HEDIS Quick Reference Guide

Wellness and Prevention: Women and Adolescent Girls

Breast CA Screening (Ages 50-74) Women who've had a screening mammogram Documentation of Mammogram performed from October 2015 through the December 2017
Cervical CA Screening (Ages 21-64) Women who've had 1 of 2 screening tests for cervical CA Documentation of 1 of the following:
Women ages 21-64 who had cervical cytology performed Q3 years OR
Women ages 30-64 who had cervical cytology/HPV co-testing performed Q5 years
Chlamydia Screening (Ages 16-24) Women identified as presumed sexually active by pharmacy or claims data who've had a Chlamydia screening Documentation of Chlamydia test in 2017
Prenatal and Postpartum Management (Pregnant Women) Women who had a Prenatal Visit in first trimester (or within 42 days of enrollment) and Postpartum Visit 21-56 days after delivery Copy of Prenatal Record for delivery of live birth between 11/6/16 and 11/5/17 AND Copy of Postpartum Visit related to delivery of live birth between 11/6/16 and 11/5/17

 

Wellness and Prevention: Adults

Adult BMI Assessment (Ages 18-74) Adults who have recorded BMI and weight in outpatient physician office via claim or medical record Documented BMI and weight in physician office in 2016 or 2017
Colorectal CA Screening (Ages 50-74) Members who had appropriate screening for colorectal cancer FOBT or Cologaurd© in 2017 OR Flexible Sigmoidoscopy between 2013-2017 OR Colonoscopy between 2008-2017
Adult Access to Preventive/Ambulatory Services Men and Women who have accessed services for ambulatory or preventive health care Claim or documented office visit in 2017

 

Utilization: Reducing Readmissions

All Cause Readmissions (Ages 18 and older) Number of acute inpatient stays during 2017 followed by acute readmission for any diagnosis within 30 days Claims based

 

Wellness and Prevention: Children

Well Child Visits in the First 15 Months of Life The number of well child visits for each child 15 months since birth Documentation from medical record indicating visit with evidence of health and developmental history, physical exam and health education/anticipatory guidance
Well Child Visits - 3, 4, 5, 6 Years Children 3-6 years who had one or more well visits with PCP in 2017 Documentation from medical record indicating visit and evidence of health and developmental history, physical exam and health education/anticipatory guidance
Well Child Visits (7-11 Years) Children 7-11 years who had one or more well visits with PCP in 2017 Documentation from medical record indicating visit with evidence of health and developmental history, physical exam and health education/anticipatory guidance
Well Child/Adolescent Visits (12-19 Years) Children/Adolescents 12-19 years who had one or more well visits with PCP in 2017 Documentation from medical record indicating visit with evidence of health and developmental history, physical exam and health education/anticipatory guidance

 

Pediatrics: Upper Respiratory Infections

Upper Respiratory Infection (URI) - Antibiotic Use (3 months - 18 Years) Children/Adolescents who were diagnosed with URI and did NOT have a prescription filled for an antibiotic on or 3 days after the initiating episode Absence of prescription given for initial episode of Upper Respiratory Infection from July 1, 2016 - June 30, 2017. Claims based.

 

Disease Specific Care: Cardiovascular

Controlling HTN (Hypertension) (Ages 18-85) Members who had a diagnosis of HTN and whose blood pressure was controlled.
  • Ages 15-59: <140/<90
  • Ages 60-85 with diabetes: <140/<90
  • Ages 60-85 without diabetes: <150/<90
A dated physician diagnosis of HTN on or before June 30, 2017 and dated documentation of most recent blood pressure taken in physician office in 2017
Persistence of Beta-Blocker Treatment after Heart Attack (Ages 18 and older) Members who were hospitalized and discharged from 7/1/16 through 6/30/17 with diagnosis of AMI who received treatment with beta blockers for 6 months after discharge Documentation of persistent beta-blocker treatment for at least 6 months post-discharge (*dispensed days must be ≥ 135 of 180 days)

 

Disease Specific Care: Diabetes

Comprehensive Diabetes Care (Ages 18-75) Members with diabetes who had EACH of the following:
  • HbA1c test
  • Nephropathy screening or evidence of nephropathy
  • Diabetic Retinopathy Eye Exam (DRE)
Documentation of EACH:
  • HbA1c test in 2017 (result <8)
  • Urine test for microalbumin in 2017 or on ACE/ARB
  • DRE in 2016 with negative result or DRE in 2017

 

Musculoskeletal Conditions

Osteoporosis Management in Women who had a Fracture (Ages 67-85) *Medicare only Women who had a fracture who had a bone mineral density (BMD) test or prescription for drug to treat or prevent osteoporosis in the six months after fracture. Documentation of BMD in 2017 OR Prescription for Osteoporosis drug in 2017
Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis (RA) (Ages 18 years and older) Members who were diagnosed with RA and who were dispensed at least one DMARD Documentation of at least one prescription for DMARD in 2017
Low Back Pain (Ages 18-50) Members with diagnosis of LBP who did not have imaging study (MRI, CT, Xray) within 28 days of diagnosis Captured through claims. Exclusions: Cancer, Recent Trauma, IV drug abuse, Neurological Impairment

 

Medication Management

Annual Monitoring for Persistent Medications (Ages 18 and older) Members who received at least 180 ambulatory days of select medication and who received at least one therapeutic monitoring event:
  • ACE/ARB
  • Digoxin
  • Diuretics
ACE/ARB: Serum Potassium AND Serum Creatinine
Digoxin: Serum Potassium AND Serum Creatinine AND Serum Digoxin
Diuretics: Serum Potassium AND Serum Creatnine
High Risk Medication in the Elderly (includes antihistamines, skeletal muscle relaxants, estrogens, and others) (Ages 65 and older) Medicare Members 65 and older who received at least 1 prescription for a drug with high risk of side effects in the elderly Claims based. Review med history for high risk meds in the elderly and consider alternative therapy choices
Diabetes Treatment (Ages 18-75) Medicare Members with diabetes and HTN who received a prescription for an ACEI, ARB or Direct Renin Inhibitor Claims based. Consider prescribing ACEI, ARB or Direct Renin Inhibitor in patients with diabetes and HTN where applicable
Statin Therapy for Patients with Diabetes (Ages 40-75) Members with diabetes but NOT diagnosed with atherosclerotic disease who received a prescription for a statin medication. Pharmacy claims based. The proportion of days covered must be 80%. Ask patients about adherence to their oral diabetes medication and encourage appropriate adherence techniques.
Medication Adherence for Oral Diabetic Medications (Biguaindes, Sulfonylureas, Thiazolidinediones, and DiPeptidyl Peptidase-IV Inhibitors) (Ages 18 and older) Medicare members 18 and older who adhere to their prescribed oral diabetes medications Pharmacy claims based. The proportion of days covered must be 80%. Ask patients about adherence to their oral diabetes medication and encourage appropriate adherence techniques.
Medication Adherence for HTN (ACEI, ARB, and Direct Renin Inhibitors) (Ages 18 and older) Medicare members 18 and older who adhere to their prescribed blood pressure medications Pharmacy claims based. The proportion of days covered must be 80%. Ask patients about adherence to their HTN medication and encourage appropriate adherence techniques.
Medication Adherence for Cholesterol (Statins) (Ages 18 and older) Medicare members 18 and older who adhere to their prescribed cholesterol medications Pharmacy claims based. The proportion of days covered must be 80%. Ask patients about adherence to their statin medication and encourage appropriate adherence techniques.

 

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