
though when necessary, the organization should use Option A and Option B.
Report only ambulatory surgeries/procedures performed at a hospital outpatient
facility or at a free-standing surgery center. Do not report office-based surgeries/
procedures in this category; report them under Outpatient Visits. Count multiple
ambulatory surgeries/procedures on the same date of service as one ambulatory
surgery/procedure.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table AMB-C: Codes to Identify Ambulatory Surgery/Procedures
Option A
CPT
POS
All codes included in the CMS 2009 ASC Approved HCPCS Codes and Payment Rates file* and
92953, 92970, 92971, 92975, 92980, 92982, 92986, 92990, 92992, 92993, 92995, 92996, 9350193533, 93600-93652
22, 24
WITH
Option B
ICD-9-CM Procedure
01-86, 88.4, 88.5, 98.5
WITH
UB Revenue
WITH
0320, 0321, 0323, 036x, 0480, 0481, 049x, 075x, 079x
UB Type of Bill
13x, 83x
* The CMS 2009 ASC Approved HCPCS Codes and Payment Rates files are available on the CMS Web site
(http://www.cms.hhs.gov/ASCPayment/) under the Addenda Updates section. Use the file that was valid at the end of the measurement
year.
Observation
Room stays
Use Table AMB-D to identify Observation Room stays.
Count once, each observation visit that does not result in an inpatient stay, regardless
of the intensity or duration of the visit. Count multiple observation visits on the same
date of service as one visit.
Table AMB-D: Codes to Identify Observation Room Stays
CPT
UB Revenue
99217-99220
0762
Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude from all categories
claims and encounters that contain any code in Table AMB-E.
Table AMB-E: Codes to Identify Exclusions
CPT
Principal ICD-9-CM Diagnosis
90801-90899
290-316
Principal ICD-9-CM Diagnosis
960-979
WITH
ICD-9-CM Procedure
94.26, 94.27, 94.6
Secondary ICD-9-CM Diagnosis
291-292, 303-305
Note
This measure provides a reasonable proxy for professional ambulatory encounters. It is neither a strict
accounting of all ambulatory resources nor an effort to be all-inclusive.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table AMB-1: Ambulatory Care
Age
Member Months
<1
______________
1-9
______________
10-19
______________
20-44
______________
45-64
______________
65-74
______________
75-84
______________
85+
______________
Unknown
______________
Total:
Outpatient Visits
ED Visits
______________
Ambulatory Surgery/
Procedures
Procedures/
1,000
Member
Procedures
Months
Observation Room Stays
Visits
Visits/1,000
Member
Months
Visits
Visits/1,000
Member
Months
Stays
Stays/
1,000 Member
Months
<1
_____
_______
_____
_______
_______
______
______
_______
1-9
_____
_______
_____
_______
_______
______
______
_______
10-19
_____
_______
_____
_______
_______
______
______
_______
20-44
_____
_______
_____
_______
_______
______
______
_______
45-64
_____
_______
_____
_______
_______
______
______
_______
65-74
_____
_______
_____
_______
_______
______
______
_______
75-84
_____
_______
_____
_______
_______
______
______
_______
85+
_____
_______
_____
_______
_______
______
______
_______
Unknown
_____
Total:
_____
Age
_____
_______
_____
_______
_______
_______
______
______
______
_______
HEDIS 2010, Volume 2
Table AMB-2/3: Ambulatory Care
Age
Member Months
<1
______________
1-9
______________
10-19
______________
20-44
______________
45-64
______________
65-74
______________
75-84
______________
85+
______________
Unknown
______________
Total:
______________
Ambulatory Surgery/
Procedures
Procedures/
1,000
Member
Procedures
Years
Observation Room
Stays
Outpatient Visits
Visits/
1,000
Member
Visits
Years
ED Visits
Visits/
1,000
Member
Visits
Years
Stays
Stays/
1,000 Member
Years
<1
_____
_______
_____
_______
______
_______
______
_______
1-9
_____
_______
_____
_______
______
_______
______
_______
10-19
_____
_______
_____
_______
______
_______
______
_______
20-44
_____
_______
_____
_______
______
_______
______
_______
45-64
_____
_______
_____
_______
______
_______
______
_______
65-74
_____
_______
_____
_______
______
_______
______
_______
75-84
_____
_______
_____
_______
______
_______
______
_______
85+
_____
_______
_____
_______
______
_______
______
_______
Unknown
_____
Age
Total:
_____
_____
_______
_____
______
_______
______
______
_______
______
_______
HEDIS 2010, Volume 2
Inpatient Utilization—Nonacute Care (NON)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
This measure summarizes utilization of nonacute inpatient care in hospice, nursing home, rehabilitation, SNF,
transitional care and respite.
Calculations
Product lines
Report the following tables for each applicable product line.
Table NON-1a
Total Medicaid
Table NON-1b
Medicaid/Medicare Dual-Eligibles
Table NON-1c
Medicaid—Disabled
Table NON-1d
Medicaid—Other Low Income
Table NON-2
Commercial—by Product or Combined HMO/POS
Table NON-3
Medicare
Member months
For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.
Discharges
Refer to the codes listed in Table NON-A to report discharges for nonacute
inpatient care.
Table NON-A: Codes to Identify Nonacute Care
Description
UB Revenue
UB Type of Bill
Hospice
0115, 0125, 0135, 0145, 0155, 0650, 0656, 0658, 0659
81x, 82x
SNF
019x
21x, 22x, 28x
Hospital transitional care, swing bed
or rehabilitation
18x
Rehabilitation
0118, 0128, 0138, 0148, 0158
Respite
0655
Other nonacute care facilities that do not use the UB revenue or type of bill codes for billing (e.g., ICF, SNF)
Days
Count all days associated with the identified discharges.
ALOS
Refer to Specific Instructions for Use of Services Tables for the formula.
Total nonacute
inpatient care
Use the codes in Table NON-A to identify nonacute care. Include care from any
institution that provides long-term/specialty nonacute care.
HEDIS 2010, Volume 2
Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude claims and
encounters that contain any of the following codes.
Table NON-B: Codes to Identify Exclusions
CPT
Principal ICD-9-CM Diagnosis
ICD-9-CM Procedure
90801-90899
290-316
94.26, 94.27, 94.6
Principal ICD-9-CM Diagnosis
960-979
WITH
Secondary ICD-9-CM Diagnosis
291-292, 303-305
Table NON-1: Inpatient Utilization—Nonacute Care
Age
Member Months
<1
______________
1-9
______________
10-19
______________
20-44
______________
45-64
______________
65-74
______________
75-84
______________
85+
______________
Unknown
______________
Total:
______________
Discharges
Discharges/1,000
Member Months
Days
Days/1,000
Member Months
Average Length
of Stay
<1
_____________
_____________
_______
_____________
____________
1-9
_____________
_____________
_______
_____________
____________
10-19
_____________
_____________
_______
_____________
____________
20-44
_____________
_____________
_______
_____________
____________
45-64
_____________
_____________
______
_____________
____________
65-74
_____________
_____________
_______
_____________
____________
75-84
_____________
_____________
_______
_____________
____________
85+
_____________
_____________
_______
_____________
____________
Unknown
_____________
Age
Total:
_____________
_______
_____________
_______
____________
_____________
____________
____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table NON-2/3: Inpatient Utilization—Nonacute Care
Age
Member Months
<1
______________
1-9
______________
10-19
______________
20-44
______________
45-64
______________
65-74
______________
75-84
______________
85+
______________
Unknown
______________
Total:
______________
Discharges
Discharges/1,000
Member Years
Days
Days/1,000
Member Years
Average Length
of Stay
<1
____________
_____________
_______
_____________
____________
1-9
_____________
_____________
_______
_____________
____________
10-19
_____________
_____________
_______
_____________
____________
20-44
_____________
_____________
_______
_____________
____________
45-64
_____________
_____________
_______
_____________
____________
65-74
_____________
_____________
_______
_____________
____________
75-84
_____________
_____________
_______
_____________
____________
85+
_____________
_____________
_______
_____________
____________
Unknown
_____________
Age
Total:
_____________
_______
_____________
_______
____________
_____________
____________
HEDIS 2010, Volume 2
Mental Health Utilization (MPT)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Table MPT-B.
