HEDIS. Healthcare Effectiveness Data & Information Set (HEDIS ) QUALITY MANAGEMENT PROGRAM SECTION 8

Transcription

1 HEDIS Healthcare Effectiveness Data & Infrmatin Set (HEDIS ) The HEDIS â audit cntains a cre set f perfrmance measures that prvide infrmatin abut custmer satisfactin, specific health care measures, and structural cmpnents that ensure quality f care. Annually, The Health Plan reprts n Effectiveness f Care measures set frth by HEDIS â. The fllwing is a list and may invlve nsite medical recrd review: HEDIS Measure Member Descriptin Measure Requirements Categry II CPT Cdes Adult BMI Assessment (ABA) yrs f BMI dcumented during the measurement year r the year prir t the measurement year: BMI: date and result BMI Percentile: date and percentile result if yunger than 20 years Weight: date and result Height: date and result Clrectal Cancer Screening (COL) yrs f Dcumentatin (date and results) f ne r mre f these screenings: Clnscpy during measurement year r nine years prir Flexible sigmidscpy during the measurement year r fur years prir CT clngraphy during the measurement year r fur years prir Fit-DNA test during the measurement year r the tw years prir FOBT during measurement year NOT ACCEPTABLE: Digital rectal exams (DRE), FOBT tests perfrmed in an ffice setting r perfrmed n a sample cllected via DRE. EXCLUSION: Clrectal cancer r ttal clectmy anytime during the patient s histry thrugh 12/31 f the measurement year. (Must be dcumented). Cntrlling High Bld Pressure (CBP) yrs f with a hypertensin diagnsis Members wh had at least tw visits n different dates f service with a diagnsis f hypertensin during the measurement year.

2 Last dcumented BP reading (date and results) in the measurement year. If BP is elevated (>140/90 mmhg), repeat BP and dcument all BP readings. BP must be <140/90 mmhg Nte: A systlic BP reading belw 140 with a diastlic reading f 90 r abve is cnsidered an elevated BP and shuld be repeated and dcumented Statin Therapy fr Patients with Cardivascular Disease (SPC) yrs f Clinical athersclertic cardivascular disease (ASCVD) diagnsis, dispensed at least ne high-intensity r mderate-intensity statin medicatin and remained n the medicatin during the measurement year. Medicatin adherence fr 80% f the treatment perid. Cmprehensive Diabetes Care (CDC) yrs f with a diagnsis f diabetes (type 1 r 2) Diabetes diagnsis in the measurement year r the year prir with all f the fllwing: A1c cntrl - The mst recent result in the measurement year. A cntrlled result is < 8.0% BP - The mst recent BP reading in the measurement year < 140/90 mmhg Eye exam - A retinal r dilated eye exam by an ptmetrist r phthalmlgist in the measurement year r an exam that is dcumented as negative fr retinpathy the year prir t the measurement year. An eye exam can be reprted by a PCP when there is dcumentatin in the medical chart that an eye exam was perfrmed/reviewed by an eye care prfessinal. HbA1c & RESULT: 3044F 3045F, 3046F BLOOD PRESSURE READING: SYSTOLIC: 3074F, 3075F, 3077F DIASTOLIC: 3078F, 3079F, 3080F EYE EXAM: 2022F, 2024F, 2026F, 3072F NEPHROPATHY: 3060F, 3061F, 3062F, 3066F, 4010F Nephrpathy - Dcumentatin f ne f the fllwing: Urine test fr prtein r albumin with results in the measurement year Evidence that an ACE r ARB was dispensed in the measurement year Diagnsis f diabetic nephrpathy, ESRD, CRF, CKD, renal insufficiency, prteinuria, albuminuria, renal dysfunctin, ARF, dialysis, hemdialysis r peritneal dialysis in the measurement year.

3 Statin Therapy fr Patients With Diabetes (SPD) Cervical Cancer Screening (CCS) yrs f yrs f Diabetics, wh d nt have ASCVD, dispensed at least ne statin medicatin f any intensity and remained n the medicatin during the measurement year. Medicatin adherence fr 80% f the treatment perid. Evidence f cervical cytlgy within the last three years. Fr wmen that d nt meet abve criteria, evidence f cervical cytlgy and human papillmavirus (HPV) with service dates fur r less days apart during the measurement year r the fur years prir t the measurement year (date and result). Childhd Immunizatin Status (CIS) 2 yrs f Vaccines administered n r befre the 2nd birthday: 3 IPV 4 DTaP 3 Hib 3 Hep B Immunizatins fr Adlescents (IMA) 1 VZV 1 MMR 2 Flu 1 Hep A 2-3 RV 4 PCV/ Prevnar 13 yrs f Vaccines administered n r befre the 13th birthday: One MCV/ meningcccal vaccine n r between the 11th and 13th birthdays One Tdap vaccine n r between the 10th and 13th birthdays Tw HPV vaccines with different DOS n r between the 9 th and 13 th birthdays (must be 146 days between dses) OR three HPV vaccines with different DOS between the 9 th and 13 th birthdays Immunizatins fr Adlescents (IMA) Prenatal and Pstpartum Care (PPC) Wmen wh delivered a live birth between Nvember 6 f the year prir t the measurement year and Nvember 5 f the measurement year Prenatal care visit in the first trimester r within 42 days f enrllment. The visit must be with an OB/GYN practitiner, ther prenatal care practitiner r PCP. Fr visits t a PCP, a diagnsis f pregnancy must be present. Dcumentatin must include the visit date and evidence f ne f the fllwing: A basic physical bstetrical examinatin that includes a pelvic exam with bstetric bservatins, auscultatin fr fetal heart tne, r measurement f fundus height (a standardized prenatal flw sheet may be used)

