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
- Anxiety and Treatment Options to Improve Health Outcomes – Commercial/Medi-Cal (PDF)
- Anxiety and Treatment Options to Improve Health Outcomes – CalViva Health (PDF)
- Anxiety and Treatment Options to Improve Health Outcomes – Community Health Plan of Imperial Valley (PDF)
- Anxiety and Treatment Options to Improve Health Outcomes – Wellcare By Health Net (PDF)
- 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)
- 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) – Community Health Plan of Imperial Valley (PDF)
- Follow Up After Emergency Department Visit for Mental Illness (FUM-30) – Wellcare By Health Net (PDF)
- Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication – Commercial/Medi-Cal (PDF)
- Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication – CalViva Health (PDF)
- Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication – Community Health Plan of Imperial Valley (PDF)
- Initiation and Engagement of Substance Use Disorder Treatment (IET) – Commercial/Medi-Cal (PDF)
- Initiation and Engagement of Substance Use Disorder Treatment (IET) – CalViva Health (PDF)
- Initiation and Engagement of Substance Use Disorder Treatment (IET) – Community Health Plan of Imperial Valley (PDF)
- Initiation and Engagement of Substance Use Disorder Treatment (IET) – Wellcare By Health Net (PDF)
- Learn How to Address Medical Needs for Patients with SPMI Tip Sheet – Commercial/Medi-Cal (PDF)
- Learn How to Address Medical Needs for Patients with SPMI Tip Sheet – CalViva Health (PDF)
- Learn How to Address Medical Needs for Patients with SPMI Tip Sheet – Community Health Plan of Imperial Valley (PDF)
- Learn How to Address Medical Needs for Patients with SPMI Tip Sheet – Wellcare By Health Net (PDF)
- Pharmacotherapy for Opioid Use Disorder (POD) Tip Sheet – Commercial/Medi-Cal (PDF)
- Pharmacotherapy for Opioid Use Disorder (POD) Tip Sheet – CalViva Health (PDF)
- Pharmacotherapy for Opioid Use Disorder (POD) Tip Sheet – Community Health Plan of Imperial Valley (PDF)
- Pharmacotherapy for Opioid Use Disorder (POD) Tip Sheet – Wellcare By Health Net (PDF)
- Share Patient Information to Improve Outcomes Tip Sheet – Commercial/Medi-Cal (PDF)
- Share Patient Information to Improve Outcomes Tip Sheet – CalViva Health (PDF)
- Share Patient Information to Improve Outcomes Tip Sheet – Community Health Plan of Imperial Valley (PDF)
- Share Patient Information to Improve Outcomes Tip Sheet – Wellcare By Health Net (PDF)
- Breast Cancer Screening (BCS) – Commercial/Medi-Cal (PDF)
- Breast Cancer Screening (BCS) – CalViva Health (PDF)
- Breast Cancer Screening (BCS) – Community Health Plan of Imperial Valley (PDF)
- Breast Cancer Screening (BCS) – Wellcare By Health Net (PDF)
- Breast Cancer Screening Codes (BCS-E) – Wellcare By Health Net (PDF)
- Care for Older Adults (COA) – Wellcare By Health Net (PDF)
- Annual Care for Older Adults (COA) and Advance Care Planning Forms – Wellcare By Health Net (PDF)
- Cervical Cancer Screening (CCS) – Commercial/Medi-Cal (PDF)
- Cervical Cancer Screening (CCS) – CalViva Health (PDF)
- Cervical Cancer Screening (CCS) – Community Health Plan of Imperial Valley (PDF)
- Colorectal Cancer Screening (COL) – Commercial/Medi-Cal (PDF)
- Colorectal Cancer Screening (COL) – CalViva Health (PDF)
- Colorectal Cancer Screening (COL) – Community Health Plan of Imperial Valley (PDF)
- Colorectal Cancer Screening (COL) – Wellcare By Health Net (PDF)
- Depression Screening – Commercial/Medi-Cal (PDF)
- Depression Screening – CalViva Health (PDF)
