HEDIS Information Collection Request (CMS-10219)

ATTACHMENT 1:

GENERAL GUIDELINES FOR
DATA COLLECTION AND REPORTING

General Guidelines for Data Collection and Reporting

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General Guidelines for
Data Collection and Reporting
SUMMARY OF CHANGES TO HEDIS 2010
Removed the requirement that organizations must report the related quality measure when reporting an
RRU measure from General Guideline 12: How Rotation Works.
Revised PPO reporting requirements in General Guideline 38: Data Collection Methods.
Added General Guideline 48: Administrative Data Refresh.
Revised Table 1 to reflect changes in reduction of sample size based on the prior year’s rate.
Clarified how the eligible member population should be sorted.

HEDIS Reporting
1. Product-Line Reporting
HEDIS results must be collected and reported separately for populations covered by commercial insurance,
Medicaid and Medicare.

2. Product-Specific Reporting
At the organization’s discretion, HEDIS results may be reported separately by product (e.g., HMO, POS,
PPO) or combined (HMO/POS). Organizations that would like to report a PPO product combined with the
HMO or POS product must submit a written request to PCS at www.ncqa.org/pcs for approval. The request
must specifically address all the elements contained in General Guideline 3: HEDIS Submission for
Organizations Seeking Accreditation.
The organization must submit data for an entire product, including consumer-directed or high-deductible
health plan (e.g., CDHP, HDHP) products that may be offered under an HMO or a PPO license. The
organization must include all members—including administrative services only (ASO) members—except
when the contract prohibits the organization from contacting members under any circumstances (a ―no-touch‖
contractual agreement). The organization may exclude no-touch members from HEDIS/CAHPS results and
from accreditation. Refer to General Guideline 24: Self-Insured Members for more information.
Definitions
HMO

Health maintenance organization. An organized health care system that is accountable
for both the financing and delivery of a broad range of comprehensive health services to
an enrolled population.
An HMO is accountable for assessing access and ensuring quality and appropriate care.
Practitioners affiliated with the health care system render health care services. In this
type of organization, members must obtain all services from affiliated practitioners and
must usually comply with a predefined authorization system to receive reimbursement.
A practitioner is a professional who provides health care services and is usually
required to be licensed as defined by law.

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POS

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Point of service. An HMO with an opt-out option. In this type of organization, members
may choose to receive services either within the organization’s health care system (e.g.,
an in-network practitioner) or outside the organization’s health care delivery system
(e.g., an out-of-network practitioner).
The level of benefits or reimbursement is generally determined by whether the member
uses in-network or out-of-network services. Common uses of ―POS‖ include references
to products that enroll each member in both an HMO (or HMO-like) system and in
an indemnity product. A POS product is also referred to as an ―HMO swing-out
organization,‖ an ―out-of-organization benefits rider to an HMO‖ or an ―openended HMO.‖

PPO

Preferred provider organization. PPOs take responsibility for providing health benefitsrelated services to covered individuals and for managing a practitioner network. They
may administer health benefits programs for employers, either by assuming insurance
risk or by providing only administrative services.

3. HEDIS Submission for Organizations Seeking Accreditation
HEDIS results must correspond with the product line/product combination for which the organization seeks
accreditation. NCQA defines the organization for accreditation and HEDIS reporting as part of the
accreditation application process.

How NCQA Defines an Organization for Accreditation
NCQA defines the accreditable organization (also called the ―accreditable entity‖) based on the legal entity
and management structure and delivery system that support the product lines/products NCQA accredits.
NCQA’s goal is to arrive at accreditation decisions that reflect the organization that is legally accountable for
services provided to its members and represents an organizational and delivery structure that is meaningful to
members. NCQA considers the following structural factors when defining the entity NCQA evaluates for
purposes of accreditation and HEDIS scoring.
Legal entity

The first factor that NCQA considers when defining an organization is its legal structure.
The goal is to identify the legal entity that issues a contract for insurance for a defined
population or contracts with an employer to provide managed care services to a selfinsured population.
For HMO and POS organizations only, if the organization consists of multiple legal
entities within a state, but otherwise operates as a single, statewide organization (i.e.,
same management structure; a single practitioner/provider network for the entire state;
centralized key functions, including quality improvement [QI], credentialing [CR] and
utilization management [UM]), NCQA awards accreditation decisions for each legal entity,
but the organization may submit one statewide HEDIS submission that is applied to each
legal entity.

Practitioner
and provider
network

The organization must have a single practitioner or provider network. If there are
separate and distinct practitioner/provider networks, NCQA may consider each network
and accompanying management structure a separate organization. NCQA recognizes
that organizations sometimes market individual products with practitioner/provider
networks that are subsets of a larger network. In this case, NCQA may define the
organization at the level of the broader network.

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Organizations that want to submit a request to report PPO/HMO/POS products in
combination must have HMO/POS and PPO practitioner and provider networks that
are at least 80 percent the same. If more than 20 percent of practitioners and
providers do not participate in networks for both the HMO/POS and PPO products,
NCQA requires separate HEDIS reporting for PPO and HMO/POS.
Centralization

NCQA considers the degree of centralization of key functions assessed by the
accreditation standards. The organization should have a single QI program and a
single set of UM, CR, Member Rights and Responsibilities (RR) and Member
Connections (MEM) policies and procedures for the functions evaluated by the
standards, including disease and complex case management, utilization
management, credentialing, managing members complaints and appeals and
developing member materials. If key functions are decentralized, with distinct
policies and procedures, NCQA may determine that there is more than one
accreditable entity.

Licensure

NCQA takes licensure into account when defining an organization. The organization
may have multiple licenses, especially if its service area crosses state lines.

HEDIS/CAHPS
reporting unit

The organization’s HEDIS/CAHPS reporting unit is a key consideration in
determining the accreditable entity (see ―HEDIS Reporting for Accreditation‖, below
for the definition of the HEDIS/CAHPS reporting unit). In general, because
evaluation of HEDIS/CAHPS results is a component of the Accreditation score and
NCQA issues a unique status for each HEDIS/CAHPS reporting unit, the
accreditable entity is the same as the HEDIS CAHPS reporting unit.

HEDIS Reporting for Accreditation
NCQA combines Accreditation Survey results with specified HEDIS results for the product lines/products
defined below, and issues accreditation decisions by product line/product.
HEDIS/CAHPS
reporting unit

Organizations annually submit HEDIS/CAHPS results for a defined set of
measures. NCQA evaluates an organization’s results at the time of its Accreditation
Survey and annually, between surveys, based on its performance on the measures.
NCQA uses the following criteria to define a HEDIS/CAHPS reporting unit.
Product line and product (refer to General Guideline 1: Product-Line
Reporting and General Guideline 2: Product-Specific Reporting)
Geographic unit

Geographic unit

HEDIS performance varies geographically throughout the United States. Results
must reflect geographic variation to be meaningful to consumers and purchasers.
For HMO and POS plans—which are generally incorporated locally and regulated
individually by states—the size of the geographic unit is limited by the legal entity.
Plans must report HEDIS/CAHPS for HMO and POS products at a reporting unit no
larger than each legal entity, except as noted below under Minimum enrollment
thresholds.
For PPO products, which may have a service area that is larger than a single state,
the plan is required to report HEDIS/CAHPS results for geographic regions no
larger than a state, except as noted below under Minimum enrollment thresholds.
Current NCQA policies that allow HEDIS/CAHPS reporting across state lines in
large metropolitan areas or when the organization has a small population out of
state remain unchanged.

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Minimum
enrollment
thresholds

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NCQA’s goal is to maximize an organization’s ability to produce HEDIS/CAHPS
results. A HEDIS/CAHPS reporting unit (accreditable entity) must have a sufficient
number of members to calculate rates. NCQA recognizes that producing HEDIS/
CAHPS results can be resource intensive, and has established a minimum
membership threshold for requiring HEDIS reporting. A geographic unit with 15,000
or more members in a product/product line must submit audited HEDIS/CAHPS
results to NCQA to be scored as part of accreditation.
If the reporting unit has fewer than 15,000 members, NCQA has established
alternative accreditation policies for combining HEDIS/CAHPS reporting units, or
accrediting an organization on standards, or standards and CAHPS only.

Combining
reporting units
with <15,000
members

Entities may be combined when, based solely on geographic reporting policy, a
single legal entity is considered to have multiple HEDIS/CAHPS reporting units and,
therefore, has multiple accreditable entities, one or more of which does not meet
the minimum membership threshold. Refer to Combining accreditable entities and
HEDIS/CAHPS reporting units. A reporting unit with less than 15,000 members that
cannot meet the criteria for combining results must follow the alternative policies
described below.

Reporting units
with <15,000
members

A HEDIS/CAHPS reporting unit (accreditable entity) with less than 15,000 members
may choose one of the following options for reporting:
Submit a unique set of audited HEDIS/CAHPS results to NCQA to be scored
as part of accreditation. If the results submitted have too many audit results
of Small Denominator (SD) or No Benefit (NB), the reporting unit may be
scored on standards and CAHPS only or on standards only.
Combine its membership with another reporting unit in accordance with the
policies described below, if applicable, to submit audited HEDIS/CAHPS
results.
Submit a unique set of CAHPS results only and be scored on standards and
CAHPS only or on standards only.
Not submit HEDIS/CAHPS or CAHPS results and be scored on standards
only.
When accrediting an organization on standards and CAHPS only or standards only,
NCQA will award a status no higher than Commendable.

Combining
accreditable
entities and
HEDIS/CAHPS
reporting units

The organization may combine two or more HEDIS/CAHPS reporting units
(accreditable entities) into a single unit in order to achieve the minimum reporting
threshold if they meet the following criteria.
Reporting units are part of a single legal entity
When combined, reporting units meet all other NCQA criteria for being
defined as a single accreditable entity (e.g., licensure, centralization, provider
network)
Reporting units share contiguous geographic borders (e.g., side-by-side or
corner-to-corner states) and are within the same CMS region

Combining

The organization may not combine reporting for product lines (commercial,
Medicare, Medicaid), and must combine the fewest number of reporting units
necessary to meet the threshold, allowing all reporting units to be able to report
HEDIS/CAHPS for accreditation. The organization must submit HEDIS/CAHPS
results for all reporting units within a CMS region when combining results.
Reporting units may combine membership for bordering states that cross CMS

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across CMS
regions in limited
situations

regions if all other conditions for combining are met, and the organization is not
―licensed‖ or ―selling‖ in the adjacent state, but has membership across the border
because of commuting or residency reasons.

Approval process
for all HEDIS
state combining
requests

All organizations that want to combine states for HEDIS reporting must submit a
request to NCQA for review and approval each year, even if NCQA has approved
combining in a prior year. Organizations must submit requests annually by
December 31 of the year prior to reporting through the NCQA Policy Clarification
Support (PCS) System; must include membership by state as of July 1 of the
HEDIS measurement year and by applicable product or product line; and must
document how the policies for combining are met. NCQA will respond to the
request within 20 business days.

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The following flow chart illustrates the combining policy.

Does the HEDIS/CAHPS reporting unit
(accreditable entity) have 15,000
or more members?

Yes

Submit audited HEDIS/CAHPS results
to NCQA

No

Does the reporting unit meet criteria to
combine with other units?

Yes

Combine the fewest number of
HEDIS/CAHPS reporting units necessary
to meet the threshold, allowing all
reporting units to be able to report
HEDIS/CAHPS for accreditation

No

Produce and submit a unique set of audited
HEDIS/CAHPS results to NCQA to be scored
as part of accreditation
or
Submit CAHPS results and be scored on
standards and CAHPS
or
Choose to be scored on standards only

Example 1

Under NCQA’s definition of accreditable entity, Plan A and Plan B are each a distinct
accreditable entity and HEDIS/CAHPS reporting unit. Each is a PPO plan that shares
contiguous geographic borders; each has a membership of 8,000. They meet all the
criteria above to combine membership, including being part of a single legal entity and
sharing borders. Plan A and Plan B may combine into a single accreditable entity and
HEDIS/CAHPS reporting unit.