Deleted CPT codes 90871, 99261-99263 from Table MPT-C.
Added CPT codes 96102, 96103, 96105, 96119, 96120, 96125 to Table MPT-D.
Deleted CPT code 90871 from Table MPT-D.
Description
The number and percentage of members receiving the following mental health services during the
measurement year.
Any services
Inpatient
Intensive outpatient or partial hospitalization
Outpatient or ED
Calculations
Product lines
Report the following tables for each applicable product line.
Table MPT-1a
Total Medicaid
Table MPT-1b
Medicaid/Medicare Dual-Eligibles
Table MPT-1c
Medicaid—Disabled
Table MPT-1d
Medicaid—Other Low Income
Table MPT-2
Commercial—by Product or Combined HMO/POS
Table MPT-3
Medicare
Count members who received inpatient, intensive outpatient, partial hospitalization,
outpatient and ED mental health services in each column. Count members only
once in each column, regardless of number of visits.
Count members in the Any Services column only if they had at least one inpatient,
intensive outpatient, partial hospitalization, outpatient or ED claim/encounter during
the measurement year.
For members who have had more than one encounter, count only the first visit in
the measurement year and report the member in the respective age category as of
the date of service or discharge.
Benefit
Mental health.
____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Member months
For each product line and table, report all member months during the measurement
year for members with the benefit. IDSS automatically produces member years data
for the commercial and Medicare product lines. Refer to Specific Instructions for
Use of Services Tables for more information.
Because some organizations may offer different benefits for inpatient and outpatient
mental health services, denominators in the columns of the member months table
may vary. The denominator in the Any column should include all members with any
mental health benefit.
Inpatient
Include inpatient care at either a hospital or treatment facility with mental health as
the principal diagnosis.
Use one of the following criteria to identify inpatient services.
An inpatient facility code in conjunction with a principal mental health diagnosis
(Table MPT-A), or
DRGs (Table MPT-B)
Include discharges associated with residential care and rehabilitation.
Table MPT-A: Codes to Identify Mental Health Diagnosis
ICD-9-CM Diagnosis
290, 293-302, 306-316
Note: DSM-IV codes mirror ICD-9-CM codes. A health plan that has access only to DSM-IV codes should use
and document them. Follow the specifications outlined above for ICD-9-CM codes.
Table MPT-B: Codes to Identify Inpatient Services
MS—DRG
876, 880-887; exclude discharges with ICD-9-CM Principal
Diagnosis code 317-319
Intensive outpatient and partial
hospitalization
Report intensive outpatient and partial hospitalization claims/encounters (Table
MPT-C) in conjunction with a principal mental health diagnosis (Table MPT-A).
Count services provided by physicians and nonphysician practitioners.
Exclude any services the health plan knows to be inpatient based on type of bill,
place of service or location of service codes.
HEDIS 2010, Volume 2
Table MPT-C: Codes to Identify Intensive Outpatient and Partial Hospitalization Services
HCPCS
UB Revenue
Visits identified by the following HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental health
practitioner (the organization does not need to determine practitioner type).
H0035, H2001, H2012, S0201, S9480
0905, 0907, 0912, 0913,
CPT
POS
90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853, 90857,
90862, 90870, 90875, 90876
WITH
52, 53*
WITH
52, 53*
Visits identified by the following CPT/POS codes must be with a mental health practitioner.
99221-99223, 99231-99233, 99238, 99239, 99251-99255
* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an intensive outpatient or partial hospitalization setting.
Report outpatient and ED claims/encounters (Table MPT-D) in conjunction with a
principal mental health diagnosis (Table MPT-A). Count services provided by
physicians and nonphysicians.
Outpatient
and ED
Only include observation stays and ED visits that do not result in an inpatient stay.
Table MPT-D: Codes to Identify Outpatient and ED Services
CPT
HCPCS
UB Revenue
Visits identified by the following CPT, HCPCS, UB Revenue and CPT/POS codes may be with a mental health or non-mental
health practitioner (the organization does not need to determine practitioner type).
90804-90815, 96101-96103, 96105, 96110,
96111, 96116, 96118-96120, 96125CPT
G0155, G0176, G0177, H0002, H0004, H0031,
H0034, H0036, H0037, H0039, H0040, H2000,
H2010, H2011, H2013-H2020, M0064, S9484,
S9485
90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876
WITH
CPT
0513, 0900-0904, 0911, 09140919
POS
03, 05, 07, 09, 11, 12, 13, 14,
15, 20, 22, 23, 33, 49, 50, 53*,
71, 72
UB Revenue
Visits identified by the following CPT and UB Revenue codes must be with a mental health practitioner.
98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 9928199285, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411,
99412, 99420, 99510
045x, 0510, 0515-0517, 0519-0523, 05260529, 0762, 077x, 0981-0983
* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an outpatient setting.
____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table MPT-1/2/3: Mental Health Utilization
Member Months (Any Services)
Male
Female
Age
Total
Male
Member Months (Inpatient)
Female
Total
0-12
_________
_________
_________
_________
_________
________
13-17
_________
_________
_________
_________
_________
________
18-64
_________
_________
_________
_________
_________
________
65+
_________
_________
_________
_________
_________
________
Unknown
_________
_________
_________
_________
_________
________
_________
_________
_________
_________
_________
________
Total:
Member Months (Intensive Outpatient/Partial Hospitalization)
Age
Male
Female
Total
Member Months (Outpatient/ED)
Male
Female
Total
0-12
_________
_________
_________
_________
_________
________
13-17
_________
_________
_________
_________
_________
________
18-64
_________
_________
_________
_________
_________
________
65+
_________
_________
_________
_________
_________
________
Unknown
_________
_________
_________
_________
_________
________
_________
_________
_________
_________
_________
________
Total:
Age
0-12
Any Services
Number
Percent
Inpatient
Number
Percent
Intensive
Outpatient/Partial
Hospitalization
Number
Percent
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Male
______
______
______
______
______
______
______
______
Female
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Sex
Total:
13-17
Total:
18-64
Total:
65+
Total:
Unknown
Total:
Total
Total:
Outpatient/ED
Number
Percent
HEDIS 2010, Volume 2
Identification of Alcohol and Other Drug Services (IAD)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Table IAD-B.
Deleted CPT codes 90871, 99261-99263 from Table IAD-C.
Added CPT codes 96102, 96103, 96105, 96119, 96120, 96125 to Table IAD-D.
Deleted CPT code 90871 from Table IAD-D.
Description
This measure summarizes the number and percentage of members with an alcohol and other drug (AOD)
claim who received the following chemical dependency services during the measurement year.
Any services
Inpatient
Intensive outpatient or partial hospitalization
Outpatient or ED
Calculations
Product lines
Report the following tables for each applicable product line.
Table IAD-1a
Total Medicaid
Table IAD-1b
Medicaid/Medicare Dual-Eligibles
Table IAD-1c
Medicaid—Disabled
Table IAD-1d
Medicaid—Other Low Income
Table IAD-2
Commercial—by Product or Combined HMO/POS
Table IAD-3
Medicare
Count members who received inpatient, intensive outpatient, partial hospitalization,
outpatient and ED chemical dependency services in each column. Count members
in each column only once, regardless of number of visits.
Count members in the Any Services column only if they had at least one inpatient,
intensive outpatient, partial hospitalization, outpatient or ED claim/encounter during
the measurement year.
For members who had more than one encounter, count only the first visit in the
measurement year and report the member in the respective age category as of the
date of service or discharge.
Benefit
Chemical dependency.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2009, Volume 2
Member months
For each product line, report all member months during the measurement year for
members with the benefit. IDSS automatically produces member years data for the
commercial and Medicare product lines. Refer to Specific Instructions for Use of
Services Tables for more information.
Because some organizations may offer different benefits for inpatient and outpatient
chemical dependency services, denominators in the columns of the member
months table may vary. The denominator in the Any column should include all
members with any chemical dependency benefit.
