Welcome to the new HEDIS section of our Office Visit newsletter! Here you will find current information on selected measures with tips from our Quality team to help you document accurately to meet HEDIS requirements. You’ll also find:
- Valuable resources.
- Updates on HEDIS changes.
What is HEDIS®?
The Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA) in the 1980s is the most widely used standard performance measure in the managed care industry.
HEDIS plays a crucial role in driving health care quality improvement, and as a provider you play a critical role in HEDIS performance.
All health insurance plans must report to regulatory agencies such as NCQA, CMS, and New York state a certain set of measurements that are assigned scores. HEDIS measures are based on preventative health guidelines and have detailed specifications on what is considered compliant. The agencies compile insurance plans’ scores and share them with the public.
How HEDIS Scores Are Used
HEDIS scores help individuals and employer groups compare performances and select a health plan. The scores also help plans and regulatory agencies identify areas of strength and those needing improvement.
How HEDIS Data Is Collected
HEDIS data is collected through many ways:
- Medical record reviews.
- Administration/claims.
- Electronic data systems.
- Surveys such as Consumer Assessment of Healthcare Providers and Systems (CAHPS).
- Supplemental files sent in by providers.
Quick Tips for HEDIS Documentation
- Every medical record submitted must have a demographic page with the patient’s first name, last name, and date of birth.
- Every medical record submitted must have the patient’s first name, last name, and date of birth, in addition to the full member demographic page.
- Allowing us access to your electronic medical record (EMR) saves you and your staff time.
Featured Measures
Breast Cancer Screenings and Osteoporosis Management in Women Who Had a Fracture (OMW)
This month we want to remind you that while Breast Cancer Awareness Month ended in October, as a provider you play a key role in educating patients about the importance of early detection and testing all year long.
For women 40–74 years of age who have had a mammogram for breast cancer screening from October, November, and December 2023 to Dec. 31, 2025, we recommend scheduling mammograms with the bone mineral density (BMD) test/DEXA scan to ensure compliance for both breast cancer and osteoporosis screenings.
Documentation Tips: Breast Cancer Screenings
- When documenting a mammogram in the patient’s history, specify mammogram and the date of service.
- If the exact date is unknown, documenting the month and year is acceptable. A result is not required.
- Documentation “mammogram completed” and the date is acceptable.
Exclusions:
- Documentation must indicate a bilateral mastectomy any time during the patient’s history through Dec. 31, 2025.
- Documentation in the patient that a unilateral mastectomy on both the left and right side on the same or different dates of service through Dec. 31, 2025.
- Patients receiving hospice or palliative care any time during the measurement year.
Osteoporosis Management in Women Who Had a Fracture (OMW)
This measure targets female patients 67–85 who suffered a fracture from July 1, 2024, through June 30, 2025, who had either a BMD test or prescription for a drug to treat osteoporosis in the 180 days (six months) of the fracture. The following illustrate triggers for being included in the measure:
- BMD test during inpatient stay is acceptable.
- Long-acting osteoporosis medication during the inpatient stay are acceptable.
Note: Fractures of the fingers, face, toes, and skull are not included in this measure.
Eye Exam for Patients with Diabetes
The Eye Exam for Patients With Diabetes (EED) HEDIS measure assesses patients 18–75 years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an optometrist or ophthalmologist. The following illustrate triggers for being included in the measure:
- A negative retinal or dilated eye exam (negative for retinopathy) in 2025 or 2024.
- A positive retinal or dilated exam (positive for retinopathy) in 2025.
Tips:
- Refer patients to an optometrist or ophthalmologist annually for dilated or retinal eye exams.
- Documentation in the medical record should include the date of the dilated or retinal exam, the results, and the name of the eye care provider and credentials.
- If a patient reports an eye exam, document the date, results, and eye care provider’s name and credentials in the medical record.
- Fundus/retinal photography may be used if the documentation includes the date, results, and eye care provider’s name and credentials.
- RetinaVue done in PCP office is accepted if the results were reviewed by an ophthalmologist/optometrist and if the documentation includes the eye care provider’s name and credentials.
- Use our Eye Fax Form to submit eye exam completed in 2024, 2025 with results and signed.
- Give the member a copy of the Eye Fax Form to bring to the ophthalmology/optometry visit so the results can be sent to you.
Look for more HEDIS tips next month.