Measure Your HEDIS Performance in 2018

Measure Your HEDIS Performance in 2018

Providers educated on new measures ensure accurate and updated patient health status.

Written by: Meera Mohanakrishnan, MS, CPC, COC, CPC-P, CRC, CPC-I, CCS

More than 90 percent of health plans use Healthcare Effectiveness Data and Information Set (HEDIS) to measure healthcare and service performance from overuse and appropriateness to chronic condition management. For 2018, the National Committee for Quality Assurance (NCQA) announced seven new HEDIS measures, changes to four existing measures, and two cross-cutting topics that address issues across multiple measures.

The seven new HEDIS measures address emerging health needs and evolving processes in care delivery. They include:

  1. Transitions of Care (TRC)
  2. Follow Up After Emergency Department (ED) Visit for Medicare Members with High-Risk Multiple Chronic Conditions (FMC)
  3. Use of Opioids at High Dosage (UOD)
  4. Use of Opioids from Multiple Providers (UOP)
  5. Depression Screening and Follow-up (DSF)
  6. Unhealthy Alcohol Use Screening and Follow-up (ASF)
  7. Pneumococcal Vaccination Coverage for Older Adults (PVC)

Let’s explore these seven measures.

Transitions of Care (TRC)

The patient should be 18 years old or older. The objective of this measure is to improve care coordination during care transitions for at-risk populations, including older adults and individuals with complex health needs. The measure assesses percentage of inpatient (IP) discharges for Medicare patients who had each of the following during the measurement year. Four rates are reported:

  1. Notification of IP Admission on the Day of Admission or the Day After
  2. The patient chart should mention about the communication between patient’s provider/staff and the patient’s primary care physician (PCP). This can be through phone call, email, or fax.
  3. Communication can be between the ED physician and the patient’s PCP.
  4. When a patient is admitted to the hospital, the specialist should indicate the patient’s PCP.

Receipt of Discharge Information on the Day of Admission or the Day After

There should be documentation of receiving discharge information on the day of discharge or the following day.

The physician is responsible for the:

  • Patient’s care during the IP stay
  • Procedure or treatment
  • Diagnoses at discharge
  • Current medication list (including allergies)
  • Test results, or documentation of pending tests or no pending tests
  • Instructions for patient care

Patient Engagement After IP Discharge

Documentation of patient engagement should be provided within 30 days of the discharge.

The patient engagement can be an actual office visit or visits to the home or telehealth where real‐time communication occurred between the patient and provider via telephone or video‐conferencing.

Medication Reconciliation

There must be:

  • Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).
  • Documentation of the current medications with a notation that the provider reconciled the current and discharge medications.
  • Documentation of the patient’s current medications with a notation that the discharge medications were reviewed.
  • Evidence that the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).

Data source: Administrative and Hybrid (administrative not available for the first two indicators)

Follow Up After Emergency Department (ED) Visit for Medicare Members with High-risk Multiple Chronic Conditions (FMC)

Follow-up care should be within seven days of ED visit.

The measures access the percentage of ED visits for patients 18 years and older who have high-risk multiple chronic conditions who had a follow-up service within seven days of the ED visit.

The goal of the measure FMC is to improve the coordination of care for Medicare patients with multiple chronic conditions who are sent home from the ED.

The follow-up visit should ensure there is a quality care of diagnoses, medications, and other follow-up requirements.

Data Source: Administrative-only

Use of Opioids at High Dosage (UOD)

UOD evaluates the rate of all health plan patients who receive long-term opioids at high dosage. It is for patients 18 years old and older. This HEDIS measure captures the rate per 1,000 receiving prescription opioids for ≥15 days during the measurement year
at a high dosage. The average morphine equivalent dose [MED] >120 mg.

A lower rate for this measure indicates better performance.

UOD measure excludes those in hospice. This measure also excludes patients who met at least one of the following during the measurement year:

  • Only a single opioid medication dispensed
  • Cancer
  • Sickle cell disease

Data Source: Administrative-only

Use of Opioids from Multiple Providers (UOP)

Risk factors for overdose and death are high doses of opioids and using multiple prescribers and pharmacies.

UOP measures access at the rate per 1,000 patients 18 years and older receiving prescription opioids for ≥15 days during 2017 who received opioids from:

  • Multiple prescribers: Receiving prescriptions for opioids from four or more different prescribers during the measurement year.
  • Multiple pharmacies: Receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
  • Multiple prescribers and multiple pharmacies: Receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.

A lower rate indicates better performance for all three rates.

Data Source: Administrative-only

Depression Screening and Follow Up (DSF)

The DSF measure is for the age group 12 years and older. DSF calculates adults who were screened for clinical depression using a standardized tool. If DSF screened positive, the patient receives follow-up care.

Depression screening: The measures access the percentage of patients who were screened for clinical depression using standardized tool.

Follow up on positive results: The measures access the percentage of patients who screened positive for depression and received follow-up care within 30 days.

Patients can be excluded if they meet any of the following criteria:

  • Bipolar disorder during the measurement year or the year prior to the measurement year
  • Depression during the year prior to the measurement year
  • In hospice or using hospice services during the measurement year

If the screening is positive for depression, there must be evidence of follow-up care documented in the medical record. If there is no follow-up plan, the visit only counts for the screening and not for follow-up care.

Data Source: ECDS (Electronic Clinical Data Systems)

Unhealthy Alcohol Use Screening and Follow-up (ASF)

Unhealthy alcohol use is a common and serious issue. Alcohol misuse is a leading cause of illness, lost productivity, and preventable death in the United States.

The ASF measure is for the age group 12 years and older. ASF monitors the patients who have had a systematic screening for unhealthy alcohol use as well as counseling or other follow-up care.

Unhealthy alcohol use screening: The measures access the percentage of patients who had a systematic screening for unhealthy alcohol use, using a standardized tool.

Counseling or other follow-up: The measures access the percentage of patients who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within two months of a positive screening.

Data Source: ECDS (Electronic Clinical Data Systems)

Pneumococcal Vaccination Coverage for Older Adults (PVC)

PVC measures the percentage of patients who are 65 and older who received the recommended series of pneumococcal vaccines, which includes 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine.

Data Source: ECDS (Electronic Clinical Data Systems)

Physician must have the educational material toolkit, the HEDIS checklist, and forms to assist them and their staff in using best practices to improve care to patients, and improving HEDIS performance. HEDIS abstractors must work closely with the reports of patients with gaps in care to help both the patient and provider. The provider should have an accurate and updated health status of the patient’s condition.


Meera Mohanakrishnan, MS, CPC, COC, CPC-P, CRC, CPC-I, CCS, ICD-10 Consultant, is director of Medical Coding Operations at IntegraNet Health and dean of IntegraNet Coding Academy in Houston, Texas (mmohanakrishnan@integranethealth.com). She has a master’s degree in biochemistry and is a member of the Houston, Texas, local chapter.

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