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Example 2

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Under NCQA’s definition of accreditable entity, Plan A, Plan B and Plan C are considered
distinct accreditable entities and HEDIS/CAHPS reporting units. Each is a PPO plan
that shares contiguous geographic borders; each has a membership of 8,000. All
organizations meet all the criteria above to combine membership, including being part of
a single legal entity and sharing borders.
If Plan A and Plan B combine, the resulting accreditable entity/reporting unit meets the
threshold and leaves Plan C unable to report HEDIS/CAHPS for accreditation. Therefore,
all three plans may combine into a single accreditable entity and HEDIS/CAHPS reporting
unit.

Example 3

Under NCQA’s definition of accreditable entity, Plan A, Plan B, Plan C and Plan D are
each a distinct accreditable entity and HEDIS/CAHPS reporting unit. Each is a PPO plan
that shares contiguous geographic borders. Plans A and B have 7,000 members each.
Plans C and D have 8,000 members each. All plans meet all the criteria above to
combine membership, including being part of a single legal entity and sharing borders.
Under the policy, Plans A and B could combine, and because they will be short of the
minimum threshold requirement of 15,000 members, they may add Plan C. This would
leave Plan D unable to report and require all four plans to combine. But the intent of the
policy is for the fewest entities to combine to meet the minimum, and therefore, Plan A
should combine with Plan C, and Plan B should combine with Plan D, creating two
reporting units with 15,000 members each.

4. HEDIS Submission for Organizations Not Seeking Accreditation
To determine how many HEDIS reports to produce, the organization must define itself using the criteria
specified by NCQA. An organization unable to determine the HEDIS reporting entity should submit written
documentation relating to the criteria described in General Guideline 3: HEDIS Submission for Organizations
Seeking Accreditation to the NCQA Policy Department via the PCS System at www.ncqa.org/pcs or by fax to
202-955-3599. NCQA staff review the organization’s structure and make the final determination.

5. Model Type and Mixed-Model Type Organizations
Model type is the type of structure the organization uses to provide members with care (e.g., Staff, Group,
IPA, Direct Contract, Mixed, Network).
Mixed-model organizations (e.g., an organization with an IPA and a group model) should report data for all
model types combined.

6. Reporting HEDIS for Medicaid
Separate Medicaid HEDIS reports should be produced for each state with which the organization has a
Medicaid contract.
If the organization contracts with a local entity (e.g., a county) rather than a state and contracts with each
locality in which it provides service, the state and organization should discuss providing one comprehensive
Medicaid HEDIS report by each organization to encompass all geographic areas served by the organization in
that state.

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7. Reporting HEDIS for Medicare
HEDIS reporting is required for the following.
Medicare Advantage (MA) contracts
Section 1876 cost contracts with active enrollment
Special Needs Plans (SNP)
Certain demonstration projects
All members covered under these contracts are included in Medicare HEDIS reporting.
CMS communicates directly with all contracted organizations on additional reporting requirements (e.g.,
market area reporting, patient identifier information). Refer to the Medicare Managed Care Manual, Chapter 5:
Quality Assessment on the CMS Web site (www.cms.gov).
SNPs are required to submit a subset of HEDIS measures. These plans include the dual-eligible, chronic care
and institutional benefit packages. For more information on SNP reporting requirements, go to
www.ncqa.org/snp.aspx.

8. Reporting HEDIS for the Children’s Health Insurance Program (CHIP)
CHIP

States may contract with an organization to provide care to Children’s Health
Insurance Programs (CHIP) members as part of the organization’s Medicaid product
line, the commercial product line, or separate from both the Medicaid and commercial
product lines. A state that contracts with an organization to care for CHIP members
should enable the contracting organization to identify CHIP members, when possible.

Reporting
guidelines

Reporting performance measures for CHIP members should be consistent with the
organization’s Medicaid contracting status and the direction of the state.
If the state has identified CHIP members to a contracting organization and the
contracting organization is also collecting and reporting Medicaid HEDIS results, the
organization should perform one of the following, as directed by the state.
Report required HEDIS measures separately for CHIP members, or
Include CHIP members in its Medicaid product-line reports
The organization must exclude CHIP members from its commercial product-line
reports, because including CHIP members in HEDIS reports for commercially enrolled
populations may affect organization-to-organization comparison.
In addition, an organization with a small number of eligible CHIP members should
follow General Guideline 37: Small Numbers. The organization should consult with its
respective states to determine specific CHIP HEDIS reporting requirements.
NCQA will continue to work with CMS, the Agency for Healthcare Research and
Quality (AHRQ), states and organizations to gain additional experience with issues
and opportunities for future reporting on children covered by CHIP.

Continuous
enrollment
requirements

Whether the CHIP population is reported separately or included in the Medicaid
HEDIS report, the organization should follow the Medicaid product line specifications
and continuous enrollment requirements.

The HEDIS Compliance Audit
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The HEDIS Compliance AuditTM is a process that runs concurrent with HEDIS Data Collection. The audit
allows comparability across organizations and ensures validity and integrity of HEDIS data. It is required for
organizations seeking NCQA Accreditation or for reporting in NCQA public reporting products, including
Quality Compass®. The audit is required by many states and employer groups.

9. Audit Preparation
Contracting
with an audit
firm

The organization should request an application for a HEDIS Audit from an NCQA
Licensed Organization (www.ncqa.org/audit.aspx) and is responsible for determining
fees and entering into contracts. The first activity in audit preparation is contract
execution. The organization should contact the NCQA Licensed Organization for bids
and select a firm to conduct the HEDIS audit.
The contracting phase includes assessing measures to report, executing the contract
with all the necessary ancillary agreements (e.g., confidentiality and conflict of
interest) and negotiating a timeline. All Licensed Organizations employ or contract
with Certified Auditors and select an audit team for the organization.

HEDIS
Roadmap

The HEDIS Record of Administration, Data Management and Processes (formerly
known as the ―BAT‖) is a comprehensive instrument that must be completed by each
organization. Auditors use the HEDIS Roadmap to review information about the
organization’s systems for collecting and processing data to produce HEDIS reports.
The HEDIS Roadmap also describes the operational and organizational structure of
the organization. It includes detailed questions about all audit standards and is used
by auditors to organize the site visit.

10. Reporting

Audit results
…for HEDIS
measures

HEDIS Compliance Audits result in audited rates or calculations at the measure level
and indicate if the measures can be publicly reported. All measures selected for
public reporting must have a final, audited result. The auditor approves the rate or
report status of each measure and survey included in the audit, as shown below.
A rate or numeric result. The organization followed the specifications and produced
a reportable rate or result for the measure.
Small Denominator (NA). The organization followed the specifications but the
denominator was too small (<30) to report a valid rate.
Benefit Not Offered (NB). The organization did not offer the health benefit required
by the measure (e.g., mental health, chemical dependency).
Not Reportable (NR). The organization calculated the measure but the rate was
materially biased or the organization chose not to report the measure.

…for survey
sample frames

Reportable (R). The survey sample frame was reviewed and approved.
Not Reportable (NR). Indicates the survey sample frame was incomplete or
materially biased, or an NCQA-Certified Survey Vendor did not administer the
survey.

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Material bias

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The organization cannot report a rate for a measure that the auditor determines is
biased. Bias is based on the degree of data completeness for the data collection
method used and differs according to measure and domain. Three assessments of
bias are used. Refer to Appendix 8: Bias Determination in Volume 5: HEDIS
Compliance Audit™: Standards, Policies and Procedures for a description of the
assessments and a list of measures to which they apply.

11. Marketing
Release by the organization of HEDIS Audit results must be in accordance with the HEDIS Compliance Audit
Guidelines for Advertising and Marketing (Appendix 5 of this volume). The organization may release the entire
Final Audit Report without prior authorization from NCQA; however, it must obtain written authorization from
NCQA before releasing any information abridged, summarized or quoted from the Final Audit Report.

Measure Rotation
12. How Rotation Works
To reduce the overall HEDIS reporting burden and allow the organization to allocate resources to
improvement activities, NCQA instituted a measure rotation strategy where the organization may rotate
select commercial and Medicaid measures and surveys on a biennial basis. Measure rotation allows the
organization to use the audited and reportable Hybrid Method rate or survey from the prior year’s data
collection in lieu of collecting the measure for the measurement year. Each year NCQA specifies a list of
measures eligible for rotation. Measures are rotated on a structured schedule and are eligible for rotation
every other year. Measures may not be rotated in a year when they are not eligible for rotation.

13. Criteria for Eligibility
The following criteria must be satisfied in order for the organization to rotate a measure.
The measure is on the list of those eligible for rotation in 2010
The organization has an audited and reportable rate produced using the Hybrid Method from the prior
year
The organization’s reporting entity has remained constant since the preceding year
The organization had a reportable small denominator audit result (NA for HEDIS 2009) and that result
still applies (NA audit result for HEDIS 2010)
Note: The HEDIS Compliance Audit may include selecting a core set of measures for source code review.
Even if the organization chooses the rotation option, the certified auditor can select an appropriate core set
(excluding rotated measures) and conduct the audit.

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14. Measures Eligible for Rotation
Measure rotation applies to the commercial and Medicaid product lines only, but the organization should defer
to state regulatory agencies about individual state decisions regarding the rotation strategy. The following
measures are eligible for rotation for HEDIS 2010.
Cervical Cancer Screening (Medicaid only)
Controlling High Blood Pressure
Frequency of Ongoing Prenatal Care
Prenatal and Postpartum Care
Weeks of Pregnancy at Time of Enrollment
CAHPS Health Plan Survey—4.0H, Child Version
Children With Chronic Conditions

15. Rotation and HEDIS Scoring for Accreditation
A number of measures eligible for rotation are used for accreditation scoring. NCQA holds thresholds
constant for rotated measures. The organization may rotate measures and retain its HEDIS results and
accreditation scores; it may also collect and report rotated measures and update HEDIS results to increase
the accreditation score, or for other reasons. When deciding to rotate a measure, an organization in the
NCQA Accreditation process should consider whether its accreditation score on the measure was
satisfactory.

16. Measure Rotation and Data Submission
The organization must use the Interactive Data Submission System (IDSS) to indicate rotated measures. The
organization retains responsibility for submitting data to NCQA through the IDSS by the HEDIS reporting
deadline. NCQA provides instructions for completing the IDSS in the IDSS Users Guide.

In Which Reports Should HEDIS Members Remain?
17. Eligible Population
The eligible population for any measure is all members who satisfy all specified criteria, including any age,
continuous enrollment, benefit, event or anchor date enrollment requirement. The organization must include
all members (regardless of benefit level) in the appropriate HEDIS report, with the exception of self-insured
members that meet the criteria outlined in General Guideline 24.
For the Administrative Method, the rate is calculated using the eligible population after any exclusions
are removed
For the Hybrid Method, the rate is calculated using the denominator (i.e., the systematic sample drawn
from the eligible population) after any exclusions are removed
Note: Refer to the measurement specifications for the criteria of eligible population for a specific measure.

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18. Commercial Members
Members enrolled through an employer group policy or through an individual or family policy should be
included in the commercial HEDIS report.

19. Employer-Specific HEDIS Reports
NCQA does not recommend calculating employer-specific HEDIS reports because of confidentiality concerns,
statistical concerns arising from small numbers and the medical record review burden for measures collected
using the Hybrid Method.

20. The “Working Aged” and Retirees
Include employees 65 years of age and older and retirees in the product line that provides their primary
coverage (Medicare or commercial).

21. Medicaid/Medicare-Eligible Members
Include these members in both the organization’s Medicaid and Medicare HEDIS report only if the members
are enrolled in the organization’s MA contract or a Section 1876 Cost Contract and its Medicaid managedcare contract. An organization with a dual-eligible SNP benefit package should also include these members in
its SNP submission.
Members who have Medicare fee-for-service (FFS) or unknown Medicare coverage as their primary insurer
may be excluded from the organization’s Medicaid report.