4 Prenatal care prcedure including screening test/bstetric panel r TORCH antibdy panel r a rubella antibdy test/titer with a Rh incmpatibility (ABO/Rh) bld typing r ultrasund/echgraphy f a pregnant uterus Dcumentatin f LMP r EDD with either a prenatal risk assessment and cunseling/educatin r cmplete bstetrical histry Pstpartum care visit n r between 21 and 56 days after delivery date with ne f the fllwing: A ntatin f a pstpartum care/checkup A pelvic exam An evaluatin f weight, BP, breasts and abdmen Nte: An ultrasund and results alne are nt cnsidered a prenatal visit; they must be cmbined with an ffice visit with an apprpriate practitiner. Weight Assessment and Cunseling fr Nutritin and Physical Activity fr Children/ Adlescents (WCC) Well-Child Visits in the Third, Furth, Fifth and Sixth Years f Life (W34) 3-17 yrs f Evidence f an utpatient visit with a PCP r OB/GYN cntaining the fllwing during the measurement year: BMI percentile - dated dcumentatin f weight, height and percentile value (can be pltted n grwth chart) Cunseling fr nutritin (diet) Cunseling fr physical activity (sprts participatin/exercise) 3-6 yrs f Dcumentatin must include a dated nte indicating a PCP visit during the measurement year with evidence f all f the fllwing: Health histry (past and present) Physical develpmental histry (develpmental milestnes) Mental develpmental histry (develpmental milestnes) Physical exam (height, weight, BMI percentile, heart, lungs, abdmen, etc.) Health educatin/anticipatry guidance (i.e., physical activity, healthy eating habits, dental care,

5 seat belt use, bike helmets, pl fences) Adlescent Well- Child Visits (AWC) yrs f Dcumentatin must include a dated nte indicating a PCP r OB/GYN visit during the measurement year with evidence f all f the fllwing: Health histry (past and present) Physical develpmental histry (physical cmpetencies, last menstrual perid, testicular exam, ther related questins) Mental develpmental histry (i.e., psychiatric exam, sex educatin r questins, depressin screening, psychscial/behaviral screening) Physical exam (height, weight, BMI percentile, heart, lungs, abdmen, etc.) Health educatin/anticipatry guidance (i.e., physical activity, healthy eating habits, seat belt use, tbacc/drug/alchl discussin) Care fr Older Adults (COA) 66 yrs r lder *DSNP ONLY* Dcumentatin f each during the measurement year: Advance care planning (ne f the fllwing): Presence f an advance care plan in the medical recrd ADVANCE CARE PLANNING: 1123F, 1124F, 1157F, 1158F Dcumentatin in the measurement year f discussin with the prvider and the date it was discussed Ntatin that the member previusly executed an advance care plan Medicatin review (ne f the fllwing): Medicatin list signed and dated during measurement year MEDICATION LIST & REVIEW: 1159F & 1160F Ntatin that the member is nt taking any medicatin and the date

6 Functinal status assessment (ne f the fllwing): Ntatin that ADLs r IADLs were assessed Ntatin that three f the fllwing fur cmpnents were assessed: cgnitive status; ambulatin status; hearing, visin and speech (i.e., sensry ability); ther functinal independence (i.e., exercise, ability t perfrm jb) Pain assessment (ne f the fllwing) Ntatin that pain was assessed Results f an assessment using a standardized pain assessment tl FUNCTIONAL STATUS ASSESSMENT: 1170F PAIN ASSESSMENT: 1125F, 1126F Medicatin Recnciliatin Pst Discharge (MRP) 18 yrs r lder All acute and nn-acute inpatient discharge. Medicatins must be recnciled within 30 days f discharge. One f the fllwing shuld be dcumented: Dcumentatin f a pst-discharge hspital fllw-up visit with a dcumented current medicatin list and evidence that the medicatins were reviewed r recnciled Dcumentatin that the prvider recnciled the current and discharge medicatins Dcumentatin f the current medicatins with a ntatin that references the discharge medicatins (i.e., n changes in medicatins since discharge, same medicatins at discharge, discntinue all discharge medicatins) Dcumentatin f the member s current medicatins with a ntatin that the discharge medicatins were reviewed Dcumentatin f a current medicatin list, a discharge medicatin list and ntatin that bth MEDICATION RECONCILIATION: 1111F

7 lists were reviewed n the same date f service Ntatin that n medicatins were prescribed r rdered upn discharge Dcumentatin in the discharge summary that the discharge medicatins were recnciled with the mst recent medicatin list in the utpatient medical recrd. There must be evidence the discharge summary was filed in the utpatient chart 30 days after discharge. Breast Cancer Screening (BCS) Osteprsis Manment in Wmen Wh Had a Fracture (OMW) yrs f Wmen yrs f Mammgram any time during the measurement year and the year prir. Wmen wh had a fracture and had either a bne mineral density test r a prescriptin fr a drug t treat steprsis in the six mnths fllwing the fracture. The HEDIS audit takes place annually between January and June and administrative (claim) data is used when applicable. The Quality Department f The Health Plan cntracted with an utside vendr in 2017 t help with the retrieval f the medical recrds that are needed fr each f the measures. A representative frm ur vendr may cntact the ffice fr chart retrieval. There may be an instance that ur nurse(s) may need t visit the ffice and every effrt will be made t crdinate the nsite visit t accmmdate the prvider and ffice staff. Our nurse(s) will need access t a pwer surce fr laptp data entry.