HEDIS Information Collection Request

HEDIS® 2020 Measures and Descriptions for Medicare
The Healthcare Effectiveness Data and Information Set (HEDIS®) is one of the most
widely used sets of health care performance measures in the United States. The term “HEDIS”
originated in the late 1980s as the product of a group of forward-thinking employers and quality
experts, and was entrusted to NCQA in the early 1990s. NCQA has expanded the size and scope
of HEDIS® to include measures for physicians, Accountable Care Organizations and other
organizations. HEDIS® 2020 is published across a number of volumes and includes 96 measures
across 6 domains for commercial plans, Medicare, and Medicaid.
NCQA’s Committee on Performance Measurement (CPM), which includes
representation from purchasers, consumers, health plans, clinicians and policy makers, oversees
the evolution of the measurement set. Multiple Measurement Advisory Panels (MAP) provide
clinical and technical knowledge required to develop the measures. Additional HEDIS® Expert
Panels and the Technical Measurement Advisory Panel (TMAP) provide invaluable assistance
by identifying methodological issues and providing feedback on new and existing measures.
For the current HEDIS® measures CMS requires, NCQA specifies the following data
collection methods:
Administrative
Method

Transaction data or other administrative data are used to identify the eligible
population and numerator. The reported rate is based on all members who
meet the eligible population criteria (after optional exclusions, if applicable)
and who are found through administrative data to have received the service
required for the numerator.

Hybrid Method

Organizations look for numerator compliance in both administrative and
medical record data. The denominator consists of a systematic sample of
members drawn from the measure’s eligible population. Organizations
review administrative data to determine if members in the systematic sample
received the service and review medical record data for members who do not
meet the numerator criteria through administrative data. The reported rate is
based on members in the sample who received the service required for the
numerator.

Requires organizations to collect data through a survey. Specifications for
survey measures are included in HEDIS® Volume 3: Specifications for
Survey Measures and HEDIS® Volume 6: Specifications for the Medicare
Health Outcomes Survey.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (“NCQA”).
Survey Method

CMS HEDIS® 2020-2022 Medicare measures:
Breast Cancer Screening (BCS)
The percentage of women 50–74 years of age who had a mammogram to screen for breast
cancer.
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Colorectal Cancer Screening (COL)
The percentage of members 50–75 years of age who had appropriate screening for colorectal
cancer.
Care for Older Adults (COA)
The percentage of adults 66 years and older who had each of the following during the
measurement year:
• Advance care planning.
• Medication review.
• Functional status assessment.
• Pain assessment.
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
The percentage of members 40 years of age and older with a new diagnosis of COPD or newly
active COPD, who received appropriate spirometry testing to confirm the diagnosis.
Pharmacotherapy Management of COPD Exacerbation (PCE)
The percentage of COPD exacerbations for members 40 years of age and older who had an acute
inpatient discharge or ED visit on or between January 1–November 30 of the measurement year
and who were dispensed appropriate medications. Two rates are reported:
1. Dispensed a systemic corticosteroid (or there was evidence of an active prescription)
within 14 days of the event.
2. Dispensed a bronchodilator (or there was evidence of an active prescription) 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.
Controlling High Blood Pressure (CBP)
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and
whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
The percentage of members 18 years of age and older during the measurement year who were
hospitalized and discharged 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.
Statin Therapy for Patients with Cardiovascular Disease (SPC)
The percentage of males 21–75 years of age and females 40–75 years of age during the
measurement year, who were identified as having clinical atherosclerotic cardiovascular disease
(ASCVD) and met the following criteria. The following rates are reported:

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1. Received Statin Therapy. Members who were dispensed at least one high-intensity or
moderate-intensity statin medication during the measurement year.
2. Statin Adherence 80%. Members who remained on a high-intensity or moderateintensity statin medication for at least 80% of the treatment period.
Comprehensive Diabetes Care (CDC)
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.
• HbA1c poor control (>9.0%).
• HbA1c control (<8.0%).
• Eye exam (retinal) performed.
• Medical attention for nephropathy.
• BP control (<140/90 mm Hg).
Statin Therapy for Patients with Diabetes (SPD)
The percentage of members 40–75 years of age during the measurement year with diabetes who
do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following
criteria. Two rates are reported:
1. Received Statin Therapy. Members who were dispensed at least one statin medication
of any intensity during the measurement year.
2. Statin Adherence 80%. Members who remained on a statin medication of any intensity
for at least 80% of the treatment period.
Osteoporosis Management in Women Who Had a Fracture (OMW)
The percentage of women 67–85 years of age who suffered a fracture and who had either a bone
mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after
the fracture.
Antidepressant Medication Management (AMM)
The percentage of members 18 years of age and older who were treated with antidepressant
medication, had a diagnosis of major depression and who remained on an antidepressant
medication treatment. Two rates are reported.
1. Effective Acute Phase Treatment. The percentage of members who remained on an
antidepressant medication for at least 84 days (12 weeks).
2. Effective Continuation Phase Treatment. The percentage of members who remained on
an antidepressant medication for at least 180 days (6 months).
Follow-Up after Hospitalization for Mental Illness (FUH)
The percentage of discharges for members 6 years of age and older who were hospitalized for
treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up
visit with a mental health practitioner. Two rates are reported:
1. The percentage of discharges for which the member received follow-up within 30 days
after discharge.
2. The percentage of discharges for which the member received follow-up within 7 days
after discharge.
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Follow-Up after Emergency Department Visit for Mental Illness (FUM)
The percentage of emergency department (ED) visits for members 6 years of age and older with
a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for
mental illness. Two rates are reported:
1. The percentage of ED visits for which the member received follow-up within 30 days
of the ED visit (31 total days).
2. The percentage of ED visits for which the member received follow-up within 7 days of
the ED visit (8 total days).
Follow-Up after Emergency Department Visit for Alcohol and Other Drug Abuse or
Dependence (FUA)
The percentage of emergency department (ED) visits for members 13 years of age and older with
a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up
visit for AOD. Two rates are reported:
1. The percentage of ED visits for which the member received follow-up within 30 days
of the ED visit (31 total days).
2. The percentage of ED visits for which the member received follow-up within 7 days of
the ED visit (8 total days).
Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
The percentage of members 18 years of age and older during the measurement year with
schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic
medication for at least 80% of their treatment period.
Medication Reconciliation Post-Discharge (MRP)
The percentage of discharges from January 1–December 1 of the measurement year for members
18 years of age and older for whom medications were reconciled the date of discharge through
30 days after discharge (31 total days).
Transitions of Care (TRC)
The percentage of discharges for members 18 years of age and older who had each of the
following. Four rates are reported:
• Notification of Inpatient Admission. Documentation of receipt of notification of
inpatient admission on the day of admission or the following day.
• Receipt of Discharge Information. Documentation of receipt of discharge information
on the day of discharge or the following day.
• Patient Engagement after Inpatient Discharge. Documentation of patient engagement
(e.g., office visits, visits to the home, tele-health) provided within 30 days after discharge.
• Medication Reconciliation Post-Discharge. Documentation of medication reconciliation
on the date of discharge through 30 days after discharge (31 total days).
Follow-Up after Emergency Department Visit for People with Multiple High-Risk Chronic
Conditions (FMC)
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The percentage of emergency department (ED) visits for members 18 years and older who have
multiple high-risk chronic conditions who had a follow-up service within 7 days of the ED visit.
Non-Recommended PSA-Based Screening in Older Men (PSA)
The percentage of men 70 years and older who were screened unnecessarily for prostate cancer
using prostate-specific antigen (PSA)-based screening.
Note: A lower rate indicates better performance.
Potentially Harmful Drug-Disease Interactions in the Elderly/Older Adults (DDE)

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 potentially harmful 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 anticonvulsants, antipsychotics,
benzodiazepines, non-benzodiazepine hypnotics or antidepressants (SSRIs, tricyclic
antidepressants and SNRIs).
• Dementia and a prescription for antipsychotics, benzodiazepines, non-benzodiazepine
hypnotics, tricyclic antidepressants, or anticholinergic agents.
• Chronic kidney disease and prescription for Cox-2 selective NSAIDs or non-aspirin
NSAIDs.
• Total rate (the sum of the three numerators divided by the sum of the three
denominators).
Note: A lower rate indicates better performance for all rates.
Use of High-Risk Medications in the Elderly/Older Adults (DAE)
The percentage of Medicare members 66 years of age and older who had at least two dispensing
events for the same high-risk medication.
Note: A lower rate represents better performance.
Use of Opioids at High Dosage (HDO)
The proportion of members 18 years and older who received prescription opioids at a high
dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the
measurement year.
Note: A lower rate indicates better performance.