22. Members With Dual Coverage in Different Organizations
The organization should not try to account for coordination of benefits with other insurance carriers. NCQA
recommends that for members with coverage in different organizations, both organizations include the
members in their HEDIS reports, regardless of primary insurer. For example, dependent children who are
enrolled in one organization’s commercial product line under the mother’s insurance, and enrolled in another
organization’s commercial product line under the father’s insurance, should be included in both HEDIS
reports.

23. Members With Dual Coverage in the Same Organization
For members with dual coverage in the organization (e.g., children enrolled under each parent), the
organization must adhere to the following criteria.
If members are enrolled twice in an HMO product, include them only once in the HMO report
If the organization reports the HMO and POS products separately, include members with dual
coverage in the HMO and POS products in both HEDIS reports
If the organization reports the HMO and POS products combined or the HMO/POS/PPO products
combined, include members in each product only once in the HMO/POS or HMO/POS/PPO combined
report

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24. Self-Insured Members
Administrative
services only

Include self-insured ASO members in the organization’s HEDIS reports. Selfinsured members may be excluded from the HEDIS reports in either one of the
following circumstances.
The contract prohibits the organization from contacting members under any
circumstances (no-touch policy). ASO members can only be excluded due
to ―no touch‖ contractual agreements with identified purchasers. A notouch contractual agreement is a contract or other written agreement
between the organization (i.e., HMO or PPO) and the ASO specifically
stating that the organization cannot contact these members under any
circumstances. The organization may exclude no-touch members from
HEDIS/CAHPS results and from accreditation because they are not
managed in the same way as other members.
The organization is not responsible for administering both in-network and
out-of-network claims for members (i.e., employer carve-out). If claims are
administered through a third party on behalf of the organization, the
organization is considered to be responsible for administering claims.

Membership Changes
25. Members Who Switch Organizations
The organization may count members who switch organizations as continuously enrolled, provided the
members joined an organization that assumes ownership of or responsibility for the member’s administrative
data and medical records for the entire period of continuous enrollment specified in the measure.
An organization that chooses to report these members as continuously enrolled must follow the same
definition of continuous enrollment as described in General Guideline 29: Continuous Enrollment, and must
follow all other guidelines affecting continuous enrollment (i.e., allow switching between products [HMO, POS,
PPO] or product lines [Medicaid, commercial, Medicare]). An organization that adopts this guideline must do
so consistently across all measures.

26. Members Who Switch Organizations as a Result of a Merger or Acquisition
Measures with
a continuous
enrollment period

The organization has the option of counting as continuously enrolled members
who switch organizations because of a merger that occurred during the
measurement year. An organization that adopts this guideline must do so
consistently across all measures.

Measures without
a continuous
enrollment period

The surviving organization has the option of including in the eligible population
members from the nonsurviving entity starting on the official date of the merger or
acquisition. For example, if the merger or acquisition occurred on March 1 of the
measurement year, the surviving organization should exclude the members
acquired from the nonsurviving entity from the eligible population for January and
February. An organization that exercises this option must do so consistently
across all measures.

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27. Members Who Switch Product Lines
Measures with
a continuous
enrollment
requirement

Members enrolled in different product lines (commercial, Medicaid, Medicare) at
different times during the measurement year should be reported in the product
line to which they belonged at the end of the continuous enrollment period. For
example, a member enrolled in the Medicaid product line who switches to the
commercial product line during the continuous enrollment period is reported in the
commercial HEDIS report.
Members who ―age in‖ to a Medicare product line that began mid-year are
considered continuously enrolled, provided that they were members of the
organization through another product line (e.g., commercial) during the
continuous enrollment period and their enrollment did not exceed any allowable
gaps.

Measures without
a continuous
enrollment
requirement

Assign members to a category based on the product line in which they were
enrolled on the date of service (outpatient services) or date of discharge (inpatient
services).

28. Members Who Switch Products
Measures with
a continuous
enrollment
requirement

If the organization reports separately by product, members who switch from the
commercial HMO product to the commercial POS product (or vice versa) in the
time specified for continuous enrollment for a measure are continuously enrolled
and should be included in the product-specific HEDIS report in which they were
enrolled as of the end of the continuous enrollment period. For HMO or POS
HEDIS reporting, count enrollment in a PPO product in the same manner as a
gap in continuous enrollment.
For PPO HEDIS reporting, count enrollment in an HMO or POS product as a
gap in continuous enrollment. For NCQA-approved combined HMO/POS/PPO
reporting, members are considered continuously enrolled.
An organization must use claims data from all products, even when there is a gap
in enrollment.
Enrollment in a Medicare Private Fee-for-Service (PFFS) plan is considered a gap
in HMO/POS and PPO enrollment.

Measures without
a continuous
enrollment
requirement

If the organization reports commercial HEDIS separately by product (e.g., HMO,
POS, PPO), members who switch between products during the measurement
year should be reported in the product to which they were enrolled on the date of
service (outpatient services) or date of discharge (inpatient services).

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Required Enrollment Periods and Benefits
29. Continuous Enrollment
Continuous enrollment specifies the minimum amount of time that a member must be enrolled in the
organization before becoming eligible for a measure. One of several criteria used to identify the eligible
population, it ensures that the organization has a sufficient amount of time to render services to its members.
The continuous enrollment period and any allowable gaps for the period are specified in each measure. The
member must also be continuously enrolled with the benefit specified for each measure (e.g., pharmacy or
mental health), accounting for any allowable gaps, to be considered continuously enrolled.
A gap is the time during which a member is not covered by the organization (i.e., the time between
disenrollment and re-enrollment). For example, if a member disenrolls on June 30 and re-enrolls on July 1,
there is no gap because the member is covered by the organization on both June 30 and July 1. If the
member disenrolls on June 30 and re-enrolls on July 2, there is a 1-day gap because the member is without
coverage on July 1.
An allowable gap can occur any time during continuous enrollment. For example, the Comprehensive
Diabetes Care measure requires continuous enrollment throughout the measurement year (i.e., January 1–
December 31) and allows one gap in enrollment of up to 45 days. A member who enrolls for the first time
on February 8 of the measurement year is considered to be continuously enrolled as long as there are no
other gaps in enrollment throughout the remainder of the measurement year. The member has one 38-day
gap (January 1–February 7).

30. Medicaid Continuous Enrollment
For an organization that applies a full-month eligibility criterion to Medicaid beneficiaries and verifies
enrollment prospectively in monthly intervals (in 1-month increments), the one gap in enrollment during the
continuous enrollment period may not exceed 45 days. A member whose coverage lapses for 2 months
(60 days) is not considered continuously enrolled.
If the organization is prospectively notified of member enrollment, use the actual date of enrollment to
calculate continuous enrollment, not the notification date.
Retroactive
eligibility

The elapsed time between the actual date on which the organization became
financially responsible for the Medicaid member and the date on which it received
notification of the new member. For measures with a continuous enrollment
requirement, the organization has the option to exclude a member if the retroactive
eligibility period exceeds the allowable gap requirement. If the organization
excludes Medicaid members with retroactive eligibility gaps, it must do so
consistently across all measures.

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31. Continuous Enrollment Over Multiple Years
Unless otherwise specified, for measures that span more than 1 year, members are allowed one gap in
enrollment of up to 45 days during each year of continuous enrollment. A gap in enrollment that extends over
multiple years of a continuous enrollment period may exceed 45 days. For example, in the Breast Cancer
Screening measure (which requires 2 years of continuous enrollment), a member who disenrolls on
November 30 of the year prior to the measurement year and re-enrolls on February 1 of the measurement
year is considered continuously enrolled as long as there are no other gaps in enrollment during either year.
The member is considered to have one gap of 31 days (December 1–31) in the year prior to the
measurement year and one gap of 31 days (January 1–31) in the measurement year.

32. Anchor Dates
If a measure requires a member to be enrolled and to have a specified benefit on a particular date, the
specified allowable gap must not include that particular date; the member must also have the benefit on that
date. For example, a 30-year-old woman who has only one gap in enrollment from November 30 of the
measurement year throughout the remainder of the year is not eligible for the Cervical Cancer Screening
measure. Although the member meets the continuous enrollment criteria, she does not meet the anchor date
criteria, which requires her to be enrolled as of December 31 of the measurement year.

33. Required Benefits
…at the
organization
level

…at the
member level
Exhausted
benefits
(optional)

The organization is responsible for reporting HEDIS measures requiring a specific
benefit that it provides to members, either directly or through a contractor.
The organization is not responsible for reporting HEDIS measures requiring a specific
benefit that it does not offer.
Members who do not have a benefit that is specified in the measure should not be
counted in that measure. For example, exclude members who do not have a pharmacy
benefit from the Outpatient Drug Utilization measure.
For measures without a continuous enrollment criteria, only services or procedures that
occurred while the member had a benefit should be included. For a member whose
benefit is lost or exhausted during the time specified in the measure, the organization
should include services or procedures that occurred while the member had the benefit.
For example, for a member whose pharmacy benefit is exhausted on November 1 of
the measurement year, only the outpatient drug expenses that occurred from January
1–October 31 should be reported.
For measures with a continuous enrollment criteria, the required benefits must be
active for the period of continuous enrollment, accounting for any allowable gap. The
organization has the option to exclude the member if the period when the benefit is
exhausted exceeds any allowable gap or anchor date. For example, the Use of
Appropriate Medications for People With Asthma measure requires a pharmacy benefit
during the measurement year. The organization may elect to exclude a member whose
pharmacy benefit is exhausted in September of the measurement year, since this
exceeds the 45-day allowable gap period. If the organization chooses to implement
this guideline, they must do so consistently across measures.

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Carved-out
benefits (optional)

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Some organizations can obtain the necessary information from a carved-out entity
and may include these members in their measures. For example, an employer
contracts directly with a pharmacy benefit manager (PBM), which shares pharmacy
information with the organization. The organization may include the employer’s
members in the measure.

34. Accessing Medical Records Prior to Enrollment
An organization that can access data from a complete medical record should use the data to calculate a
measure, but an organization that cannot access data from a medical record, because the data were updated
before the member was enrolled, should calculate the measure with only the data available.

HEDIS Data Submission and Reporting
35. HEDIS Reporting Date
The previous calendar year is the standard measurement year for HEDIS data. For HEDIS 2010, the
organization should submit data to NCQA on or before June 15, 2010.
State Medicaid agencies will notify a Medicaid-contracting organization of the submission date for Medicaid
HEDIS 2010 data, but an organization with a Medicaid product in the accreditation process must meet the
submission deadline of June 15, 2010.
CMS will notify a Medicare-contracting organization of the submission date for Medicare HEDIS 2010 data,
but an organization with a Medicare product in the accreditation process must meet the submission deadline
of June 30, 2010.

36. Required Data Elements
An organization that submits HEDIS data to NCQA must report the data elements identified in each measure
specification. Data elements are standard for hybrid measures and administrative measures. Refer to
Appendix 4: Data Element Definitions. Data elements with an asterisk ( * ) are optional and are used by
NCQA as part of first-year analysis; they are included only for the first two years of data collection.

37. Small Numbers
Effectiveness of
Care and
Access/
Availability of
Care domains

If during the entire measurement year fewer than 100 members are in the eligible
population for a reported measure, include in the denominator all members
who meet the criteria and report a 95 percent confidence interval. Reporting a
confidence interval is required because the small denominator leads to a rate that is
not as precise as a rate based on a larger denominator. If the denominator used to
calculate a measure is smaller than 30 using either the Administrative or Hybrid
Method, the organization is not required to report the rate but must provide all other
information, including the following.
A count of all members eligible for the measure, as defined by the measure
specification (the eligible population/denominator)
A count of all members who received the treatment or service as indicated
(the numerator)
Separate reporting of numerator and eligible population/denominator information
allows CMS and states to aggregate the data with those of other organizations to
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produce national or statewide data or to calculate a rate. It also serves as a reminder
of the threat of small numbers to the credibility of performance measures. The
Guidelines for Calculations and Sampling contain more information on sample size
and selection and confidence interval calculation.
Tabular Use of
Services
measures

The organization should not suppress reporting for any particular cell in the table
(Discharges; Discharges/1,000 Member Months; Procedures; Days/1,000 Member
Months), regardless of the total member months or member years for the particular
age or sex cohort or the number of measured events (visits, days, discharges, stays,
procedures).