Include inpatient care, including inpatient detoxification, at either a hospital or
treatment facility with any diagnosis of chemical dependency.
Inpatient
Use one of the following criteria to identify inpatient services.
An inpatient facility code in conjunction with any diagnosis of chemical
dependency (Table IAD-A), or
A code in Table IAD-B
Include discharges associated with residential care and rehabilitation.
Table IAD-A: Codes to Identify Chemical Dependency Diagnosis
ICD-9-CM Diagnosis
291-292, 303-304, 305.0, 305.2-305.9, 535.3, 571.1
Table IAD-B: Codes to Identify Inpatient Services
ICD-9-CM Procedure
MS—DRG
94.6x WITH an inpatient facility code
894-897
Intensive outpatient and partial
hospitalization
Report intensive outpatient and partial hospitalization claims/encounters (Table
IAD-C) in conjunction with any chemical dependency diagnosis (Table IAD-A).
Count services provided by physician and nonphysician practitioners.
Intensive outpatient and partial hospitalization are reported separate from outpatient
and ED services because these programs represent a significant number of
services rendered.
Exclude any services the health plan knows to be inpatient based on type of bill,
place of service or location of service codes.
HEDIS 2010, Volume 2
Table IAD-C: Codes to Identify Intensive Outpatient and Partial Hospitalization Services
HCPCS
UB Revenue
Visits identified by the following HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental health
practitioner (i.e., the organization does not need to determine practitioner type).
H0015, H0035, H2001, H2012, S0201, S9480
0905-0907, 0912, 0913
CPT
POS
90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853,
90857, 90862, 90870, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 9925199255
WITH
52, 53*
*POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an intensive outpatient or partial hospitalization setting.
Outpatient
and ED
Report outpatient and ED claims/encounters (Table IAD-D) in conjunction with any
chemical dependency diagnosis (Table IAD-A).
Count services provided by physicians and nonphysician practitioners.
Only include observation stays and ED visits that do not result in an inpatient stay.
Table IAD-D: Codes to Identify Outpatient and ED Services
CPT
HCPCS
UB Revenue
Visits identified by the following CPT, HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental
health practitioner (i.e., the organization does not need to determine practitioner type).
90804-90815, 96101-96103, 96105, 96110, 96111,
96116, 96118-96120, 96125, 98960-98962, 99078,
99201-99205, 99211-99215, 99217-99220, 9924199245, 99281-99285, 99341-99345, 99347-99350,
99381-99387, 99391-99397, 99401-99404, 99408,
99409, 99411, 99412, 99420, 99510
G0155, G0176, G0177, G0396, G0397, H0001,
H0002, H0004, H0005, H0007, H0012-H0014,
H0016, H0020, H0022, H0031, H0034, H0036,
H0037, H0039, H0040, H0049, H0050, H2000,
H2010, H2011, H2013-H2020, H2035, H2036,
M0064, S9475, S9484, S9485, T1006, T1012
CPT
90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875,
90876
045x, 0510, 0513, 05150517, 0519-0523, 05260529, 0762, 077x, 09000904, 0911, 0914-0919,
0944, 0945, 0981-0983
POS
WITH
03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 23,
33, 49, 50, 53*, 57, 71, 72
* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an outpatient setting.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.
HEDIS 2010, Volume 2
Table IAD-1/2/3: Identification of Alcohol and Other Drug Services
Member Months (Any Services)
Male
Female
Age
Total
Male
Member Months (Inpatient)
Female
Total
0-12
_________
_________
_________
_________
_________
________
13-17
_________
_________
_________
_________
_________
________
18-24
_________
_________
_________
_________
_________
________
25-34
_________
_________
_________
_________
_________
________
35-64
_________
_________
_________
_________
_________
________
65+
_________
_________
_________
_________
_________
________
Unknown
_________
_________
_________
_________
_________
________
_________
_________
_________
_________
_________
________
Total:
Member Months (Intensive Outpatient/Partial Hospitalization)
Age
Male
Female
Total
Member Months (Outpatient/ED)
Male
Female
Total
0-12
_________
_________
_________
_________
_________
________
13-17
_________
_________
_________
_________
_________
________
18-24
_________
_________
_________
_________
_________
________
25-34
_________
_________
_________
_________
_________
________
35-64
_________
_________
_________
_________
_________
________
65+
_________
_________
_________
_________
_________
________
Unknown
_________
_________
_________
_________
_________
________
_________
_________
_________
_________
_________
________
Total:
Age
0-12
Any Services
Number
Percent
Inpatient
Number
Percent
Intensive
Outpatient/Partial
Hospitalization
Number
Percent
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
______
______
______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Sex
Total:
13-17
Total:
18-24
Total:
25-34
Total:
Outpatient/ED
Number
Percent
HEDIS 2010, Volume 2
Table IAD-1/2/3: Identification of Alcohol and Other Drug Services (continued)
Age
35-64
Any Services
Number
Percent
Inpatient
Number
Percent
Intensive
Outpatient/Partial
Hospitalization
Number
Percent
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
______
______
______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Sex
Total:
65+
Total:
Unkno
wn
Total
Total:
Total:
Outpatient/ED
Number
Percent
HEDIS 2010, Volume 2
Outpatient Drug Utilization (ORX)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age, during
measurement year. The following data are reported.
Total cost of prescriptions
Average cost of prescriptions PMPM
Total number of prescriptions
Average number of prescriptions PMPY
Calculations
Product lines
Report the following tables for each applicable product line.
Table ORX-1a
Total Medicaid
Table ORX-1b
Medicaid/Medicare Dual-Eligibles
Table ORX-1c
Medicaid—Disabled
Table ORX-1d
Medicaid—Other Low Income
Table ORX-2
Commercial—by Product or Combined HMO/POS
Table ORX-3
Medicare
Age
Age as of the date the prescription is dispensed.
Benefit
Pharmacy.
Member
months
Report all member months for the measurement year for members with the benefit.
Refer to Specific Instructions for Use of Services Tables.
Prescription
One 30-day (or less) supply of pharmaceuticals.* Supplies (e.g., syringes) do not count
toward this measure.
* To calculate dispensing events for prescriptions longer than 30 days, divide the days
supply by 30 and round up to convert. For example, a 100-day prescription is equal to
4 dispensing events (100/30 = 3.33, rounded up to 4).
Formulas
Total cost of prescriptions = Discounted ingredient cost + dispensing or professional
fees + administrative fees – formulary or other rebates.
The plan may be responsible for part of the total prescription cost and the member may
be responsible for the remainder of the total cost. The total cost of prescriptions may be
alternatively calculated as:
Total cost of prescriptions = plan cost + member cost.
HEDIS 2010, Volume 2
Average total cost of prescriptions per member per month = [Discounted ingredient
costs (before member copayments or deductibles) + dispensing or professional fees +
administrative fees – formulary or other rebates]/member months for members with a
pharmacy benefit.
Alternatively, average total cost of prescriptions = [plan costs + member costs]/ member
months for members with a pharmacy benefit. For example, the average wholesale price
for prescription ―X‖ is $50. The plan negotiates a 20 percent discount with the pharmacy.
There is a $5 dispensing fee and member copay is $4. Assuming no administrative
fees or other rebates or formularies, the discounted ingredient cost is $40 ($50 average
wholesale price less the 20 percent discount). The total cost of prescriptions is $45 ($40
discounted ingredient cost + $5 dispensing fee). While the cost to the member is $4 and
the plan cost is $41 (for a total of $45), the breakdown of total prescription cost between
the plan and the member is not reported.
Average total number of prescriptions per member per year = [Total number of
prescriptions/member months for members with a pharmacy benefit] 12 months.
Note
Results of this measure might be affected by differences in pharmacy benefits across health plans.
A health plan that dispenses rebates on a lump-sum basis should average the rebates over the total number
of prescriptions.