- Depression Screening – Community Health Plan of Imperial Valley (PDF)
- Depression Screening – 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)
- Child and Adolescent Well-Care Visits (WCV) – Community Health Plan of Imperial Valley (PDF)
- Convert Pediatric Sick Visits to Well-Care Visits – Commercial/Medi-Cal (PDF)
- Convert Pediatric Sick Visits to Well-Care Visits – CalViva Health (PDF)
- Convert Pediatric Sick Visits to Well-Care Visits – Community Health Plan of Imperial Valley (PDF)
- Childhood Immunization Status: Combination 10 (CIS-10) – Commercial/Medi-Cal (PDF)
- Childhood Immunization Status: Combination 10 (CIS-10) – CalViva Health (PDF)
- Childhood Immunization Status: Combination 10 (CIS-10) – Community Health Plan of Imperial Valley (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
- Developmental Screening in the First Three Years of Life (DEV) – Community Health Plan of Imperial Valley (PDF)
- 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) – Community Health Plan of Imperial Valley (PDF)
- Lead Screening in Children (LSC) – Medi-Cal (PDF)
- Lead Screening in Children (LSC) – CalViva Health (PDF)
- Lead Screening in Children (LSC) – Community Health Plan of Imperial Valley (PDF)
- Topical Fluoride for Children (TLC-CH) – Medi-Cal (PDF)
- Topical Fluoride for Children (TLC-CH) – CalViva Health (PDF)
- Topical Fluoride for Children (TLC-CH) – Community Health Plan of Imperial Valley (PDF)
- 0 to 15 Months (W30-6+) – Medi-Cal (PDF)
- 0 to 15 Months (W30-6+) – CalViva Health (PDF)
- 0 to 15 Months (W30-6+) – Community Health Plan of Imperial Valley (PDF)
- Well-Child Visits in the First 30 Months of Life - 15 to 30 Months (W30-2+) – Commercial/Medi-Cal (PDF)
- Well-Child Visits in the First 30 Months of Life - 15 to 30 Months (W30-2+) – CalViva Health (PDF)
- Well-Child Visits in the First 30 Months of Life - 15 to 30 Months (W30-2+) – Community Health Plan of Imperial Valley (PDF)
- 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) – Community Health Plan of Imperial Valley (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) – Community Health Plan of Imperial Valley (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) – Community Health Plan of Imperial Valley (PDF)
- Eye Exam for Patients with Diabetes (EED) – Wellcare By Health Net (PDF)
- Glycemic Status Assessment for Patients with Diabetes – Commercial/Medi-Cal (PDF)
- Glycemic Status Assessment for Patients with Diabetes – CalViva Health (PDF)
- Glycemic Status Assessment for Patients with Diabetes – Community Health Plan of Imperial Valley (PDF)
- Glycemic Status Assessment for Patients with Diabetes – Wellcare By Health Net (PDF)
- Blood Pressure Control for Patients With Diabetes (BPD) – Commercial (PDF)
- Blood Pressure Control for Patients With Diabetes (BPD) – CalViva Health (PDF)
- Blood Pressure Control for Patients With Diabetes (BPD) – Community Health Plan of Imperial Valley (PDF)
- Blood Pressure Control for Patients With Diabetes – Wellcare By Health Net (PDF)
- Kidney Health Evaluation for Patients With Diabetes (KED) – Commercial/Medi-Cal (PDF)
- Kidney Health Evaluation for Patients With Diabetes (KED) – CalViva Health (PDF)
- Kidney Health Evaluation for Patients With Diabetes (KED) – Community Health Plan of Imperial Valley (PDF)
- Kidney Health Evaluation for Patients With Diabetes (KED) – Wellcare By Health Net (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Commercial (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Medi-Cal (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – CalViva Health (PDF)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) – Community Health Plan of Imperial Valley (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) – Community Health Plan of Imperial Valley (PDF)