Use of Services
measures that
request a
percentage

For Use of Services measures that request a percentage (Frequency of Ongoing
Prenatal Care, Well-Child Visits in the First 15 Months of Life; Well-Child Visits in the
Third, Fourth, Fifth and Sixth Years of Life; and Adolescent Well-Care Visits) follow
the instructions for Effectiveness of Care measures described above.

Data Collection Methods and Data Sources
38. Data Collection Methods
HEDIS measures are specified for one or more of three data collection methods.
Administrative Method
Hybrid Method
Survey Method
The organization must use the data collection methods specified in a measure for reporting. If the measure
includes both the Administrative and Hybrid Methods, the organization may choose which method to use.
Administrative
Method

Requires the organization to identify the eligible population and numerator using
transaction data or other administrative databases. The organization reports a rate
based on all members who meet the eligible population criteria (after optional
exclusions, if applicable) and who are found through administrative data to have
received the service required for the numerator.

Hybrid Method

Requires the organization to look for numerator compliance in both administrative
and medical record data. The denominator consists of a systematic sample of
members drawn from the measure’s eligible population. The organization reports a
rate based on members in the sample who are found through either administrative or
medical record data to have received the service required for the numerator.

Survey Method

Requires the organization to collect data through a survey. Specifications for survey
measures are included in HEDIS Volume 3: Specifications for Survey Measures;
HEDIS Volume 3 (PPO Version): Specifications for Survey Measures; and HEDIS
Volume 6: Specifications for the Medicare Health Outcomes Survey.

PPO reporting
for HEDIS 2010

Beginning with HEDIS 2010, NCQA allows PPOs to report HEDIS using the Hybrid
Method for all measures, with the exception of the Colorectal Cancer Screening
measure. Because this measure is scored for accreditation using administrative
benchmarks and thresholds, all PPOs must continue to report the measure using the
Administrative Method.

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39. Supplemental Electronic Data
Definitions
Standard files

Supplemental electronic files have a standard format that is well documented and
remains stable from year to year.
Laboratory data in HL-7 format
Immunization data in state registries (may vary from state to state, but are
consistent for all records in each state’s registry)
Encounter data from behavioral health vendors

Nonstandard
files

Supplemental electronic data sources might not follow a standard layout and formats
might differ from source to source.
Electronic files from electronic medical records (EMR)
Electronic files from disease management (DM) or case management systems
Electronic files from measure-exclusion databases

External data

Any automated data supplied by contracted practitioners, vendors or public agencies
(e.g., pharmacies, labs, hospitals, schools, state public health agencies). External
data may also come from EMR. An EMR system is typically developed and
maintained at the hospital or physician office and may be integrated (or linked) to the
organization’s system. External data files can be standard or nonstandard.

Internal data

An automated data file created by the organization that supplements the claim/
encounter data in the HEDIS repository. Data may come from internal systems such
as DM programs. Internal files are nonstandard.

Required data
elements

All supplemental electronic data files must include all the data elements specified in
the measure (e.g., date and place of service, procedure, prescription, practitioner
type). Services must have been rendered within the period specified in the measure.
For data obtained from an EMR, the organization must be able to distinguish between
ordered and completed visits, procedures, lab and radiology orders; only completed
events count toward compliance.

Data collection
timing
…for external
data

External data, including lab data or data files from hospitals and providers, can be
collected throughout the year and during the HEDIS reporting year period, allowing a
reasonable lag for end-of-the-year services.
The organization may send a request for supplemental data to external sources
during the measurement year or early in the reporting year. A request may be for
services for the entire eligible population, for noncompliant members in the full
population or for noncompliant members in the systematic sample, for hybrid
measures.

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data

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The organization may load supplemental data from internal sources during the
measurement year or early in the reporting year. Data may be for services for the
entire eligible population; for noncompliant members in the full population; or for
noncompliant members in the systematic sample, for hybrid measures.
Note: For hybrid measures, only electronic files may be loaded and used like
administrative data to calculate compliance for members in the systematic sample; all
other data for members in the sample come from chart review and must follow the
hybrid measure chart review specifications described in General Guideline 41:
Obtaining Information From Medical Records and EMRs.

Audit
requirements
…for standard
files

All supplemental electronic data are subject to audit review and differ only in the
degree of review required.
For standard files, the auditor is not required to conduct primary source verification to
check the accuracy and validity of data obtained from standard files such as laboratory
data, but the auditor must request documentation to ensure that the agency or
organization responsible for the data has reasonable processes in place for data
collection and accuracy.

…for nonstandard files

For nonstandard files, internal or external, the auditor is required to perform primary
source verification that involves the following tasks.
Create a randomly selected sample using acceptable methods (e.g., the sample
feature in Excel).
Create a sample with a minimum number of records equal to 5 percent of the
total or 25 records (whichever is less). If the number of records in the database
is fewer than the minimum required sample, the auditor must perform primary
source verification for all records.
Review the original paper chart or electronic record (e.g., EMR screen) for each
member in the sample.

…for all files

For each supplemental electronic file, the organization must provide the auditor with
the following documentation.
How the supplemental data file was created
Quality assurance or oversight used
Data quality controls in place
Data security in place
Ongoing maintenance
How the supplemental data file was transmitted
The auditor will further evaluate the policies and procedures for collecting and
managing, mapping, importing and reporting the data.

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40. Supplemental Paper Data
Definitions
Medical record
data

The organization may create data files using information from one or more of the
member’s medical records.
Note: Data pulled from medical records as a result of chart review for a hybrid
measure may be added to a database and used in subsequent HEDIS reporting years,
but the elements must comply with the guidelines concerning data element
requirements and audit review.

Providerreported data

The organization may create internal files containing information from providerreported results.
Note: The organization should not create records or an ongoing database of
exclusions for clinical conditions that can change.

Memberreported data

The only member-reported information that the organization may use is information
obtained by a provider or clinician in the following circumstances.
While taking a patient’s history, orally or from a questionnaire completed by the
patient and presented to the provider, if the following criteria are met.
– The information is in the medical record by the deadline established for the
measure, and
– The medical record includes a note indicating the date of service and the
result (for measures requiring a result)
While taking the patient’s history or experience and recording it in a DM system

Notes
Electronic results from DM systems should be treated as electronic supplemental data.
Data from DM systems can be used if the system is related to the disease being managed, the reported
value was measured by a health care provider, and the DM system information is either in the patient’s
medical record or if the physician has the ability to access the DM system information during a visit.
Member-reported biometric values (e.g., blood pressure [BP] readings, HbA1c levels, LDL-C levels, body
mass index [BMI]) from self-administered tests are not acceptable for HEDIS reporting purposes.
Member survey
data

Organizations and providers may not use information obtained from member surveys.

Required data
elements

All supplemental paper data must include all the data elements specified in the
measure, such as date and place of service, procedure, prescription and practitioner
type. Services must have been rendered within the period specified in the measure.
For data obtained from an EMR, the organization must be able to distinguish between
ordered and completed visits, procedures, lab and radiology orders; only completed
events count toward compliance. Provider forms should resemble provider abstraction
tools and include all data elements required for the measure. They may not be simple
attestations (i.e., a ―yes or no‖ response to the members’ compliance or exclusion);
they must have all necessary data and should be signed by the provider.

Data collection
timing

Note: Organizations and providers may continue to use existing supplemental
databases collected from patient surveys before HEDIS 2008 and approved by a
certified auditor.

Provider-reported data can be collected throughout the year and during the HEDIS
reporting year collection period. Requests for data may be sent to the provider during
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the measurement year or early in the reporting year. A form may be sent for the
entire eligible population or the noncompliant members in the full population.
Note: Provider forms may not be sent for noncompliant members in the systematic
sample for hybrid measures. All paper reviews for members in the sample must
follow the hybrid measures’ chart review specifications described in General
Guideline 41.
Audit
requirements

All supplemental paper data are subject to audit review. For provider forms, the
organization must ensure the following.
Providers were selected appropriately
Forms contain all information necessary to meet the measure requirements
Auditors must review the forms (preferably before mailing), approve the list of
members and selected providers and validate that the organization imported,
evaluated and reported the data properly. The auditor is also required to perform
primary source verification, which includes the following tasks.
Create a randomly selected sample using acceptable methods (e.g., the
sample feature in Excel).
Create a sample with a minimum number of records equal to 5 percent of the
total or 25 records (whichever is less). If the number of paper records is fewer
than the minimum required sample, the auditor must do primary source
verification for all records.
Review of the original paper chart or the electronic record (e.g., EMR screen)
for each member in the sample.

41. Obtaining Information From Medical Records and EMRs
An organization (and its contractors) using the Hybrid Method is responsible for determining compliance with
HEDIS measurement specifications. Information from the medical record or EMR may be abstracted by one
of the following groups.
The organization
Contractors hired to conduct a chart audit
Practitioners of care
Processes used to determine the validity and integrity of abstracted data, including interrater reliability,
quality control and rater-to-standard tests, are subject to review by the HEDIS Compliance Auditor. The
organization must include these records in the HEDIS Compliance Audit medical record review validation.
The organization should not use practitioner attestation forms because they do not require the practitioner to
verify services using the medical record.
Organization or
contractor
abstraction

The organization may count a service if the medical record or EMR contains the
following information.
The date and the result, or
A consultation, laboratory or imaging report
All services must be rendered by the deadline for delivery of the service established
in the measure (e.g., by the child’s second birthday, for the Childhood Immunization
Status measure).

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The organization may review EMR screens at the practitioner’s office or review
printed records (including printed copies of screen-shots) containing the patient’s
name, the practitioner’s name and the date. The organization should develop and
implement confidentiality guidelines consistent with EMR abstraction.
When reviewing an EMR, the organization must be able to distinguish between
ordered and completed visits, procedures, lab and radiology tests; only completed
events count toward HEDIS compliance. Some EMRs record CPT codes when the
practitioner enters a service order in the ―order‖ screen. A CPT code found on the
―order‖ list alone does not comply with the numerator criteria.

Practitioner
abstraction

Guidelines for
practitioner
abstraction

The organization may review a copy of the record mailed from the practitioner’s
office, containing the patient’s name, the practitioner’s name and the date. Although
faxing relevant portions from the medical record is acceptable, it is not a preferred
method because of patient confidentiality issues. Regardless of the method used,
the organization should develop and implement confidentiality guidelines.
An organization for which a practitioner supplies measure-specific information from a
medical record must use an abstraction tool to perform the following functions.
Provide guidelines for abstraction
Complete quality control processes, such as interrater reliability or rater-tostandard reliability validation
The organization must provide guidelines for practitioner abstraction. Verbal or
written guidance should include clear instructions for applying the technical
specifications to medical record review. Instructions are subject to review by the
HEDIS Compliance Auditor. The organization does not need to use the same tool for
practitioner chart abstraction that it uses for the chart abstractions its contracted
vendors perform, but all abstraction tools are required to have all necessary data
elements and are subject to review by the HEDIS Compliance Auditor.

