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HEDIS Measures & Billing Codes

What is HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) to objectively measure, report, and compare quality across health plans. NCQA develops HEDIS measures through a committee represented by purchasers, consumers, health plans, health care providers, and policy makers.

What Are the Scores Used For?

As state and federal governments move toward a quality-driven healthcare industry, HEDIS rates are becoming more important for both health plans and individual providers. State purchasers of healthcare use aggregated HEDIS rates to evaluate health insurance companies' efforts to improve preventive health outreach for members.

Physician-specific scores are also used to measure your practice's preventive care efforts. Your practice's HEDIS score determines your rates for physician incentive programs that pay you an increased premium — for example Pay For Performance or Quality Bonus Funds.

How Are Rates Calculated?

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the need for medical record review. If services are not billed or not billed accurately, they are not included in the calculation.

How Can I Improve My HEDIS Scores?

  • Submit claim/encounter data for each and every service rendered
  • Make sure that chart documentation reflects all services billed
  • Bill (or report by encounter submission) for all delivered services, regardless of contract status
  • Ensure that all claim/encounter data is submitted in an accurate and timely manner
  • Consider including CPT II codes to provide additional details and reduce medical record requests

Improve Health Outcomes – a Guide for Providers

HEDIS and HIPAA
As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.

Provider Quality Resources

Cancer Prevention

Breast Cancer Screening: 22-968

23-1090

Chronic Disease Management

23-479

23-129

23-439

23-134

23-134

23-134

22-010

23-948

23-806

Hospital

23-749

23-760

Osteoporosis Management

23-421

23-444

22-374

Overuse

23-1038

23-1085: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) and Appropriate Treatment for Upper Respiratory Infection (URI)

HEDIS Tip Sheet: Effectiveness of Care Measure

CAHPS: Additional Resources

22-050

22-883

약국

22-688m

Preventative Care Management

23-1175

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Y0020_WCM_100876E Last Updated On: 10/1/2023