What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of norms employed by most of the health care plans in the US for measuring performance in relation to service and care. HEDIS was created by the NCQA (National Committee for Quality Assurance) and is vital for locating gaps in the performance and making the required changes to improve customer satisfaction.

HEDIS is a combination of 75 measures spanning 8 care domains. Accurate HEDIS coding for all the procedures within these measures is essential for organizations looking for NCQA accreditation, health care practices thinking of improving HEDIS rates, and MAOs (Medicare Advantage Organizations).

Why HEDIS Coding?

HEDIS coding is carried as follows: Reimbursement claims are coded with ICD-10 (Diagnosis Codes) and CPT (Procedure Codes). These are the codes that offer the encounter and claim information needed for payment and measurement of the quality of the care goals for the NCQA accreditation.

The right ICD-10 and CPT codes approved by the NCQDA must be attributed for indicating that good care was provided. The HEDIS quality care goals need to be indicated through the claims data.

Bills must be prepared only with CPT-4 or ICD-10 codes. Only properly paid bills must be used in the HEDIS report. Improper bills would bring about miscalculation.

The HEDIS report must be submitted only on confirmation of the accuracy of the information in that report. This will bring down the chances of obtaining revisions for the calculation of HEDIS scores.

CodeMatrix can help with HEDIS coding services to help insurers meet the quality goals set by NCQA and enable healthcare practices to maximize their HEDIS reimbursement.

Physician Documentation Guidelines and Administrative Codes

Each HEDIS measure identified below has criteria that are required for your patient’s chart or claims review to be considered valid towards HEDIS measurement.

The following would be the HEDIS measures and the documentation varies with each.

• Adult BMI Assessment (ABA) Medicare Health Plan Rating Measure
• Adult Access to Preventive/Ambulatory Health Services (AAP)
• Controlling High Blood Pressure (CBP)
• Comprehensive Diabetes Care (CDC) Diabetic HbA1c Testing
• Comprehensive Diabetes Care: Diabetic eye exam (retinal)
• Comprehensive Diabetes Care: Medical Attention for Nephropathy:
• Breast Cancer Screening (BCS)
• Chlamydia Screening in Women (CHL)
• Cervical Cancer Screening (CCS)
• Postpartum Care
• The frequency of Prenatal Care
• Human Papillomavirus Vaccine for Female Adolescents
• Weight Assessment/Counseling for Nutrition & Phys.
• Activity for Children/Adolescents
• Childhood Immunization Status
• Lead Screening in Children
• Immunizations for Adolescents
• Well-child Visits in the First 15 months of Life
• Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
• Adolescent Well-Care Visits
• Children and Adolescents’ Access to Primary Care Practitioners
• Annual Monitoring for Patients on Persistent Medications
• Asthma Medication Ratio
• Medication Management for People with Asthma
• Antidepressant Medication Management