42. Measures That Require Use of Results From the Most Recent Test
For measures that require the use of results from the most recent test, the organization should search for
medical record documentation that indicates a test was performed and not merely ordered. Medical record
documentation that only indicates a test was ordered (and not performed) should not be included when
identifying the most recent test. For example, documentation that the patient was sent to the lab or that labs
were ordered may indicate the test was ordered, but it does not mean the test was actually performed. These
situations should not be included when identifying the most recent test.
Medical record evidence indicating that a test was performed (and which, therefore, should be included when
identifying the most recent test) includes documentation of a numeric value, interpretation of a numeric value
(e.g., within normal limits, average, high) or documentation that a test was performed but results could not be
calculated (e.g., LDL could not be calculated due to high triglycerides). To determine numerator compliance
for rates that require results to be at a certain level, documentation of a numeric result is required. For
example, documentation that a result is ―within normal limits‖ or ―under control‖ should be included when
identifying the most recent test; its result would be considered ―missing.‖
Additionally, if the organization uses both administrative and medical record data, the most recent test must
be used even if it is found administratively and does not contain a result.
_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

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43. Date Specificity
HEDIS requires that a date be specific enough to determine that an event occurred during the time
established in the measure. For example, in the Childhood Immunization Status measure, members should
receive three hepatitis B vaccines. Assume a member was born on February 5, 2007. Documentation in the
medical record that the first hepatitis B vaccine was given ―at birth‖ is specific enough to determine that it was
given prior to the deadline for this measure (i.e., the child’s second birthday), but if the medical record states
that the third hepatitis B vaccine was given in February 2009, the organization cannot count the immunization
because the date is not specific enough to confirm that it occurred prior to the member’s second birthday.
There are instances when documentation of the year alone is adequate; these include most optional
exclusions and measures that look for events in the ―measurement year or the year prior to the measurement
year.‖ Terms such as ―recent,‖ ―most recent‖ or ―at a prior visit‖ are not acceptable.
For documented history of an event (e.g., documented history of a disease), undated documentation may be
used as long as it is specific enough to determine that the event occurred during the time frame specified in
the measure. For example, for the Childhood Immunization Status measure, undated documentation on an
immunization chart stating ―chicken pox at age 1‖ is specific enough to determine that it occurred prior to the
child’s second birthday. Similarly, for the Breast Cancer Screening measure, undated documentation on a
problem list stating ―bilateral mastectomy in 1999‖ is specific enough to determine that this exclusion occurred
prior to December 31 of the measurement year.

44. Indicators That Require the Same Data Collection Method
The organization must use the same data collection method (Administrative or Hybrid) for reporting the
following indicators within each measure.
Cholesterol Management for Patients With Cardiovascular Conditions
– LDL-C screening
– LDL-C control <100 mg/dL
Comprehensive Diabetes Care
– HbA1c testing
– HbA1c poor control >9%
– HbA1c control <8%
– HbA1c control <7%
Comprehensive Diabetes Care
– LDL-C screening
– LDL-C control <100
Comprehensive Diabetes Care
– BP control <130/80 mm Hg
– BP control <140/90 mm Hg

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45. Using the Hybrid Method to Collect Measures With Multiple Numerator Events
The following measures can be collected using the Hybrid Method and require more than one event to satisfy
the numerator.
Childhood Immunization Status
Well-Child Visits in the First 15 Months of Life
For example, three separate antigens are collected to report the IPV rate for Childhood Immunization Status.
For all measures listed above, the organization may use a combination of administrative and medical record
data for a member in the denominator, if the events across medical record and administrative data are at least
14 days apart. The organization may count two IPV vaccines identified through administrative and the third
IPV identified through medical record review for a member in the denominator, if the medical record date of
service is not within 14 days of either administrative date of service. The organization may also count three
IPVs identified through administrative and four DTaPs identified through medical record data for the same
individual. An organization that has one event from the medical record and one from administrative data and
is unable to determine if the dates are at least 14 days apart must use only the medical record event.

46. Measures That Use Pharmacy Data
Some measures require the use of pharmacy data. The specifications include medication tables that should
be referenced in conjunction with the National Drug Code (NDC) lists posted to NCQA’s Web site. The tables
include a Description column that indicates the therapeutic category, and a Prescription column that includes
all appropriate medications in their generic form. The organization is required to use the NDC lists for each
pharmacy-dependent measure. Final NDC lists for pharmacy-related measures will be posted to the NCQA
Web site on November 16, 2009.

47. Identifying Events/Diagnoses Using Laboratory Data
Laboratory data may not be used to identify an event, disease or condition (e.g., acute myocardial infarction
[AMI], diabetes) unless listed in a code table that contains LOINC codes. Many organizations find a high rate
of false positives when they use laboratory data to identify members with a disease or condition. Diagnosis
codes are frequently reported on laboratory tests in cases where the condition is being ruled out; therefore,
organizations should not use laboratory data or claims when identifying the following criteria.
Eligible Population Event/Diagnosis
Negative Diagnosis History
Negative Competing Diagnosis
Negative Comorbid Condition History
Exclusions
Laboratory claims and data may be used for any code tables that contain LOINC codes.

48. Administrative Data Refresh
The organization has the option of refreshing administrative data after the hybrid sample is drawn. If an
organization elects to refresh administrative data, it must only use the refresh to identify additional numerator
hits. It should not use the refresh to identify additional exclusions or adjust the eligible population or sample
denominator. Members found to be numerator compliant prior to the data refresh remain so regardless of
what is found during the claims refresh. The organization can apply the data refresh on an indicator-byindicator basis, but cannot apply it on a member-by-member basis. Data refreshes should be used
consistently across screening and control indicators for Cholesterol Management for Patients With
Cardiovascular Conditions and Comprehensive Diabetes Care.

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HEDIS Coding Conventions
49. Coding Systems Included in HEDIS
HEDIS includes codes from the following coding systems.
CMS Place of Service (POS)
Current Procedural Terminology (CPT)
Diagnosis-Related Group (DRG)
Healthcare Common Procedure Coding System (HCPCS) Level II
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Logical Observation Identifiers Names and Codes (LOINC)
Uniform Bill (UB) revenue and type of bill

50. Presentation of Codes
Unless otherwise noted, codes in HEDIS are stated to the minimum specificity required. For example, if a
code is presented to the third digit, any valid fourth or fifth digits may be used for HEDIS reporting. When
necessary, a code may be specified with an ―x,‖ which represents a required digit; for example, ICD-9-CM
Diagnosis code 640.0x indicates a fifth digit is required, but the fifth digit could be any number allowed by the
coding manual. All coding systems in the HEDIS specifications use this presentation format. The table below
contains examples of codes and the included ranges.
ICD-9-CM Diagnosis Code
299
299.x
299.xx
299.0x
299.05

Included Ranges
299, 299.0-299.9 and 299.00-299.99
299.0-299.9 and 299.00-299.99
299.00-299.99
299.00-299.09
299.05 only

When reading HEDIS coding tables, assume there is an ―or‖ in between each column unless otherwise noted;
each code set is not dependent on another code set unless otherwise noted.

51. Principal vs. Secondary Diagnoses
Principal and secondary diagnoses are mentioned throughout HEDIS. Generally, a principal diagnosis or
primary diagnosis is the diagnosis given at discharge and the one that is listed in the first position on a claim
form. A secondary diagnosis is a diagnosis listed on a claim or encounter form that is not classified as the
principal diagnosis. A claim form may contain several secondary diagnoses. The organization should follow
the specifications stated within each particular measure to determine whether a diagnosis must be principal or
may be secondary.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

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27

Some measures require a specific principal diagnosis for eligibility; other measures allow any diagnosis
(principal or secondary). For example, the Persistence of Beta-Blocker Treatment After a Heart Attack
measure specifies that any diagnosis of an initial AMI is eligible. If a member’s claim lists the principal
diagnosis as ―severe head injury trauma,‖ but an initial AMI is listed as a second, third, fourth or fifth diagnosis
on the same claim form, the member would still be included in the Persistence of Beta-Blocker Treatment
After a Heart Attack measure.
On a UB-04 claim form, the principal diagnosis is listed in Form Locator 67, Principal Diagnosis Code, and
secondary diagnoses are listed in Form Locators 67A–Q, Other Diagnosis Codes. Data in Form Locators 69,
Admitting Diagnosis Code, and 70a–c, Patient’s Reason for Visit, should not be included in HEDIS reporting.
On a CMS1500 claim form, the principal diagnosis is listed in Item Number 21, line 1, and secondary
diagnoses are listed in Item Number 21, lines 2–4.

52. CPT Code Modifiers
CPT modifiers are two- or five-digit extensions that, when added to CPT codes, provide additional
information about a service or procedure. With the exception of myringotomies and mastectomies in the
Frequency of Selected Procedures measure, the same procedure should never be counted twice for the
same date of service. The organization should follow the guidelines below when procedure codes in its
databases have modifiers (xxxxx denotes the five-digit CPT code).
xxxxx-26 indicates the professional component of a service (xxxxx-TC is used by some organizations
to indicate the technical component of the same service). For a given procedure, the organization
should count one or the other of these codes, but not both.
xxxxx-54 denotes surgical care only; xxxxx-55 denotes postoperative management only; xxxxx-56
denotes preoperative management only. For a given procedure, the organization should count only one
of these codes.
xxxxx-80 and xxxxx-82 indicate charges for surgical assistant services; xxxxx-81 indicates a charge
for minimum surgical assistant services. If the primary surgeon does not submit a claim for a given
procedure, the organization should count only one of these codes. If a primary surgeon submits a
claim, the organization should not count any of these codes.
Unless otherwise specified, if a CPT code specified in HEDIS appears in the organization’s database with any
modifier other than those specified above, the code may be counted in the HEDIS measure.

53. Uniform Bill Code Specificity
Uniform Bill (UB) codes, primarily type of bill and revenue codes, are used to identify services. As with the
ICD-9-CM codes, an ―x‖ may be used in place of a digit.
HEDIS specifies UB type of bill codes using three digits. The organization may also use the equivalent fourdigit version of the code (which consists of the three-digit code plus a leading zero); for example, to identify
skilled nursing facility (SNF) encounters, it may use 21x or 021x.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

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28

54. Mapping Proprietary or Other Codes
For all HEDIS measures, an organization that does not use the coding systems specified (e.g., CPT or
ICD-9-CM) must ―map‖ the codes it uses to the codes specified in HEDIS. Organizations may map proprietary
codes, Level III and state-specific Level II HCPCS codes and NDC codes; they may not map standard
codes or deleted codes to the codes used in the measures. When mapping codes, it is important that the
organization match the clinical specificity required for HEDIS. NDC code mapping should be linked to the
generic name, strength/dose and route indicated in the HEDIS NDC lists posted on the NCQA Web site
(www.ncqa.org).
For audit purposes, the organization should document the method used to map codes. At a minimum,
documentation should include a crosswalk containing the relevant codes, descriptions and clinical
information. The organization must document the policies and procedures used to implement codes. For
Level III and state-specific Level II HCPCS mapping, the organization must provide the state’s instructions for
using state-specific codes. Auditors may request additional information.

55. Retirement of Codes
NCQA annually tracks billing, diagnostic and procedure codes designated obsolete. NCQA does not remove
codes in the year in which they receive the designation because of the look-back period in many HEDIS
measures. Obsolete codes are deleted from the HEDIS specifications one year after the look-back period is
exhausted. For example, since the Breast Cancer Screening measure counts a mammogram in
the measurement year or the year prior to the measurement year, mammography codes have a two-year
look-back period. A mammogram code that is designated obsolete effective January 1, 2008, is deleted from
the specifications in HEDIS 2011 after the two-year look-back period (2009, 2010) plus one additional year
(2008) is exhausted.
NCQA uses the NDC system. Obsolete NDC codes are phased out of the specifications three years after the
look-back period to allow pharmacies and organizations to use their inventory and change their systems.
NCQA encourages organizations to update their information systems and to ensure that complete, accurate
and consistent coding is used for all encounters and claims so that HEDIS specifications can be followed.
This will help the industry move toward a uniform system of performance measurement.

56. Table Names
Measure specifications contain two types of tables: one to present specification requirements and one used
by organizations to submit data. A standardized naming system is used to refer to the tables. Table names
begin with the three-character abbreviation for the measure; for example, Comprehensive Diabetes Care
tables begin with ―CDC.‖
Specification
tables

Tables that are part of the specifications (i.e., coding and pharmaceutical tables) begin
with the measure abbreviation and end with a hyphen (-) and a capital letter to
distinguish its order in the measure’s specifications. For example, the first table in the
Comprehensive Diabetes Care measure is CDC-A.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

General Guidelines for Data Collection and Reporting
Reporting
tables

29

Data element tables begin with the measure abbreviation. Each product line
(commercial, Medicaid, Medicare) is assigned a number.
CDC-1 (Medicaid)
CDC-2 (commercial)
CDC-3 (Medicare)
If there is more than one table to be reported for a product line, it is assigned a
lowercase letter. For example, the Medicaid tables for Enrollment by Product Line are
ENP-1a (Total Medicaid) and ENP-1b (Medicaid/Medicare Dual-Eligibles).

