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
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
- Follow Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-30) – Commercial/Medi-Cal (PDF)
- Follow Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-30) – CalViva Health (PDF)
- Follow Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-30) – Wellcare by Health Net (PDF)
- Pharmacotherapy for Opioid Use Disorder (POD) – Commercial/Medi-Cal (coming soon)
- Pharmacotherapy for Opioid Use Disorder (POD) – CalViva Health (not applicable)
- Pharmacotherapy for Opioid Use Disorder (POD) – Wellcare by Health Net (not applicable)
- Follow Up After Emergency Department Visit for Mental Illness (FUM-30) – Commercial/Medi-Cal (PDF)
- Follow Up After Emergency Department Visit for Mental Illness (FUM-30) – CalViva Health (PDF)
- Follow Up After Emergency Department Visit for Mental Illness (FUM-30) – Wellcare by Health Net (not applicable)
- Breast Cancer Screening (BCS) – Commercial/Medi-Cal (PDF)
- Breast Cancer Screening (BCS) – CalViva Health (PDF)
- Breast Cancer Screening (BCS) – Wellcare by Health Net (PDF)
- Cervical Cancer Screening (CCS) – Commercial/Medi-Cal (PDF)
- Cervical Cancer Screening (CCS) – CalViva Health (PDF)
- Cervical Cancer Screening (CCS) – Wellcare by Health Net (not applicable)
- Colorectal Cancer Screening (COL) – Commercial/Medi-Cal (PDF)
- Colorectal Cancer Screening (COL) – CalViva Health (coming soon)
- Colorectal Cancer Screening (COL) – Wellcare by Health Net (PDF)
- Child and Adolescent Well-Care Visits (WCV) – Commercial/Medi-Cal (PDF)
- Child and Adolescent Well-Care Visits (WCV) – CalViva Health (PDF)
- Childhood Immunization Status: Combination 10 (CIS-10) – Commercial/Medi-Cal (PDF)
- Childhood Immunization Status: Combination 10 (CIS-10) – CalViva Health (PDF)
- Developmental Screening in the First Three Years of Life (DEV) – Medi-Cal
- Developmental Screening in the First Three Years of Life (DEV) – CalViva Health
- Immunizations for Adolescents: Combination 2 (IMA-2) – Medi-Cal (PDF)
- Immunizations for Adolescents: Combination 2 (IMA-2) – CalViva Health (PDF)
- Immunizations for Adolescents: Combination 2 (IMA-2) – Wellcare by Health Net (not applicable)
- Lead Screening in Children (LSC) – Medi-Cal (PDF)
- Lead Screening in Children (LSC) – CalViva Health (PDF)
- Lead Screening in Children (LSC) – Wellcare by Health Net (not applicable)
- Topical Fluoride for Children (TLC-CH) – Medi-Cal (PDF)
- Topical Fluoride for Children (TLC-CH) – CalViva Health (PDF)
- Well-Child Visits in the First 30 Months of Life – Medi-Cal (PDF)
- Well-Child Visits in the First 30 Months of Life – CalViva Health (PDF)
- Annual Flu Vaccine (FVA) – Commercial/Medi-Cal (not applicable)
- Annual Flu Vaccine (FVA) – CalViva Health (not applicable)
- Annual Flu Vaccine (FVA) – Wellcare by Health Net (coming soon)
- Asthma Medication Ratio (AMR) – Commercial/Medi-Cal (PDF)
- Asthma Medication Ratio (AMR) – CalViva Health (PDF)
- Asthma Medication Ratio (AMR) – Wellcare by Health Net (PDF)
- Controlling High Blood Pressure (CBP) – Commercial/Medi-Cal (PDF)
- Controlling High Blood Pressure (CBP) – CalViva Health (PDF)
- Controlling High Blood Pressure (CBP) – Wellcare by Health Net (PDF)
- Eye Exam for Patients with Diabetes (EED) – Commercial/Medi-Cal (PDF)
- Eye Exam for Patients with Diabetes (EED) – CalViva Health (PDF)
- Eye Exam for Patients with Diabetes (EED) – Wellcare by Health Net (PDF)
- HbA1c Control for Patients with Diabetes (HBD) – Commercial/Medi-Cal (PDF)
- HbA1c Control for Patients with Diabetes (HBD) – CalViva Health (PDF)
- HbA1c Control for Patients with Diabetes (HBD) – Wellcare by Health Net (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Commercial only (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Medi-Cal only (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – CalViva Health (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Wellcare by Health Net (PDF)
- Statin Therapy for Patients with Cardiovascular Disease (SPC_STCVD) – Commercial/Medi-Cal (PDF)
- Statin Therapy for Patients with Cardiovascular Disease (SPC_STCVD) – CalViva Health (PDF)
- Statin Therapy for Patients with Cardiovascular Disease (SPC_STCVD) – Wellcare by Health Net (PDF)
- Statin Use in Persons with Diabetes (SUPD) – Commercial/Medi-Cal (not applicable)
- Statin Use in Persons with Diabetes (SUPD) – CalViva Health (not applicable)
- Statin Use in Persons with Diabetes (SUPD) – Wellcare by Health Net (coming soon)