Table ORX-1/2/3: Outpatient Drug Utilization
Age
Member Months
0-9
______________
10-17
______________
18-34
______________
35-49
______________
50-64
______________
65-74
______________
75-84
______________
85+
______________
Unknown
______________
Total:
______________
HEDIS 2010, Volume 2
Table ORX-1/2/3: Outpatient Drug Utilization (continued)
Total Cost of
Prescriptions
Average Cost of
Prescriptions PMPM
Total Number of
Prescriptions
Average Number of
Prescriptions PMPY
0-9
______________
______________
______________
______________
10-17
______________
______________
______________
______________
18-34
______________
______________
______________
______________
35-49
______________
______________
______________
______________
65-74
______________
______________
______________
______________
75-84
______________
______________
______________
______________
85+
______________
______________
______________
______________
Unknown
______________
Total:
______________
Age
50-64
______________
______________
______________
______________
HEDIS 2010, Volume 2
Antibiotic Utilization (ABX)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
This measure summarizes the following data on outpatient utilization of antibiotic prescriptions during the
measurement year, stratified by age and gender.
Total number of antibiotic prescriptions
Average number of antibiotic prescriptions per member per year (PMPY)
Total days supplied for all antibiotic prescriptions
Average days supplied per antibiotic prescription
Total number of prescriptions for antibiotics of concern
Average number of prescriptions PMPY for antibiotics of concern
Percentage of antibiotics of concern for all antibiotic prescriptions
Average number of antibiotics PMPY reported by drug class:
For selected ―antibiotics of concern‖
For all other antibiotics
Note: NCQA will provide a list of NDC codes for antibiotic medications on its Web site (www.ncqa.org) by
November 16, 2009.
Measure Attributes
Product lines
Report the following tables for each applicable product line.
Table ABX-1a
Total Medicaid
Table ABX-1b
Medicaid/Medicare Dual-Eligibles
Table ABX-1c
Medicaid—Disabled
Table ABX-1d
Medicaid—Other Low Income
Table ABX-2
Commercial—by Product or Combined HMO/POS
Table ABX-3
Medicare
Report the information in Tables ABX-1/2/3 (a–c) by age and sex.
Age
Age as of the date the prescription is dispensed.
Benefit
Pharmacy.
Member months
Report all member months for the measurement year for members with the benefit.
IDSS automatically produces member years data for all product lines: Medicaid,
commercial and Medicare. Refer to Specific Instructions for Use of Services Tables.
Antibiotic
prescription
A dispensed antibiotic for any duration.
HEDIS 2010, Volume 2
Calculations
Total number
of antibiotic
prescriptions
Total number of all antibiotic prescriptions for the measurement year of any
duration of the medication.
Average number
of antibiotic
prescriptions PMPY
Annual total number of antibiotic prescriptions PMPY = [Total number of antibiotic
prescriptions in the year/member months for members with a pharmacy benefit]
12 months.
Total days supplied
for all antibiotic
prescriptions
Count the number of days supplied for all antibiotic prescriptions during the
measurement year. Organizations should identify the number of days supplied for
each antibiotic prescription and sum the days for all antibiotic prescriptions during
the measurement year.
Average number
of days supplied
per antibiotic
prescription
Average number of days supplied per prescription = [Total days supplied for
all antibiotics prescription in the year/Total number of antibiotic prescriptions in
the year].
Table ABX-A: Antibiotic Medications
Description
Antibiotics of concern
All other antibiotics
Prescription
amoxicillin-clavulanate
azithromycin
aztreonam
clarithromycin
cefaclor
cefdinir
cefditoren
cefepime
cefixime
cefotaxime
cefotetan
cefoxitin
amikacin
amoxicillin
ampicillin
ampicillin-sulbactam
carbenicillin
cefadroxil
cefazolin
cephalexin
cephradine
daptomycin
doxycycline
erythromycin
erythromycin estolate
erythromycin ethylsuccinate
erythromycin lactobionate
erythromycin stearate
cefpodoxime
cefprozil
ceftazidime
ceftibuten
ceftizoxime
ceftriaxone
cefuroxime
clindamycin
chloramphenicol
ciprofloxacin
dalfopristin-quinupristin
gatifloxacin
erythromycin-sulfisoxazole
fosfomycin
gentamicin
kanamycin
lincomycin
metronidazole
minocycline
nafcillin
nitrofurantoin
nitrofurantoin macrocrystals
dicloxacillin
oxacillin
penicillin G benzathine
penicillin G potassium
penicillin G procaine
penicillin G sodium
gemifloxacin
levofloxacin
lomefloxacin
moxifloxacin
loracarbef
linezolid
norfloxacin
ofloxacin
sparfloxacin
telithromycin
vancomycin
penicillin V potassium
piperacillin
piperacillin-tazobactam
rifampin
sulfadiazine
sulfamethoxazole-trimethoprim
sulfasalazine
sulfisoxazole
tetracycline
ticarcillin
ticarcillin-clavulanate
streptomycin
tobramycin
trimethoprim
HEDIS 2010, Volume 2
Calculations for Antibiotics of Concern
Total number of
prescriptions for
antibiotics of concern
Total number of all prescriptions for antibiotics of concern during the
measurement year. Table ABX-B contains all antibiotics of concern.
Average number of
prescriptions PMPY for
antibiotics of concern
Annual total number of prescriptions for antibiotics of concern per member per
year = [Annual number of prescriptions for antibiotics of concern/member
months for members with a pharmacy benefit] 12 months.
Percentage of
antibiotics of concern
of all antibiotic
prescriptions
Percentage of prescriptions for antibiotics of concern of all antibiotic
prescriptions = [Total number of prescriptions for antibiotics of concern in the
year/Total number of antibiotic prescriptions in the year].
Table ABX-B: Antibiotics of Concern by NCQA Drug Class
Description
Prescription
Quinolone
ciprofloxacin
gatifloxacin
gemifloxacin
levofloxacin
lomefloxacin
moxifloxacin
norfloxacin
ofloxacin
sparfloxacin
Azithromycin and clarithromycin
azithromycin
clarithromycin
Cephalosporin (second, third,
fourth generation)
cefaclor
cefdinir
cefditoren
cefepime
cefixime
cefotaxime
cefotetan
cefoxitin
cefpodoxime
cefprozil
ceftazidime
ceftibuten
ceftizoxime
ceftriaxone
cefuroxime
loracarbef
Amoxicillin/clavulanate
amoxicillin-clavulanate
Ketolide
telithromycin
Clindamycin
clindamycin
Miscellaneous antibiotics of
concern
aztreonam
chloramphenicol
dalfopristin-quinupristin
linezolid
vancomycin
Calculations for Reporting by Drug Class
Antibiotic utilization
by drug class
For each product line, report the utilization of antibiotic prescriptions by drug class
in Tables ABX-1/2/3(b) and (c) for the following.
Antibiotics of concern
All other antibiotics
Antibiotics of
concern
Report the utilization of antibiotics of concern by the following antibiotic drug
classes in Table ABX-1/2/3(b).
Amoxicillin/clavulanate
Azithromycin and clarithromycin
Cephalosporin (includes second-, third- and fourth-generation cephalosporins)
Clindamycin
HEDIS 2010, Volume 2
Ketolide
Quinolone
Miscellaneous antibiotics of concern
Refer to Table ABX-B for a list of antibiotics of concern and therapeutic classes.
All other antibiotics
Report the utilization of all other antibiotics by the following antibiotic drug classes
in Table ABX-1/2/3(c).
Absorbable sulfonamide
Aminoglycoside
Cephalosporin (includes first generation only)
Lincosamide (other than clindamycin)
Macrolide (other than azithromycin and clarithromycin)
Penicillin (other than amoxicillin/clavulanate)
Tetracycline
Miscellaneous antibiotics
Refer to Table ABX-C for a list of all other antibiotics of concern and therapeutic
classes.