Measures Reportable With a Partial Year of Data
If an organization has a new product or product line licensed during the measurement period, a number of
HEDIS measures may be reported with a partial year of data. In general, a measure without a continuous
enrollment requirement is reportable with less than a full measurement period of data. Organizations that
want to submit HEDIS measures using data from a portion of the measurement period must present a written
request for approval to the PCS System at www.ncqa.org/pcs.

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and Sampling

Guidelines for Calculations and Sampling

31

HEDIS 2010, Volume 2

Guidelines for Calculations and Sampling

32

Guidelines for Calculations and Sampling
This section contains guidelines relating to calculating rates based on the Administrative and Hybrid Methods,
as well as specifications for sampling when using the Hybrid Method. An organization using this method must
follow the systematic sampling methodology described in this chapter or must receive written authorization
from NCQA for an alternative sort or sampling method. Proper utilization and implementation of these
methods is assessed as part of NCQA’s HEDIS Compliance Audit™.

How to Use the Administrative Method
An organization that uses the Administrative Method to collect and report measures must complete the
following steps.
Step 1

Identify the eligible population.

Step 2

Search administrative systems to identify numerator events for all members in the eligible
population.

Step 3

If applicable, for members for whom administrative data do not show a positive numerator
event, search administrative data for an exclusion to the service/procedure being measured.
Note: This step applies only to measures for which optional exclusions are specified and for
which the organization has chosen to search for exclusions. The organization is not required to
search for optional exclusions.

Step 4

Exclude from the eligible population members from step 3 for whom administrative system data
identified an exclusion to the service/procedure being measured.

Step 5

Calculate the rate.

Guidelines for the Hybrid Method
Measures that can be collected using the Hybrid Method are listed in Table 1. Each hybrid measure can be
classified into one of the following categories:
Membership-dependent denominator—Defined by membership data only (e.g., women between 24
and 64 years of age for Cervical Cancer Screening), or
Claims-dependent denominator—Defined by membership and claims data (e.g., members who were
diagnosed with hypertension for Controlling High Blood Pressure)
Drawing the
sample prior to
the reporting
year

The organization is strongly encouraged to draw samples no earlier than January
2010 for the 2009 measurement year. This increases the accuracy and
completeness of the eligible population from which the sample is drawn.
The organization must adhere to the following guidelines if it draws samples prior to
January 2010.

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Guidelines for Calculations and Sampling
Membershipdependent
denominators

33

For measures where the eligible population is determined through membership-data
(the bulleted list below), do not draw the sample prior to December 1 of the
measurement year.
Childhood Immunization Status
Lead Screening in Children
Cervical Cancer Screening
Colorectal Cancer Screening
Care for Older Adults
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
An organization that draws its sample on or between December 1 and December 31 of
the measurement year must perform the following tasks.
Oversample to account for individuals included in the sample who were found to
be noncompliant with the denominator criteria, subsequent to December 31 of the
measurement year.
On or after December 31 of the measurement year, verify that members included
in the sample remain eligible for the particular measure. For any member who
does not meet all the denominator criteria, another record must be substituted.
– For example, for the Childhood Immunization Status measure, on December 5
of the measurement year, an organization draws a sample of children who turn
2 years of age during the measurement year. On or after December 31 of the
measurement year, the organization must ensure that all members included in
the sample remain eligible for the measure (e.g., meet the continuous
enrollment criteria and were members of the organization as of their second
birthday). Any ineligible member (i.e., does not meet one or more of the
denominator criteria) must be excluded and replaced by an eligible member
from the oversample group.

Claimdependent
denominators

For measures where the eligible population is determined through membership data
and claims data (the bulleted list below), do not draw the sample before the end of the
measurement year.
Adult BMI Assessment
Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents
Controlling High Blood Pressure
Cholesterol Management for Patients With Cardiovascular Conditions
Comprehensive Diabetes Care
Medication Reconciliation Post-Discharge
Prenatal and Postpartum Care
Frequency of Ongoing Prenatal Care
Weeks of Pregnancy at Time of Enrollment

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34

To be drawn from a complete eligible population, the sample must be selected no
earlier than January of the reporting year. The organization should allow claims incurred
through December 31 to be captured on its administrative systems before identifying the
eligible population and drawing the sample.
Determining
the required
sample size

Using the Hybrid Method to collect and report a measure requires the organization to
draw a sample from the eligible population. Use Table 1 to determine the appropriate
sample size for measures. For hybrid measures reported in the prior year, use the last
column of Table 1 to determine whether the prior year’s audited result can be used to
reduce the current year’s sample size.
Use Table 2 if the organization uses the prior year’s rate to determine the current
year’s sample. The organization may use the product line-specific rate derived from
administrative data for the current measurement year and Table 2 to reduce the
required sample size. The required sample size decreases as the organization’s rate
improves; for example, the organization calculates a 77 percent administrative rate for
the commercial product line for a new measure and decides to implement the Hybrid
Method.
Instead of using a sample size of 411, the organization reduces the sample size for this
measure for its commercial product line by using the 77 percent administrative rate and
Table 2. According to Table 2, the minimum required sample size is 296.

Population
definition

In some cases, the size of the eligible population for a measure may be smaller than the
required sample size. In this case, the organization must use its entire eligible
population and report the data with a 95 percent confidence interval.
Why should a 95 percent confidence interval be used when the entire eligible population
is included? When these data are used for decision-making, an inference is made to
expected future performance or to a group of potential members. In either case, the
user is interested in the ―process of care,‖ which goes beyond organization performance
in a single year for a static product line.
It is therefore appropriate to consider the organization’s entire eligible population for a
measure as a sample from the universe of ―all years‖ or ―all populations.‖

Finite
population
correction

When calculating the sample size for the Hybrid Method, the organization may be
interested in applying a finite population correction (FPC) factor to reduce the sample
size; however, since HEDIS views organization enrollment as a sample from a larger
potential population (see above), and the use of the FPC decreases the power to detect
differences between organizations, it is not appropriate to use the FPC for public
reporting of HEDIS measures.

HEDIS 2010, Volume 2

Guidelines for Calculations and Sampling
Calculating the 95
percent confidence
interval

35

The formula for calculating the 95 percent confidence interval around an
organization’s HEDIS rate is:
lower = p

1.96

upper = p

1.96

p (1

p)

1
2n

p)

1
2n

n

p (1
n

where p = the organization’s rate and n = the sample size.
For example, suppose the organization has a sample size of 96 eligible women for
its Cervical Cancer Screening rate. Of these, 50 received a Pap Test during the
year. The calculation would proceed as follows:
p = 50 = 52%
96

lower = .52

1.96

.52 (1

upper = .52

1.96

.52 (1

.52)

96

96

1
192

.52)

1
192

= 41.5%

= 62.5%

Thus, the user can be 95 percent certain that the organization’s true Pap test rate
is between 41.5 percent and 62.5 percent.

Note
For rates near 0 percent, the lower limit may be negative. If this occurs, replace the lower limit with
0 percent. For rates near 100 percent, the upper limit may exceed 100 percent. If this occurs, replace the
upper limit with 100 percent. The IDSS automatically calculates these percentages.
There are more complex confidence interval calculations with better properties at extreme values. This
formula is provided because it performs adequately over a wide range of percentages and is simple to
compute.
Statistical
assumptions for
sample size

Sample size is calculated assuming a two-tailed test of significance between two
proportions ( = .05, 80 percent power, two-tailed test of significance). A normal
approximation to the binomial with a continuity correction was employed in the
sample size calculation. The worst-case assumption of a 50 percent expected value
was assumed.
The detectable difference for most measures is 10 percentage points. This was
chosen because it is a big enough difference to be actionable, it is not unduly
burdensome for data collection and it is not so small as to be ―swamped‖ by
nonsampling error.

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Table 1: Sample Size Information for Hybrid Measures
Medicaid

Commercial

Medicare

Prior Year’s Rate
May Be Used to Reduce
MY 2009 Sample Size1

Adult BMI Assessment

411

411

411

Y

Weight Assessment and Counseling for Nutrition and
Physical Activity for Children/Adolescents

411

411

NA

Y2

Childhood Immunization Status

411

411

NA

N3

Immunizations for Adolescents

411

411

NA

N

Lead Screening in Children

411

NA

NA

Y4

Cervical Cancer Screening

411

411

NA

Y

Colorectal Cancer Screening

NA

411

411

Y

Care for Older Adults

NA

NA

411

Y2

Cholesterol Management for Patients With Cardiovascular Conditions

411

411

411

Y2

Controlling High Blood Pressure

411

411

411

Y

Comprehensive Diabetes Care

548

548

548

Y5

Medication Reconciliation Post-Discharge

NA

NA

411

Y

411

411

NA

Y6

Frequency of Ongoing Prenatal Care

411

NA

NA

Y6

Well-Child Visits in the First 15 Months of Life

411

411

NA

Y7

Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life

411

411

NA

Y

Adolescent Well-Care Visits

411

411

NA

Y

411

NA

NA

N

Measure
Domain 1: Effectiveness of Care

Domain 2: Access/Availability of Care
Prenatal and Postpartum Care
Domain 5: Use of Services

Domain 8: Health Plan Descriptive Information
Weeks of Pregnancy at Time of Enrollment
1 Refer

to Table 2: Sample Sizes When Data Are Available on the Product Line Being Measured in this section to determine the minimum
required sample size.
2 If reducing the sample size based on the current year’s administrative rate or the prior year’s product line-specific rate for this measure, the
lowest rate from all the indicators must be used.
3If reducing the sample based on the current year’s administrative rate for the Childhood Immunization Status measure, the lowest rate must
be used.
4 If a separate sample from the Childhood Immunization Status measure is used for Lead Screening in Children, the organization can reduce
the sample based on the product-line specific current measurement year’s administrative rate or the prior year’s reported rate for Lead
Screening in Children.
5 If reducing the sample size based on the product-line-specific rate for Comprehensive Diabetes Care, the organization should first take the
inverse of the HbA1c poor control >9.0% rate (100 minus the HbA1c poor control rate) and then reduce using the lowest rate among all the
reported CDC indicators.
6 If reducing the sample size based on the product-line-specific current measurement year’s administrative rate or the prior year’s reported
rate, the lowest of the three rates for Timeliness of Prenatal Care, Postpartum Care and the rate for women who received 81 percent or
more of expected prenatal care visits must be used for both Prenatal and Postpartum Care and Frequency of Ongoing Prenatal Care.
7 If reducing the sample size based on the product-line-specific current measurement year’s administrative rate or the prior year’s reported
rate for Well-Child Visits in the First 15 Months of Life, the rate for children who received six or more well-child visits must be used.

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37

Table 2: Sample Sizes When Data Are Available on the Product Line Being Measured
The organization may use a rate calculated from the current year’s administrative rate or the prior year’s
reported rate to determine the sample size. Table 1: Sample Size Information for Hybrid Measures must be
used first to determine if a prior year’s rate can be used to reduce the sample size for a particular measure.
If the Current Year’s
Administrative Rate or the Prior
Year’s Reported Rate Is…

…the Sample Size Is

If the Current Year’s
Administrative Rate or the Prior
Year’s Reported Rate Is…

…the Sample Size Is

50%

411

73%

328

51%

411

74%

321

52%

410

75%

313

53%

410

76%

305

54%

409

77%

296

55%

407

78%

288

56%

405

79%

279

57%

403

80%

270

58%

401

81%

260

59%

398

82%

250

60%

395

83%

240

61%

392

84%

229

62%

388

85%

219

63%

384

86%

207

64%

380

87%

196

65%

376

88%

184

66%

371

89%

172

67%

366

90%

159

68%

360

91%

147

69%

354

92%

134

70%

348

93%

120

71%

342

94%

106

72%

335

95%

100

Note: Truncate the decimal portion of the rate to obtain a whole number.