- Plan All-Cause Readmissions O/E Ratio (PCR) – Commercial/Medi-Cal (PDF)
- Plan All-Cause Readmissions O/E Ratio (PCR) – CalViva Health (not applicable)
- Plan All-Cause Readmissions O/E Ratio (PCR) – Wellcare by Health Net (PDF)
- Transition of Care (TRC) – Commercial/Medi-Cal (not applicable)
- Transition of Care (TRC) – CalViva Health (not applicable)
- Transition of Care (TRC) – Wellcare by Health Net (coming soon)
- Appropriate Testing for Pharyngitis (CWP) – Commercial only (coming soon)
- Appropriate Treatment for Upper Respiratory Infection (URI) – Commercial only (coming soon)
- Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) – Commercial only (coming soon)
- Medication Adherence for Cholesterol (Statins) (MAC) – Commercial/Medi-Cal (not applicable)
- Medication Adherence for Cholesterol (Statins) (MAC) – CalViva Health (not applicable)
- Medication Adherence for Cholesterol (Statins) (MAC) – Wellcare by Health Net (coming soon)
- Medication Adherence for Diabetes Medications (MAD) – Commercial/Medi-Cal (not applicable)
- Medication Adherence for Diabetes Medications (MAD) – CalViva Health (not applicable)
- Medication Adherence for Diabetes Medications (MAD) – Wellcare by Health Net (coming soon)
- Medication Adherence for Hypertension (RAS antagonists) (MAH) – Commercial/Medi-Cal (not applicable)
- Medication Adherence for Hypertension (RAS antagonists) (MAH) – CalViva Health (not applicable)
- Medication Adherence for Hypertension (RAS antagonists) (MAH) – Wellcare by Health Net (coming soon)
- Chlamydia Screening in Women (CHL) – Commercial/Medi-Cal (PDF)
- Chlamydia Screening in Women (CHL) – CalViva Health (PDF)
- Postpartum Care (PPC-POST) – Commercial/Medi-Cal (PDF)
- Postpartum Care (PPC-POST) – CalViva Health (PDF)
- Prenatal Care (PPC-PRE) – Commercial/Medi-Cal (coming soon)
- Prenatal Care (PPC-PRE) – CalViva Health (coming soon)
- Care Coordination (COC) – Wellcare by Health Net only (coming soon)
- Care for Older Adults – Medication Review (COA_MR) – Wellcare by Health Net only (coming soon)
- Care for Older Adults – Pain Assessment (COA_PA) – Wellcare by Health Net only (coming soon)
- Monitoring Physical Activity (MPA) – Wellcare by Health Net only (coming soon)
- Reducing the Risk of Falling (RRF) – Wellcare by Health Net only (coming soon)
- Use of Imaging Studies for Low Back Pain (LBP) – Commercial only (coming soon)
- Use of Imaging Studies for Low Back Pain (LBP) – CalViva Health (not applicable)
- Use of Imaging Studies for Low Back Pain (LBP) – Wellcare by Health Net (not applicable)
- CAHPS Tip Sheet – Commercial/Medi-Cal (PDF)
- CAHPS Tip Sheet – CalViva Health (PDF)
- CAHPS Tip Sheet – Wellcare by Health Net (PDF)
- Keep Patients Healthy with Flu Vaccine Recommendations (PDF)
- Keep Patients Healthy with Flu Vaccine Recommendations (PDF) - CalViva Health
- Keep Patients Healthy with Flu Vaccine Recommendations (PDF) - Wellcare by Health Net
- Blood Pressure Control for Patients With Diabetes (PDF)
- Blood Pressure Control for Patients With Diabetes (PDF) - CalViva Health
- Blood Pressure Control for Patients With Diabetes (PDF) - Wellcare by Health Net
- Kidney Health Evaluation for Patients With Diabetes (PDF)
- Kidney Health Evaluation for Patients With Diabetes (PDF) - CalViva Health
- Kidney Health Evaluation for Patients With Diabetes (PDF) - Wellcare by Health Net
- Learn How to Address Medical Needs for Patients with SPMI (PDF)
- Learn How to Address Medical Needs for Patients with SPMI (PDF) - CalViva Health
- Learn How to Address Medical Needs for Patients with SPMI (PDF) - Wellcare by Health Net
- Learn How to Improve Your HEDIS Rates for Children Prescribed ADHD Medication (PDF)
- Learn How to Improve Your HEDIS Rates for Children Prescribed ADHD Medication (PDF) - CalViva Health
- Learn How to Improve Your HEDIS Rates for IET (PDF)
- Learn How to Improve Your HEDIS Rates for IET (PDF) - Wellcare by Health Net
- Learn How to Improve Your HEDIS Rates for Transitions of Care Measure (PDF) - Wellcare by Health Net
- Learn More About Anxiety and Treatment Options to Improve Health Outcomes (PDF)
- Learn More About Anxiety and Treatment Options to Improve Health Outcomes (PDF) - CaViva Health
- Learn More About Anxiety and Treatment Options to Improve Health Outcomes (PDF) - Wellcare by Health Net
- Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) (PDF)
Refer to Provider Quality Improvement page for more resources.