Table ABX-C: All Other Antibiotics by NCQA Drug Class
Description
Prescription
Absorbable sulfonamide
sulfadiazine
sulfamethoxazole-trimethoprim
sulfasalazine
sulfisoxazole
Aminoglycoside
amikacin
gentamicin
kanamycin
streptomycin
Cephalosporin (first generation)
cefadroxil
cefazolin
cephalexin
cephradine
Lincosamide (other than clindamycin)
lincomycin
Macrolide (other than azithromycin and
clarithromycin)
erythromycin
erythromycin estolate
erythromycin ethylsuccinate
erythromycin lactobionate
erythromycin stearate
erythromycin-sulfisoxazole
Penicillin (other than amoxicillin/
clavulanate)
ampicillin
ampicillin-sulbactam
amoxicillin
carbenicillin
dicloxacillin
nafcillin
oxacillin
penicillin G benzathine
penicillin G potassium
penicillin G procaine
penicillin G sodium
penicillin V potassium
piperacillin
piperacillin-tazobactam
ticarcillin
ticarcillin-clavulanate
Tetracyclines
doxycycline
minocycline
Miscellaneous antibiotics
daptomycin
fosfomycin
metronidazole
nitrofurantoin
nitrofurantoin macrocrystals
rifampin
trimethoprim
tobramycin
tetracycline
HEDIS 2010, Volume 2
Table ABX-1/2/3: Plan Member Months
Age
Male
Member Months
Female
Total
0-9
_________
_________
_________
10-17
_________
_________
_________
18-34
_________
_________
_________
35-49
_________
_________
_________
50-64
_________
_________
_________
65-74
_________
_________
_________
85+
_________
_________
_________
Unknown
_________
_________
_________
_________
_________
_________
75-84
Total:
Table ABX-1/2/3(a): Antibiotic Utilization
Age
0-9
Total Antibiotic
Scrips
Average Scrips
for Antibiotics
PMPY
Total Days
Supplied for All
Antibiotic Scrips
Average Days
Supplied per Antibiotic Scrip
Total Scrips for
Antibiotics of
Concern
Average Scrips
for Antibiotics of
Concern PMPY
% of Antibiotics of
Concern of All
Antibiotic Scrips
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Sex
Total:
10-17
Total:
18-34
Total:
HEDIS 2010, Volume 2
Table ABX-1/2/3(a): Antibiotic Utilization (continued)
Age
35-49
Total Antibiotic
Scrips
Average Scrips
for Antibiotics
PMPY
Total Days
Supplied for All
Antibiotic Scrips
Average Days
Supplied per Antibiotic Scrip
Total Scrips for
Antibiotics of
Concern
Average Scrips
for Antibiotics of
Concern PMPY
% of Antibiotics of
Concern of All
Antibiotic Scrips
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Male
__________
___________
___________
___________
___________
___________
_________%
Female
__________
___________
___________
___________
___________
___________
_________%
__________
___________
___________
___________
___________
___________
_________%
Sex
Total:
50-64
Total:
65-74
Total:
75-84
Total:
85+
Total:
Unknown
Total:
Total
Total:
HEDIS 2010, Volume 2
Table ABX-1/2/3(b): Antibiotics of Concern Utilization by Drug Class
Age
0-9
10-17
18-34
35-49
50-64
65-74
75-84
Total
Azithromycin &
Clarithromycin
Scrips
Avg
Scrips
for
Azithromycin &
Clarithromycin
PMPY
Total
Amoxicillin/
Clavulanate
Scrips
Avg
Scrips
PMPY
for
Amoxicillin/
Clavulanate
PMPY
Total
Quinolone
Scrips
Avg
Scrips
for
Quinolone
PMPY
Total
Cephalosporin
Scrips
Avg
Scrips
for
Cephalosporin
PMPY
Male
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
Total:
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
Total:
_______
_______
_______
_______
Male
_______
_______
_______
Female
_______
_______
Total:
_______
_______
Male
_______
Female
Total:
Total
Misc
Antibiotics
of
Concern
Scrips
Avg
Scrips
for Misc
Antibiotics
of
Concern
PMPY
Total
Ketolide
Scrips
Avg
Scrips
for
Ketolide
PMPY
Total
Clindamycin
Scrips
Avg
Scrips
for
Clindamycin
PMPY
_______
_______
______
______
______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Total:
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Total:
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Male
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Total:
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
Sex
HEDIS 2010, Volume 2
Table ABX-1/2/3(b): Antibiotics of Concern Utilization by Drug Class (continued)
Age
85+
Unknown
Total:
Total
Azithromycin &
Clarithromycin
Scrips
Avg
Scrips
for
Azithromycin &
Clarithromycin
PMPY
Total
Amoxicillin/
Clavulanate
Scrips
Avg
Scrips
PMPY
for
Amoxicillin/
Clavulanate
PMPY
Total
Quinolone
Scrips
Avg
Scrips
for
Quinolone
PMPY
Total
Cephalosporin
Scrips
Avg
Scrips
for
Cephalosporin
PMPY
Male
_______
_______
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
_______
_______
Total:
_______
_______
_______
_______
_______
_______
Male
_______
_______
_______
_______
_______
Female
_______
_______
_______
_______
Total:
_______
_______
_______
_______
Male
_______
_______
_______
Female
_______
_______
_______
_______
Sex
Total:
Total
Misc
Antibiotics
of
Concern
Scrips
Avg
Scrips
for Misc
Antibiotics
of
Concern
PMPY
Total
Ketolide
Scrips
Avg
Scrips
for
Ketolide
PMPY
Total
Clindamycin
Scrips
Avg
Scrips
for
Clindamycin
PMPY
_______
_______
______
______
______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
HEDIS 2010, Volume 2
Table ABX-1/2/3(c): All Other Antibiotic Utilization by Drug Class
Age
Total
Aminoglycoside
Scrips
Avg
Scrips
for
Aminoglycoside
PMPY
Total
1st Gen
Cephalosporins
Scrips
Avg
Scrips
for 1st
Gen
Cephalosporins
PMPY
Total
Lincosamide
Scrips
Avg
Scrips
for
Lincosamide
PMPY
Total
Macrolides
(not
azith.,
clar.)
Scrips
Avg
Scrips
for
Macrolides
(not
azith. ,
clar.)
PMPY
______
_____
______
______
_____
______
_____
______
______
______
_____
______
______
_____
______
_____
Tot.
______
______
_____
______
______
_____
______
M
______
______
_____
______
______
_____
F
______
______
_____
______
______
Tot.
M
______
______
_____
______
F
______
______
_____
______
______
_____
Tot.
______
______
M
______
F
Sex
Total
Absorb
-able
sulfona
-mide
Scrips
Avg
Scrips
for
Absorb
-able
sulfona
-mide
PMPY
M
______
F
Total
Tetracycline
Scrips
Avg
Scrips
for
Tetracycline
PMPY
Total
Misc.
Antibiotics
Scrips
Avg
Scrips
for
Misc.
Antibiotics
PMPY
______
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
______
_____
______
______
______
______
_____
______
______
_____
______
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
______
_____
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
M
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
F
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
Tot.
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
M
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
F
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
Tot.
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
Total
Penicillin
Scrips
Avg
Scrips
for
Penicillin
PMPY
______
_____
______
______
_____
______
______
_____
_____
______
______
_____
______
______
______
______
_____
______
______
_____
______
______
Tot.
______
M
______
F
Tot.
0-9
10-17
18-34
35-49
50-64
65-74
75-84
HEDIS 2010, Volume 2
Table ABX-1/2/3(c): All Other Antibiotic Utilization by Drug Class (continued)
Age
85+
Un.
Total
Total
Aminoglycoside
Scrips
Avg
Scrips
for
Aminoglycoside
PMPY
Total
1st Gen
Cephalosporins
Scrips
Avg
Scrips
for 1st
Gen
Cephalosporins
PMPY
______
_____
______
______
______
______
_____
______
Tot.
______
______
_____
M
______
______
Sex
Total
Absorb
-able
sulfona
-mide
Scrips
Avg
Scrips
for
Absorb
-able
sulfona
-mide
PMPY
M
______
F
Total
Lincosamide
Scrips
Avg
Scrips
for
Lincosamide
PMPY
Total
Macrolides
(not
azith.,
clar.)
Scrips
Avg
Scrips
for
Macrolides
(not
azith. ,
clar.)