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38

Systematic Sampling Methodology
NCQA implemented a systematic sampling scheme for the Hybrid Method. Proper utilization and
implementation of this method ensures ongoing integrity of HEDIS data and supports increasing requests for
audited data. For each hybrid measure, the organization should complete the following steps.
Step 1

Determine the eligible member (EM) population. Develop a list of EMs, including full name
(last, first), date of birth and event (if applicable). An organization that chooses to report on
combined HMO/POS or HMO/POS/PPO products must include all EMs from all products.

Step 2

Determine the minimum required sample size (MRSS) from Table 1 or Table 2. This becomes
the denominator for the measure. Use either Table 1 or Table 2, as appropriate, to determine
the MRSS. (Refer to Determining the required sample size for instructions.) If the EM is
≤MRSS, proceed to step 4.
Note: The MRSS can only be the appropriate value from Table 1 or Table 2.

Step 3

Determine the final sample size (FSS). The FSS includes the MRSS (from step 2) plus an
adequate number of additional records to make substitutions. The organization should attempt
to oversample only enough to guarantee that the MRSS is met. Keep substitution criteria in
mind when making this decision.
The following oversampling rates are acceptable.
5 percent
10 percent
15 percent
20 percent
An organization that wants to use oversample rates larger than 20 percent must obtain written
approval from NCQA. Refer to Oversample requests to NCQA for further details.
The FSS is calculated by the following formula:
FSS = MRSS + (MRSS

oversampling rate)

(round up to the next whole number), where MRSS = the minimum required sample size
(step 2).
For example, if the MRSS is 411 and a 10 percent oversample is needed,
FSS = 411 + (411

0.10) = 453.

Step 4

If EM >FSS, go to step 5. If EM MRSS, all eligible members are included in the sample. If
MRSS 311, go to step 5.

Step 5

Sort the list alphabetically and in this order: last name, first name and date of birth.

.05) = 310.8 (the next whole number above is 311, so FSS = 311).

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Guidelines for Calculations and Sampling

Step 6

N = 9,000/311 = 28.

Step 7

For this example, assume that RAND = 0.66, so START = 0.66 x 28 = 18.48.

41

Rounding using the .5 rule, START = 18
The 18th sorted member is chosen first
The 2nd member chosen is the 18 + [(2-1) x 28.93] = 18 + 29 = 47th sorted member, after
rounding the term [(2-1) x 28.93] to 29, using the .5 rule
The 3rd member chosen is the 18 + [(3-1) x 28.93] = 18 + 58 = 76th sorted member
The 296th member (the last one in the primary list) is the 18 + [(296-1) x 28.93] = 18 +
8,534 = 8,555th sorted member
The last member in the auxiliary sample is the 18 + [(311-1) x 28.93] = 18 + 8,968 =
8,986th sorted member

Example 2
The eligible member population for Cholesterol Screening for Members With Acute Cardiovascular Events is
389. This measure was not collected last year, nor will the administrative rate from this year be used to
reduce the sample size. Follow the systematic sampling scheme.
Step 1

EM = 389.

Step 2

From Table 1, the MRSS is 411. Since 389 <411, skip to step 4.

Step 3

Skip this step.

Step 4

Include all 389 members in your primary list.

Example 3
The eligible member population for Childhood Immunization Status is 436. The sample size will not be
adjusted using this year’s administrative rate. Based on experience with this population, about 10 percent of
the members from the primary sample will have to be excluded. Follow the systematic sampling scheme.
Step 1

EM = 436.

Step 2

From Table 1, the MRSS is 411.

Step 3

FSS = 411 + (411

Step 4

Since 411 <436, skip to step 6.

Step 5

Skip this step.

Step 6

Sort the list and choose the first 411 as the primary list. The remaining 25 members become the
auxiliary list.

.10) = 452.1 (the next whole number above is 453, so FSS = 453).

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42

Complex Probability Sampling
Organization
responsibility

Properly applied, other techniques such as stratified sampling, cluster sampling and
other complex probability approaches can improve precision and increase sampling
efficiency. An organization that uses a probability sampling approach different from
the one specified must provide written rationale and documentation of the approach
to NCQA, through the PCS System (www.ncqa.org/pcs) or by fax at 202-955-3599,
to the attention of HEDIS Policy. The organization must demonstrate that the
sampling approach is auditable and that it does not introduce bias against particular
members being chosen. A committee of statisticians and health policy experts
staffed by NCQA reviews the approach. Written notification of NCQA approval or
disapproval is provided within 10 business days.
If complex sampling methods are used, the estimated rate should be reported, in
addition to any information required to perform a valid test of significance between
that rate and another organization’s rate.
The organization should also report the sample size (if different from the HEDIS
recommendation) and document the method used in the calculation (including
software used, if applicable). The organization should consult a statistician before
implementing a complex sampling methodology.

Substituting Medical Records

Acceptable
circumstances
for substitution:
1. Errors in
sampling data

The organization should specify the number of records it substitutes. The
organization may not substitute members who are noncompliant because they
refused the service or because the organization is unable to locate their chart.
Unless otherwise noted in the specifications for a particular measure, the
organization should not drop members from the sample or make substitutions,
except under the three circumstances described below.
Chart review reveals that a member does not meet the eligibility criteria for inclusion
in the sample. Data errors can be due to incorrect member or clinical information.
The following are examples of valid data errors.
A member selected for the Childhood Immunization Status sample is found to
be 22 years old
A member in the Comprehensive Diabetes Care sample has a diagnosis in
the chart that shows a prescription for oral hypoglycemics was not due to
diabetes
A member in the Cholesterol Management for Patients With Cardiovascular
Conditions sample because of a diagnosis of ischemic vascular disease (IVD)
is ruled out by a negative test result
A member in the sample for any measure has a notation, entered by the
deadline established for the measure, explaining the reason for the erroneous
inclusion or stating the member does not have the condition
The medical record must have evidence that a member does not meet the criteria
for the measure; a chart without any notation either substantiating or refuting the
diagnosis is not evidence that the member does not have the condition being
measured.

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2. Exclusion to
treatment being
measured

43

A member has a valid exclusion to the treatment being measured; for example, a
member with a diagnosis of colorectal cancer or total colectomy is a valid exclusion
in the denominator for the Colorectal Cancer Screening measure.
Valid exclusions are included in the measure specifications. An organization that
removes members based on exclusions may do so only for members in the
denominator for whom administrative data or medical record data do not show that
the service/procedure was rendered within the appropriate period specified. The
organization must verify that the exclusion occurred by the deadline established for
the measure.

3. Selecting an
employee/
dependent for
the sample

An employee of the organization or the vendor, or the employee’s dependent, was
selected for the sample, and the employee or dependent’s medical record must be
reviewed to determine compliance with the measure. The organization or vendor
may exclude employees and their dependents in this situation only.

Hybrid Method: Three Approaches
There are three approaches to conducting the Hybrid Method; they differ only in the timing for identifying
individuals in the denominator who have a valid exclusion. The first two approaches allow the organization to
first select the sample and then search for valid exclusions. The third allows the organization to search for
valid exclusions on the entire eligible population prior to selecting the sample. The organization may use any
of the three approaches.

Approach 1
Step 1

Search the administrative systems for numerator events for the sampled members. Starting with
the primary list, follow the administrative specification to search administrative systems for
numerator events.

Step 2

Search the administrative systems for an exclusion. For members for whom administrative data
does not show a positive numerator event, search administrative data for an exclusion to the
service/procedure being measured, if applicable.
Note: This step applies only to measures for which optional exclusions are specified and in
which the organization has chosen to search for exclusions. The organization is not required to
search for optional exclusions.

Step 3

From the oversampled population, substitute for the excluded records.

Step 4

Search the medical records for numerator events for the sampled population. Review the
medical records of members in the sample for whom a numerator event or exclusion to the
service/procedure being measured was not identified using administrative data.
For measures in which more than one service is captured (e.g., four DTaPs are needed to
satisfy the DTaP rate for Childhood Immunization Status), the organization may combine
services identified through administrative and medical record data as long as the dates of
service between the administrative and the medical record dates are at least 14 days apart.

HEDIS 2010, Volume 2

Guidelines for Calculations and Sampling
Step 5

44

Search the record for an exclusion to the service/procedure being measured. For members for
whom the medical record does not show a positive numerator event, search the record for an
exclusion to the service/procedure being measured, if applicable.
Note: This step applies only to measures for which optional exclusions are specified and in
which the organization has chosen to search for exclusions. The organization is not required to
search for optional exclusions.

Step 6

Remove members with medical-record identified exclusions. Remove from the denominator
members for whom the medical record identified an exclusion.

Step 7

From the oversampled population, substitute for the excluded records. Refer to Substituting
Medical Records.

Step 8

Use either administrative or medical record data to identify the numerator event for additional
members used as replacements.

Step 9

Determine the numerator. Include only members in the sample who were identified through
either administrative data or medical record review as having had received or experienced the
numerator event.

Step 10

Calculate the rate. The organization may calculate a rate using the denominator (MRSS with
substitutions) or the denominator plus the entire oversample (FSS), but should be consistent
across measures.

Approach 2
Step 1

Search the administrative systems for numerator events for the sampled members. Starting
with the primary list, follow the administrative specification to search administrative systems for
numerator events.

Step 2

Search the medical records for numerator events for the sampled population. Starting with the
primary list, review the medical records of members in the sample for whom a numerator event
was not identified using administrative data. For measures in which more than one service is
captured (e.g., four DTaPs are needed to satisfy the DTaP rate for Childhood Immunization
Status), the organization may include services identified through administrative data and
medical record review, provided that each date of service is at least 14 days apart.

Step 3

Search for administratively identified and medical record exclusions. For members for whom
administrative data or the medical record does not show a positive numerator event,
search administrative data or the medical record for an exclusion to the service/procedure
being measured, if applicable.
Note: This step applies only to measures for which optional exclusions are specified and in
which the organization has chosen to search for exclusions. The organization is not required to
search for optional exclusions.

Step 4

Remove members with exclusions identified in administrative data or in the medical record.
Remove from the denominator members from step 3 for whom administrative data or the
medical record identified an exclusion to the service/procedure being measured.

Step 5

From the oversampled population, substitute for the excluded records. Refer to Substituting
Medical Records.

Step 6

Use either administrative or medical record data to identify the numerator event for additional
members used as replacements.

HEDIS 2010, Volume 2

Guidelines for Calculations and Sampling
Step 7

Determine the numerator. Include in the numerator for the measure only, members in the
sample who were identified through either administrative data or medical record review as
having had received or experienced the numerator event.

Step 8

Calculate the rate. The organization may calculate a rate using the denominator (MRSS with
substitutions) or the denominator plus the entire oversample (FSS), but should be consistent
across measures.

45

Approach 3
Step 1

Identify the EM population (members who satisfy all of the denominator criteria).

Step 2

Search the administrative systems for numerator events for the entire EM population. Follow
the administrative specifications to search administrative systems for numerator events for the
eligible member population identified in step 1.

Step 3

Search for administratively identified exclusions. For members for whom administrative data
does not show a positive numerator event, search administrative data for an exclusion to the
service/procedure being measured, if applicable.
Note: This step applies only to measures for which optional exclusions are specified and in
which the organization has chosen to search for exclusions. The organization is not required
to search for optional exclusions.

Step 4

Exclude members with administratively identified exclusions. Remove from the eligible
population members from step 3 for whom administrative data identified an exclusion to the
service/procedure being measured.

Step 5

Determine the FSS, using the guidelines for Systematic Sampling Methodology.

Step 6

Search the administrative systems for numerator events for the sampled members. From the
members identified as compliant for numerator events from step 2, pull the members included
in the FSS.

Step 7

Search the medical records for numerator events for the sampled population. Review the
medical records of members in the sample for whom a numerator event or exclusion to the
service/procedure being measured was not identified using administrative data.
For measures in which more than one service is captured (e.g., four DTaPs are needed to
satisfy the DTaP rate for Childhood Immunization Status), the organization may combine
services identified through administrative and medical record data, provided that the dates of
service are at least 14 days apart.