- Statin Therapy for Patients with Cardiovascular Disease (SPC_STCVD) – Wellcare By Health Net (PDF)
- Plan All-Cause Readmissions O/E Ratio (PCR) – Commercial/Medi-Cal (PDF)
- Plan All-Cause Readmissions O/E Ratio (PCR) – CalViva Health (PDF)
- Plan All-Cause Readmissions O/E Ratio (PCR) – Community Health Plan of Imperial Valley (PDF)
- Plan All-Cause Readmissions O/E Ratio (PCR) – Wellcare By Health Net (PDF)
- Appropriate Testing for Pharyngitis (CWP) – Commercial/Medi-Cal (PDF)
- Appropriate Testing for Pharyngitis (CWP) – CalViva Health (PDF)
- Appropriate Testing for Pharyngitis (CWP) – Wellcare By Health Net (PDF)
- Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) and Appropriate Treatment for Upper Respiratory Infection (URI) – Commercial/Medi-Cal (PDF)
- Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) and Appropriate Treatment for Upper Respiratory Infection (URI) – CalViva Health (PDF)
- Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) and Appropriate Treatment for Upper Respiratory Infection (URI) – Wellcare By Health Net (PDF)
- Use of Imaging Studies for Low Back Pain (LBP) – Commercial/Medi-Cal (PDF)
- Use of Imaging Studies for Low Back Pain (LBP) – CalViva Health (PDF)
- Use of Imaging Studies for Low Back Pain (LBP) – Community Health Plan of Imperial Valley (PDF)
- Use of Imaging Studies for Low Back Pain (LBP) – Wellcare By Health Net (PDF)
- Chlamydia Screening in Women (CHL) – Commercial/Medi-Cal (PDF)
- Chlamydia Screening in Women (CHL) – CalViva Health (PDF)
- Chlamydia Screening in Women (CHL) – Community Health Plan of Imperial Valley (PDF)
- Postpartum Care (PPC-POST) – Commercial/Medi-Cal (PDF)
- Postpartum Care (PPC-POST) – CalViva Health (PDF)
- Postpartum Care (PPC-POST) – Community Health Plan of Imperial Valley (PDF)
- Prenatal Care (PPC-PRE) – Commercial/Medi-Cal (PDF)
- Prenatal Care (PPC-PRE) – CalViva Health (PDF)
- Prenatal Care (PPC-PRE) – Community Health Plan of Imperial Valley (PDF)
- Improve CAHPS Results and Patient Experience – Commercial/Medi-Cal (PDF)
- Improve CAHPS Results and Patient Experience – CalViva Health (PDF)
- Improve CAHPS Results and Patient Experience – Community Health Plan of Imperial Valley (PDF)
- Improve CAHPS Results and Patient Experience – Wellcare By Health Net (PDF)
- CAHPS Tip Sheet – Commercial/Medi-Cal (PDF)
- CAHPS Tip Sheet – CalViva Health (PDF)
- CAHPS Tip Sheet – Community Health Plan of Imperial Valley (PDF)
- CAHPS Tip Sheet – Wellcare By Health Net (PDF)
- Want Healthy Patients? Recommend the Flu Vaccine – Commercial/Medi-Cal (PDF)
- Want Healthy Patients? Recommend the Flu Vaccine – CalViva Health (PDF)
- Want Healthy Patients? Recommend the Flu Vaccine – Community Health Plan of Imperial Valley (PDF)
- Want Healthy Patients? Recommend the Flu Vaccine – Wellcare By Health Net (PDF)
- HEDIS Incentive Crosswalk – Medi-Cal (PDF)
- HEDIS Incentive Crosswalk – Calviva Health (PDF)
- HEDIS Incentive Crosswalk – Community Health Plan of Imperial Valley (PDF)
- HEDIS Provider Pocket Guide – Medi-Cal (PDF)
- HEDIS Provider Pocket Guide – CalViva Health (PDF)
- HEDIS Provider Pocket Guide – Community Health Plan of Imperial Valley (PDF)
- IHA Provider Tip Sheet – Medi-Cal (PDF)
- IHA Provider Tip Sheet – CalViva Health (PDF)
- IHA Provider Tip Sheet – Community Health Plan of Imperial Valley (PDF)
Refer to Provider Quality Improvement page for more resources.