PMPY
_____
______
_____
______
______
_____
______
_____
______
______
_____
______
_____
______
______
_____
Total
Tetracycline
Scrips
Avg
Scrips
for
Tetracycline
PMPY
Total
Misc.
Antibiotics
Scrips
Avg
Scrips
for
Misc.
Antibiotics
PMPY
______
______
_____
______
______
_____
______
______
_____
______
______
______
_____
______
______
_____
______
______
______
______
_____
______
______
_____
______
______
Total
Penicillin
Scrips
Avg
Scrips
for
Penicillin
PMPY
______
_____
______
______
_____
______
______
_____
F
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
Tot:
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
M
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
F
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
Tot.
______
______
_____
______
______
_____
______
_____
______
______
_____
______
______
_____
______
______
HEDIS 2010, Volume 2
Board Certification (BCR)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that physicians listed in an organization’s directory should be included.
Description
The percentage of the following physicians whose board certification is active as of December 31 of the
measurement year.
Family medicine physicians
Pediatricians
Geriatricians
Internal medicine physicians
OB/GYN physicians
Other physician specialists
Board certification refers to the various specialty certification programs of the American Board of Medical
Specialties and the American Osteopathic Association. The organization should report separately for each
product as of December 31 of the measurement year.
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Physicians
This measure applies to independent physicians or group of physicians who provide
care for members.
Organizations
must include:
Physicians who have an independent relationship with the organization. An
independent relationship exists when the organization selects and directs its
members to see a specific physician or group of physicians. An independent
relationship is not synonymous with an ―independent contract.‖ Physicians may
contract directly with the organization or indirectly (e.g., physicians contract with
an IPA).
Physicians who are listed in the organization’s directory.
Physicians who see members outside of the inpatient hospital setting or outside of
free-standing facilities.
Physicians who are hospital based and who see members as a result of their
independent relationship with the organization; for example:
Anesthesiologists with pain management practices
Hospital-based cardiologists
Hospital-based faculty (provided that they meet the criteria listed above)
Organizations
must exclude:
Physicians who practice exclusively within the inpatient hospital setting and who
provide care for members only as a result of members being directed to the
hospital; for example:
Pathologists
ED physicians
Radiologists
Chiropractors
Anesthesiologists
Podiatrists
Neonatologists
HEDIS 2010, Volume 2
Physicians who practice exclusively within free-standing facilities and who provide
care for members only as a result of members being directed to the facility; for
example:
Mammography centers
Urgent care centers
Surgicenters
Dentists who do not provide care under the organization’s medical benefits; for
example:
Endodontists
Oral surgeons
Periodontists
Dentists who provide primary dental care under a dental plan or rider.
Table BCR-A indicates how to identify physicians.
Categories
Table BCR-A: Identifying Physicians
Product Line
Family
Medicine
Internal
Medicine
Commercial
Medicaid
Medicare
Pediatricians
OB/GYN
Geriatricians
Other
Physician
Specialists
Definitions
Family medicine
physician
A physician who provides preventive and diagnostic health care services for
individuals and families. Report general practitioners in the Family Medicine
category.
Internal
medicine
physician
A physician who provides long-term and comprehensive care and manages common
and complex illness of adolescents, adults and the elderly.
Pediatrician
A physician who provides preventive and diagnostic health care services for infants,
children and adolescents.
OB/GYN
physician
A physician who provides medical and surgical care relating to the female
reproductive system and associated disorders.
Geriatrician
A family medicine or internal medicine physician who has special knowledge of the
aging process and special skills in the diagnostic, therapeutic, preventive and
rehabilitative aspects of illness in the elderly.
Other physician
specialist
Any other physician specialist or physician subspecialist not specified above.
HEDIS 2010, Volume 2
Calculation of Board Certification
Number of
physicians in
each practice
area
Refer to Table BCR-1/2/3. For each product line, identify the number of physicians (with
active or inactive board certification) in each practice area, by type and number, with
whom the organization contracted as of December 31 of the measurement year.
Physicians are assumed to practice in the clinical area or areas in which they are listed
in the organization’s internal directory or classification system. Physicians listed under
more than one category should be counted as many times as they are listed and should
be included in each area of practice. For example, a family medicine physician who also
practices as a geriatrician should be reported in both the Family Medicine category and
the Geriatrician category.
Physicians do not have to be listed in the organization’s external provider directory to be
included in the measure. Physicians associated with an entity (e.g., vendor) should only
be counted if located in areas where the organization is licensed to operate.
Board
certification
number
Report the number of physicians in each practice area with active board certification.
For example, to be counted as a board-certified geriatrician, a physician must have a
specialty certification in geriatric medicine.
A physician with recent board certification who has not completed a residency/fellowship may be counted as board certified.
Confirmation by the appropriate certifying body that a physician is eligible for, and has
applied to, a board-certification program, may not be counted as board certification.
Board
certification
percentage
For each type of physician, calculate the percentage whose board certification is active
by dividing the board certification number by the number of physicians in each practice
area.
First, determine the number of areas of specialization and board certification status for
each physician; then determine how to count them in the denominator (i.e., number of
physicians in each practice area) and numerator (i.e., number of active board-certified
physicians) of the calculation.
A physician with only one specialty who is not board certified in that specialty counts as
1 in the denominator and 0 in the numerator.
A physician with only one specialty whose board certification is active in that specialty
counts as 1 in the denominator and 1 in the numerator.
A physician with more than one specialty counts as 1 in the denominator for each
specialty. Count in the numerator the number of specialty areas in which the physician
has active board certification.
Example
A physician listed under both hematology and medical oncology counts as 2 in the
denominator for Other Physician Specialists.
A physician whose board certification is active in both hematology and medical
oncology counts as 2 in the numerator.
A physician whose board certification is active in only one of these two areas counts
as 1 in the numerator.
A physician whose board certification is not active in either area counts as 0 in the
numerator.
HEDIS 2010, Volume 2
Note
The physician definitions for this measure are based on the American Board of Medical Specialties (ABMS)
definitions for physician specialties.
The numbers in the column Number of Physicians in Each Practice Area may not be the same as the
organization’s actual number of physicians because some physicians may practice in more than one area
and will be counted in the denominators of several percentages.
Table BCR-1/2/3: Board Certification
Type of Physician
Number of Physicians in
Each Practice Area
Active Board Certification
Number
Percentage
Family medicine
Internal medicine
Pediatricians
OB/GYN
Geriatricians
Other physician specialists
HEDIS 2010, Volume 2
Enrollment by Product Line (ENP)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The total number of members enrolled in the product line, stratified by age and sex.
Calculations
Product lines
Member
months
Report the following tables for each applicable product line, stratified by age and sex.
Table ENP-1a
Total Medicaid
Table ENP-1b
Medicaid/Medicare Dual-Eligibles
Table ENP-1c
Medicaid—Disabled
Table ENP-1d
Medicaid—Other Low Income
Table ENP-2
Commercial—by Product or Combined HMO/POS
Table ENP-3
Medicare
For each product line, report all member months for the measurement year. IDSS
automatically produces member years data for the commercial and Medicare product
lines. Refer to Specific Instructions for Use of Services Tables in Guidelines for Use of
Services Measures for more information.
Medicaid Beneficiary Category Assignment
The organization assigns Medicaid members to beneficiary categories based on a state-provided list of all
payment-rate categories used by that state and the organization in their contract. The state should use the
algorithm provided below (described in Categories A–D) to assign each payment-rate category it uses to one
of the three beneficiary categories and provide this categorization of rate categories to the organization. The
organization should then report Medicaid members using the state’s categories. The state should classify
beneficiaries according to the hierarchy below, beginning with Category A.
This algorithm addresses variables most likely to influence utilization patterns.
The presence of a Medicare benefit
The presence of a disability
Whether or not there is a restricted benefits package
This last group is not reported separately because of its anticipated small numbers, but it is included in
the total count of Medicaid members
HEDIS 2010, Volume 2
Category A
Total Medicaid—
Table ENP-1a
Include all Medicaid members enrolled in the organization who receive Medicaid
benefits, including those who receive a restricted benefits package smaller in
scope than the other Medicaid members enrolled in the same organization.