Use of Opioids from Multiple Providers (UOP)
The proportion of members 18 years and older, receiving prescription opioids for ≥15 days
during the measurement year who received opioids from multiple providers. Three rates are
reported.
1. Multiple Prescribers. The proportion of members receiving prescriptions for opioids
from four or more different prescribers during the measurement year.
2. Multiple Pharmacies. The proportion of members receiving prescriptions for opioids
from four or more different pharmacies during the measurement year.
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3. Multiple Prescribers and Multiple Pharmacies. The proportion of members receiving
prescriptions for opioids from four or more different prescribers and four or more
different pharmacies during the measurement year (i.e., the proportion of members who
are numerator compliant for both the Multiple Prescribers and Multiple Pharmacies
rates).
Note: A lower rate indicates better performance for all three rates.
Medicare Health Outcomes Survey (HOS)
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, considering risk adjustment factors.
Organization-specific results are assigned as percentages of members whose health status was
better, the same or worse than expected.
Fall Risk Management (FRM)
The two components of this measure assess different facets of fall risk management.
• Discussing Fall Risk. The percentage of Medicare members 65 years of age and older
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 a recommendation for how
to prevent falls or treat problems with balance or walking from their current practitioner.
Management of Urinary Incontinence in Older Adults (MUI)
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 urine leakage in the past six months and who discussed
their urinary leakage problem with a health care provider.
• Discussing Treatment of Urinary Incontinence. The percentage of Medicare members
65 years of age and older who reported having urine leakage in the past six months and
who discussed treatment options for their current urine leakage problem.
• Impact of Urinary Incontinence. The percentage of Medicare members 65 years of age
and older who reported having urine leakage in the past six months and who reported that
urine leakage made them change their daily activities or interfered with their sleep a lot.
Osteoporosis Testing in Older Women (OTO)
The percentage of Medicare women 65–85 years of age who report ever having received a bone
density test to check for osteoporosis.
Physical Activity in Older Adults (PAO)
The two components of this measure assess different facets of promoting physical activity in
older adults.
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• 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.
Flu Vaccinations for Adults Ages 65 and Older (FVO)
The percentage of Medicare members 65 years of age and older who received a flu vaccination
between July 1 of the measurement year and the date when the Medicare CAHPS survey was
completed.
Medical Assistance with Smoking and Tobacco Use Cessation (MSC)
The three 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 cessation medications 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 and who
discussed or were provided cessation methods or strategies during the measurement year.
Pneumococcal Vaccination Status for Older Adults (PNU)
The percentage of Medicare members 65 years of age and older who have ever received one or
more pneumococcal vaccinations.
Adults’ Access to Preventive/Ambulatory Health Services (AAP)
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.
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
(IET)
The percentage of adolescent and adult members with a new episode of alcohol or other drug
(AOD) abuse or 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, tele-health or medication treatment within 14 days of the
diagnosis.

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• Engagement of AOD Treatment. The percentage of members who initiated treatment
and who were engaged in ongoing AOD treatment within 34 days of the initiation visit.
Frequency of Selected Procedures (FSP)
This measure summarizes the utilization of frequently performed procedures that often show
wide regional variation and have generated concern regarding potentially inappropriate
utilization.
Identification of Alcohol and Other Drug Services (IAD)
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:
• Inpatient.
• Intensive outpatient or partial hospitalization.
• Outpatient or medication treatment.
• ED.
• Tele-health.
• Any service.
Mental Health Utilization (MPT)
This measure summarizes the number and percentage of members receiving the following mental
health services during the measurement year:
• Inpatient.
• Intensive outpatient or partial hospitalization.
• Outpatient.
• ED.
• Tele-health.
• Any service.
Antibiotic Utilization (ABX)
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.
Plan All-Cause Readmissions (PCR)
For members 18 years of age and older, the number of acute inpatient and observation stays
during the measurement year that were followed by an unplanned acute readmission for any
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diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported
in the following categories:
1. Count of Index Hospital Stays (IHS) (denominator).
2. Count of Observed 30-Day Readmissions (numerator).
3. Count of Expected 30-Day Readmissions.
Note: For commercial and Medicaid, report only members 18–64 years of age.
Hospitalization Following Discharge From a Skilled Nursing Facility (HFS)
For members 18 years of age and older, the percentage of skilled nursing facility discharges to
the community that were followed by an unplanned acute hospitalization for any diagnosis
within 30 and 60 days. Data are reported in the following categories:
1. Count of skilled nursing facility discharges (SND) to the community.
2. Count of observed 30-day hospitalizations.
3. Count of expected 30-day hospitalizations.
4. Count of observed 60-day hospitalizations.
5. Count of expected 60-day hospitalizations.
Acute Hospital Utilization (AHU)
For members 18 years of age and older, the risk-adjusted ratio of observed-to-expected acute
inpatient and observation stay discharges during the measurement year reported by Surgery,
Medicine and Total.
Emergency Department Utilization (EDU)
For members 18 years of age and older, the risk-adjusted ratio of observed to expected
emergency department (ED) visits during the measurement year.
Hospitalization for Potentially Preventable Complications (HPC)
For members 67 years of age and older, the rate of discharges for ambulatory care sensitive
conditions (ACSC) per 1,000 members and the risk-adjusted ratio of observed to expected
discharges for ACSC by chronic and acute conditions.
Language Diversity of Membership (LDM)
An unduplicated count and percentage of members enrolled at any time during the measurement
year by spoken language preferred for health care and preferred language for written materials.
Total Membership (TLM)
The number of members enrolled as of December 31 of the measurement year.

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