A restricted benefits package meets one of the following criteria.
Pregnant women whose Medicaid eligibility is based on poverty-related
coverage and whose Medicaid benefits are restricted to services related to
pregnancy and other conditions that may complicate pregnancy, or
Other individuals whose benefits are limited (e.g., emergency services)
The organization should include individuals in either of these two groups in this
category. Total Medicaid also includes the sum of Categories B–D.
Go to Category B if a member does not meet the criteria for Category A.
Category B
Medicaid/Medicare
Eligible—
Table ENP-1b
Include all Medicaid members (including children) entitled both to the state’s full
Medicaid benefit for which the organization has contracted and to Medicare Part A
or B benefits.
Qualified Medicare Beneficiaries (QMB), other specified low-income Medicare
beneficiaries, Qualified Disabled and Working Individuals (QDWI) and Qualified
COBRA Continuation Beneficiaries whose Medicaid benefit is limited to the
payment of a premium for Medicare or commercial coverage are not included in
this category because these individuals do not receive the Medicaid benefit
package.
Go to Category C if a member does not meet the criteria for Category B.
Category C
Disabled—
Table ENP-1c
Include all Medicaid members who do not meet the criteria for Category B and who
receive Medicaid benefits wholly or in part because of physical or mental disability.
This category includes supplemental security income (SSI) beneficiaries, SSIrelated beneficiaries and other disabled, medically needy beneficiaries.
Go to Category D if a Medicaid beneficiary does not meet the criteria for Category
B and does not receive Medicaid based on a disability (Category C).
Category D
Other Low
Income—
Table ENP-1d
Include all non-disabled, non-Medicare, low-income Medicaid beneficiaries who do
not meet the criteria for Category B or Category C.
Note
NCQA recognizes that most organizations do not serve Medicaid beneficiaries in all categories. Not many
serve the few individuals with a restricted benefits package (see Category A).
HEDIS 2010, Volume 2
Table Instructions
Use Table ENP-1/2/3 to report the organization’s enrollment by product line for the most recent calendar year,
based on member months.
Medicaid
(Tables 1a-1d)
Assign Medicaid beneficiaries to Categories A–D based on the definitions provided
above.
Report by eligibility category the number of member months by age and sex, including
subtotals.
Calculate the subtotal percentages within each eligibility category by dividing the total
subtotal member months into total member months by sex (e.g., [X member months of
enrolled Medicaid disabled males, 0–19/Y member months for all Medicaid disabled
males, 0–90+ and age unknown] x 100 = Z percent of member months for Medicaid
disabled males, 0–19 years of all male Medicaid disabled member months).
Commercial
(Table 2)
Report by commercial product line the number of member months by age and sex,
including subtotals.
Calculate the subtotal percentages within the commercial product line by dividing the
total subtotal member months into total member months by sex (e.g., [X member
months of enrolled commercial product males, 0–19/Y member months for all
commercial product males, 0–90+ and age unknown] x 100 = Z percent of member
months for commercial product males, 0–19 years of age of all male commercial
product member months).
Medicare
(Table 3)
Report by Medicare product line the number of member months by age and sex,
including subtotals.
Calculate the subtotal percentages within the Medicare product line by dividing the total
subtotal member months into total member months by sex (e.g., [X member months of
enrolled Medicare males 0-19/Y member months for all Medicare males, 0–90+ and age
unknown] x 100 = Z percent of member months for Medicare males, 0–19 years of age
of all male Medicare member months).
HEDIS 2010, Volume 2
Table ENP-1/2/3: Member Months of Enrollment by Product Line
Age
Male
Female
Total
<1
_______________
_______________
_______________
1-4
_______________
_______________
_______________
5-9
_______________
_______________
_______________
10-14
_______________
_______________
_______________
15-17
_______________
_______________
_______________
18-19
_______________
_______________
_______________
0-19 Subtotal:
_______________
_______________
_______________
_______________%
_______________%
_______________%
20-24
_______________
_______________
_______________
25-29
_______________
_______________
_______________
30-34
_______________
_______________
_______________
35-39
_______________
_______________
_______________
40-44
_______________
_______________
_______________
20-44 Subtotal:
_______________
_______________
_______________
_______________%
_______________%
_______________%
45-49
_______________
_______________
_______________
50-54
_______________
_______________
_______________
55-59
_______________
_______________
_______________
60-64
_______________
_______________
_______________
45-64 Subtotal:
_______________
_______________
_______________
_______________%
_______________%
_______________%
65-69
_______________
_______________
_______________
70-74
_______________
_______________
_______________
75-79
_______________
_______________
_______________
80-84
_______________
_______________
_______________
85-89
_______________
_______________
_______________
>90
_______________
_______________
_______________
_______________
_______________
_______________
>65 Subtotal (%):
_______________%
_______________%
_______________%
Age unknown
_______________
_______________
_______________
_______________
_______________
_______________
0-19 Subtotal (%):
20-44 Subtotal (%):
45-64 Subtotal (%):
>65 Subtotal:
Total:
HEDIS 2010, Volume 2
Enrollment by State (EBS)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
The number of members enrolled as of December 31 of the measurement year, by state.
Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Anchor Date
December 31 of the measurement year.
Calculation
Calculate enrollment by state using the address on record for members on December 31 of the measurement
year, to be determined according to the organization’s administrative processes. Report by categories (states
and territories) listed in Table EBS-1/2/3. If the member’s address is unknown or does not match, report as
―Other.‖ If a child’s address is not captured, the organization may use the address of the policyholder, parent
or caretaker.
Report on total unduplicated membership as of December 31 of the measurement year. If the organization
assigns a new member number to members who disenroll and reenroll during the measurement year, it must
develop a system to avoid double-counting members.
Table EBS-1/2/3: Member Enrollment by State
State
Number
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
State
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Number
State
Number
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Fed. Sts. of Micronesia
Guam
Cmnwlth. of N. Marianas
Puerto Rico
Virgin Islands
Other
Total:
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
HEDIS 2010, Volume 2
Race/Ethnicity Diversity of Membership (RDM)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
An unduplicated count and percentage of members enrolled any time during the measurement year, by race
and ethnicity.
Product lines
Medicaid, Medicare (report each product line separately).
Calculations
Table
instructions
Report the number and percentage of members by race/ethnicity stratified by gender
for the product population. If a member’s race or ethnicity is unknown or unavailable
from the state agency or CMS, report as ―Unknown.‖
Report on total unduplicated membership during the measurement year. If the
organization assigns a new member number to members who disenroll and reenroll
during the measurement year, it must develop a system to prevent double counting
members.
Data source
Obtain race and ethnicity data from enrollment information furnished by state
Medicaid agencies or by CMS, or supplemented through the organization’s own direct
data collection from members (e.g., surveys, health risk assessments, disease
management registries) or through other available indirect methods (e.g., surname
analysis, geocoding). When using CMS as the data source, refer to Table RDM-A for
a crosswalk of reporting categories for the RDM measure.
Race Reporting Category Definitions
White
People whose origins are in any of the original peoples of Europe, the Middle East or
North Africa; including people who indicated their race or races as ―White‖ or wrote in
entries such as Irish, German, Italian, Lebanese, Near Easterner, Arab or Polish.
Black or African
American
People whose origins are in any of the Black racial groups of Africa; including people
who indicated their race or races as ―Black, African Am., or Negro,‖ or wrote in entries
such as African American, Afro-American, Nigerian or Haitian.
American Indian
and Alaska
Native
People whose origins are in any of the original peoples of North and South America
(including Central America), and who maintain tribal affiliation or community
attachment; including people who indicated their race or races by marking this
category or writing in their principal or enrolled tribe, such as Rosebud, Sioux,
Chippewa or Navajo.
Asian
People who are Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese and
―Other Asian,‖ which may include people who are Burmese, Hmong, Pakistani, Thai
or from two or more Asian subgroups.
HEDIS 2010, Volume 2
Native Hawaiian
and Other Pacific
Islander
People whose origins are in any of the original peoples of Hawaii, Guam, Samoa
or other Pacific Islands; including Carolinian, Fijian, Kosraean, Melanesian,
Micronesian, Northern Mariana Islander, Palauan, Papua New Guinean, Ponapean
(Pohnpelan), Polynesian, Solomon Islander, Tahitian, Tarawa Islander, Tokelauan,
Tongan, Trukese (Chuukese) and Yapese.
Some Other
Race
People whose race information has been collected but does not fit into any of the
other seven race categories. This category includes people who may be Mulatto,
Creole and Mestizo or another race not specified in the Census race categories.
Two or More
Races
People with any combination of races, including ―Some Other Race.‖
Ethnicity
reporting
category:
Hispanic or
Latino
People of Spanish, Mexican, Puerto Rican or Cuban origins.
Note: NCQA encourages collecting and reporting race and Hispanic ethnicity based
on categories adapted from the official U.S. census forms established by the U.S.
Department of Commerce, Bureau of the Census and defined by the Office of
Management and Budget (OMB). Because CMS and state agencies may have
varying classification schemes for race and ethnicity, refer to Table RDM-A for
HEDIS reporting.
Table RDM-A: CMS/HEDIS Crosswalk for Reporting Categories
CMS Category
HEDIS Race
HEDIS Ethnicity
0 = Unknown
Unknown
Unknown
1 = White not Hispanic
White
Not Hispanic
2 = Black not Hispanic
Black
Not Hispanic
3 = Other
Some Other Race
Unknown
4 = Asian
Asian
Unknown
5 = Hispanic
Unknown
Hispanic
6 = North American Native
American Indian/AN
Unknown
Table RDM-1/3: Race/Ethnicity Diversity of Membership
Data Source: __________________
Values include NR, CMS, Health plan direct, Surname analysis/geo-coding, Multiple sources, Other
Total unduplicated membership during the measurement year:
Number of members: _________________
The total unduplicated count of members in the organization is the denominator for calculating the percentages. Each cell represents the
proportion of members of a specific race/ethnicity combination of the total unduplicated count of members in the organization.
Percentage of members with known race information (sum all the race categories, except Unknown Race, and divide by the number
of total unduplicated members during the measurement year): _________________
Percentage of members with known ethnicity information (sum all the ethnicity categories, except Unknown Ethnicity, and divide by
the number of total unduplicated members during the measurement year): _________________
HEDIS 2010, Volume 2
Table RDM-1/3: Race/Ethnicity Diversity of Membership (continued)
Hispanic or Latino
Race
White
Sex
Number
Percentage
Number
Percentage
Number
Percentage
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
______
_______
_______
_______
_______
_______
_______
______
______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
______
_______
_______
_______
_______
_______
_______
______
______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
______
_______
_______
_______
_______
_______
_______
______
______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
______
_______
_______
_______
_______
_______
_______
______
______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
_______
_______
_______
_______
_______
_______
_______
______
_______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
_______
_______
_______
_______
_______
_______
_______
______
_______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
_______
_______
_______
_______
_______
_______
_______
______
_______
Male
_______
_______
_______
_______
_______
_______
______
______
Female
_______
_______
_______
_______
_______
_______
______
_______
_______
_______
_______
_______
_______
_______
______
_______
Male
_______
_______
_______
_______
_______
_______
______
_______
Female
_______
_______
_______
_______
_______
_______
______
_______
_______
_______
_______
_______
_______
_______
______
100%
Total:
Asian
Total:
Native Hawaiian
and Other
Pacific Islander
Total:
Some other
race
Total:
Two or more
races
Total:
Unknown
Total:
Total
Total
Percentage
Total:
American-Indian
and Alaska
Native
Unknown Ethnicity
Number
Total:
Black or AfricanAmerican
Not Hispanic or
Latino
Total:
HEDIS 2010, Volume 2
Language Diversity of Membership (LDM)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
An unduplicated count and percentage of Medicaid and Medicare members enrolled at any time during the
measurement year by demand for language interpreter services and spoken language.
Product lines
Medicaid, Medicare (report each product line separately).
Calculations
Table
instructions
Report the number and percentage of members by demand for language interpreter
services and spoken language stratified by gender for each product population. If a
member’s interpreter service needs or spoken language is unknown or unavailable
from the state agency or CMS, report as ―Unknown.‖
Report total unduplicated membership during the measurement year. If the
organization assigns a new member number to members who disenroll and reenroll
during the measurement year, it must develop a system to prevent double-counting
members.
Data source
Obtain interpretation service needs and language spoken from enrollment information
furnished by state Medicaid agencies or supplemented through data that the
organization collected from its members (e.g., surveys, health risk assessments,
disease management registries) or through indirect methods (e.g., surname analysis,
geo-coding).
Need/Want
Interpreter
Identify individuals who need or want interpreter services; enter this information in
Table LDM-1/3. This information should be reported by gender for the organization
population.
Data collection guidance for organizations and agencies. This information can be
gathered through a two-part question to beneficiaries/members:
(Does the Medicaid or Medicare beneficiary) Do you need or want an interpreter to
communicate with a doctor or health care practitioner?
No
Yes
Unknown (if data are unavailable)
Spoken
Language
Indicate the language spoken by the member at home most of the time; enter this
information in Table LDM-1/3. This information should be reported by gender for the
organization population.
Data collection guidance for organizations and agencies. This information may be
gathered through the second part of a two-part question:
What language (does the beneficiary) do you speak most of the time at home?
HEDIS 2010, Volume 2
Note
The U.S. Census asks Does this person speak a language other than English at home?
Table LDM-1/3: Language Diversity of Membership
Data source: __________________
Values include NR, CMS, Health plan direct, Surname analysis/geo-coding, Multiple sources, Other
Total unduplicated membership during the measurement year:
Number of members _________________
The total unduplicated count of members in the organization is the denominator for calculating the percentages. Each cell represents the
proportion of members with identified demand for interpreter services and indicated spoken language of the total unduplicated count of
members in the organization.
Demand for Language Interpretation Services
Need/Want an Interpreter
Yes
Number
Percentage
Male
Sex
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
Total:
Need/Want an Interpreter
No
Total:
Need/Want an Interpreter
Unknown
Total:
Total: (This should sum to 100%)
Total:
Percentage of members with known interpretation needs:
(Sum the Yes/No categories and divide by the number of total unduplicated
members during the measurement year )
English
Total:
Spanish (or Spanish Creole)
Total:
Other Indo-European Languages (e.g., French or French Creole, Italian,
Portuguese or Portuguese Creole, German, Yiddish, Scandinavian
languages, Greek, Russian, Polish, Serbo-Croatian, Armenian, Persian,
Gujarathi, Hindi, Urdu)
Male
____________
____________
Female
____________
____________
____________
____________
Asian and Pacific Island Languages (e.g., Chinese, Japanese, Korean,
Mon-Khmer, Cambodian, Miao, Hmong, Thai, Laotian, Vietnamese,
Tagalog and Other Pacific Island languages)
Male
____________
____________
Female
____________
____________
____________
____________
Total:
Total:
HEDIS 2010, Volume 2
Table LDM-1/3: Language Diversity of Membership (continued)
Spoken Language at Home
Other Languages (e.g., Navajo, Other Native North American languages,
Hungarian, Arabic, Hebrew, African languages)
Sex
Number
Percentage
Male
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
Male
____________
____________
Female
____________
____________
____________
____________
____________
____________
Total:
Unknown
Total:
Total: (this should sum to 100%)
Total:
Percentage of members with known spoken language:
(Sum all the language categories, except unknown and divide by the number of total
unduplicated members during the measurement year)
Note
CMS does not provide language information on its Medicare beneficiaries. Medicare organizations should
obtain language data through alternate sources, including surveys and case management and enrollment
registries.
HEDIS 2010, Volume 2
HEDIS 2010, Volume 2
| File Type | application/pdf |
| Author | Courtney Breece |
| File Modified | 2010-05-12 |
| File Created | 2010-05-12 |