Step 8

Search for medical record exclusions. For members for whom administrative data or the
medical record does not show a positive numerator event, search the medical record for an
exclusion to the service/procedure being measured, if applicable.
Note: This step applies only to measures for which optional exclusions are specified and in
which the organization has chosen to search for exclusions. The organization is not required
to search for optional exclusions.

Step 9

Exclude members with medical record identified exclusions. Remove from the denominator
members for whom the medical record identified an exclusion.

Step 10

From the oversampled population, substitute for the excluded records. Refer to Substituting
Medical Records.

Step 11

Use either administrative or medical record data to identify the numerator event for additional
members used as replacements.

HEDIS 2010, Volume 2

Guidelines for Calculations and Sampling

46

Step 12

Determine the numerator. Include in the numerator for the measure only members in the sample
who were identified through either administrative data or medical record review as having had
received or experienced the numerator event.

Step 13

Calculate the rate. The organization may calculate a rate using the denominator (MRSS with
substitutions) or the denominator plus the entire oversample (FSS), but should be consistent
across measures.

References
Deming, W.E. On the interpretation of censuses as samples. 1941. Journal of the American Statistical
Association. 36: 45–9.
Fleiss, L. Statistical Methods for Rates and Proportions. 2nd Ed. (New York: John Wiley & Sons, Inc.): 38–42.

HEDIS 2010, Volume 2

HEDIS 2010, Volume 2

Adult BMI Assessment (ABA)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 99341–99345, 99347–99350 to Table ABA-A.
Added ICD-9-CM Diagnosis codes 678, 679 to Table ABA-C.

Description
The percentage of members 18–74 years of age who had an outpatient visit and who had their body mass
index (BMI) documented during the measurement year or the year prior the measurement year.

Definitions
BMI

Body mass index. A statistical measure of the weight of a person scaled according to
height.

BMI percentile

The percentile ranking based on the Centers for Disease Control and Prevention’s
(CDC) BMI-for-age growth charts, which indicates the relative position of the
patient’s BMI number among those of the same sex and age.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18 years as of January 1 of the year prior to the measurement year to 74 years as of
December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in continuous enrollment of up to 45 days during each year of
continuous enrollment. To determine continuous enrollment for a Medicaid
beneficiary for whom enrollment is verified monthly, the member may not have more
than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2
months [60 days] is not considered continuously enrolled).

Anchor date

None.

Benefit

Medical.

Event/diagnosis

Members who had an outpatient visit (Table ABA-A) during the measurement year or
the year prior to the measurement year.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table ABA-A: Codes to Identify Outpatient Visits
CPT

HCPCS

99201-99205, 99211-99215, 99217-99220, 99241-99245,
99341-99345, 99347-99350, 99385-99387, 99395-99397,
99401-99404, 99411, 99412, 99420, 99429, 99455, 99456

G0344

ICD-9-CM Diagnosis

UB Revenue

V70.0, V70.3, V70.5, V70.6,
V70.8, V70.9

051x, 0520-0523, 05260529, 077x, 0982, 0983

Administrative Specification
Denominator

The eligible population.

Numerator

BMI (Table ABA-B) during the measurement year or year prior to the measurement
year.

Table ABA-B: Codes to Identify BMI
HCPCS

ICD-9-CM Diagnosis

G8417-G8420

V85.0-V85.5

Exclusions (optional)
Members who have a diagnosis of pregnancy (Table ABA-C) during the measurement year or the year prior
to the measurement year.

Table ABA-C: Codes to Identify Exclusions
Description

ICD-9-CM Diagnosis

Pregnancy

630-679, V22, V23, V28

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population. The organization may
reduce the sample size using the current year’s administrative rate or the prior year’s
audited, product line-specific rate. Refer to the Guidelines for Calculations and
Sampling for information on reducing the sample size.

Numerator

BMI during the measurement year or year prior to the measurement year as
documented through either administrative data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from the
administrative data.

Medical record

Documentation in the medical record must indicate the date of the BMI and the BMI
value.
For members younger than 19 years on the date of service, documentation of BMI
percentile also meets criteria:
BMI percentile documented as a value (e.g., 85th percentile)
BMI percentile plotted on an age-growth chart.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Exclusions (optional)
Refer to Administrative Specification for exclusion criteria. Exclusionary evidence in the medical record must
include a note indicating a diagnosis of pregnancy. The diagnosis must have occurred during the
measurement year or the year prior to the measurement year.

Note
The following notations or examples of documentation are considered ―negative findings‖ and do not count as
numerator compliant.
No BMI or BMI percentile documented in medical record or plotted on age-growth chart
Notation of height and weight only
BMI or BMI percentile noted before the look-back period or after the measurement year

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table ABA-1/2/3: Data Elements for Adult BMI Assessment
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population

Administrative

Hybrid









Number of numerator events by administrative data in eligible population (before
exclusions)



Current year’s administrative rate (before exclusions)



















Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of administrative data records excluded
Number of medical records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data



Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval





HEDIS 2010, Volume 2

Breast Cancer Screening (BCS)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

Women 42–69 years as of December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of
continuous enrollment. To determine continuous enrollment for a Medicaid
beneficiary for whom enrollment is verified monthly, the member may not have
more than a 1-month gap in coverage during each year of continuous enrollment.

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

None.

Administrative Specification
Denominator

The eligible population.

Numerator

One or more mammograms during the measurement year or the year prior to the
measurement year. A woman had a mammogram if a submitted claim/encounter
contains any code in Table BCS-A.

Table BCS-A: Codes to Identify Breast Cancer Screening
CPT

HCPCS

ICD-9-CM Diagnosis

ICD-9-CM Procedure

UB Revenue

76090-76092, 77055-77057

G0202, G0204, G0206

V76.11, V76.12

87.36, 87.37

0401, 0403

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Exclusion (optional)
Women who had a bilateral mastectomy. Look for evidence of a bilateral mastectomy as far back as possible
in the member’s history through December 31 of the measurement year. Exclude members for whom there
is evidence of two unilateral mastectomies. Refer to Table BCS-B for codes to identify exclusions.

Table BCS-B: Codes to Identify Exclusions
Description

CPT

ICD-9-CM Procedure

Bilateral mastectomy

19180, 19200, 19220, 19240, 19303-19307
WITH
Modifier .50 or modifier code 09950*

85.42, 85.44, 85.46, 85.48

Unilateral mastectomy (members must have
2 separate occurrences on 2 different dates of
service)

19180, 19200, 19220, 19240, 19303-19307

85.41, 85.43, 85.45, 85.47

*.50 and 09950 modifier codes indicate the procedure was bilateral and performed during the same operative session.

Note
The purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or
MRIs for this measure because they are not appropriate methods for primary breast cancer screening.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table BCS-1/2/3: Data Elements for Breast Cancer Screening
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Colorectal Cancer Screening (COL)
SUMMARY OF CHANGES TO HEDIS 2010
Lowered the upper age limit from 80 to 75 years of age.
Removed double contrast barium enema (DCBE) from the numerator criteria.
Clarified requirements for medical record documentation for the FOBT.
Deleted HCPCS code G0107 from Table COL-A.
Deleted LOINC code 50196-5 from Table COL-A ―FOBT‖ description.

Description
The percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.

Eligible Population
Product lines

Commercial, Medicare (report each product line separately).

Ages

51–75 years as of December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in continuous enrollment of up to 45 days during each year
of continuous enrollment.

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

None.

Administrative Specification
Denominator

The eligible population.

Numerator

One or more screenings for colorectal cancer. Appropriate screenings are defined
by any one of the following criteria.
Fecal occult blood test (FOBT) during the measurement year. Regardless of
FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the
required number of samples was returned.
Flexible sigmoidoscopy during the measurement year or the four years prior to
the measurement year
Colonoscopy during the measurement year or the nine years prior to the
measurement year
A member had an appropriate screening if a submitted claim/encounter contains
any code in Table COL-A.

HEDIS 2010, Volume 2

Table COL-A: Codes to Identify Colorectal Cancer Screening
Description

CPT

HCPCS

ICD-9-CM
Diagnosis

ICD-9-CM
Procedure

LOINC

FOBT

82270, 82274

G0328, G0394

V76.51

2335-8, 12503-9,
12504-7, 14563-1,
14564-9, 14565-6,
27396-1, 27401-9,
27925-7, 27926-5,
29771-3

Flexible
sigmoidoscopy

45330-45335, 4533745342, 45345

G0104

45.24

Colonoscopy

44388-44394, 44397,
45355, 45378-45387,
45391, 45392

G0105, G0121

45.22, 45.23, 45.25,
45.42, 45.43

Exclusion (optional)
Members with a diagnosis of colorectal cancer or total colectomy. Look for evidence of colorectal cancer or
total colectomy as far back as possible in the member’s history. Refer to Table COL-B for codes to identify
exclusions.

Table COL-B: Codes to Identify Exclusions
Description

CPT

Colorectal cancer
Total colectomy

HCPCS
G0213-G0215, G0231

ICD-9-CM Diagnosis

ICD-9-CM Procedure

153, 154.0, 154.1, 197.5,
V10.05

44150-44153, 4415544158, 44210-44212

45.8

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population for each product line. The
organization may reduce the sample size using the current year’s administrative rate or
the prior year’s audited, product line-specific rate. Refer to the Guidelines for
Calculations and Sampling for information on reducing the sample size.

Numerator

One or more screenings for colorectal cancer. Appropriate screenings are defined by
any one of the following criteria.
FOBT during the measurement year
Flexible sigmoidoscopy during the measurement year or the four years prior to the
measurement year
Colonoscopy during the measurement year or the nine years prior to the
measurement year

Administrative

Refer to Administrative Specification to identify positive numerator hits from the
administrative data.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Medical record

Documentation in the medical record must include a note indicating the date the
colorectal cancer screening was performed. A result is not required if the
documentation is clearly part of the ―medical history‖ section of the record. If it is
unclear whether the documentation is part of the medical history, then the result or
finding must also be present (this ensures that the screening was performed and not
merely ordered).
There are two types of FOBT tests: guaiac (gFOBT) and immunochemical (iFOBT).
Depending on the type of FOBT test, a certain number of samples are required for
numerator compliance. Follow the instructions below to determine member
compliance.
If the medical record does not indicate the type of test and there is no indication as
to how many samples were returned, assume the required number was
returned. The member meets the screening criteria for inclusion in the
numerator.
If the medical record does not indicate the type of test and the number of returned
samples is specified, the member would only meet the screening criteria if the
number of samples specified is greater than or equal to three samples. If the
number of samples is less than three, the member does not meet the screening
criteria for inclusion in the numerator.
iFOBT tests may require fewer than three samples. If the medical record indicates
that an iFOBT was done, the member meets the screening criteria for inclusion
in the numerator regardless of the number of returned samples.
If the medical record indicates that a gFOBT was done, follow the scenarios below.
If the medical record does not indicate the number of returned samples, assume
the required number was returned. The member meets the screening criteria
for inclusion in the numerator.
If the medical record indicates that three or more samples were returned, the
member meets the screening criteria for inclusion in the numerator.
If the medical record indicates that fewer than three samples were returned, the
member does not meet the screening criteria.
Do not count digital rectal exam as evidence of a colorectal screening because it is not
specific or comprehensive enough to screen for colorectal cancer.

Exclusion (optional)
Refer to Administrative Specification for exclusion criteria. Exclusionary evidence in the medical record must
include a note indicating a diagnosis of colorectal cancer or total colectomy. The diagnosis must have
occurred by December 31 of the measurement year. Use the codes in Table COL-B as synonyms for a
diagnosis of colorectal cancer or total colectomy.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table COL-2/3: Data Elements for Colorectal Cancer Screening
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population

Administrative

Hybrid



























Number of numerator events by administrative data in eligible population (before exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of administrative data records excluded
Number of medical records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data



Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval





HEDIS 2010, Volume 2

Glaucoma Screening in Older Adults (GSO)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of Medicare members 65 years and older, without a prior diagnosis of glaucoma or glaucoma
suspect, who received a glaucoma eye exam by an eye care professional for early identification of
glaucomatous conditions.

Eligible Population
Product line

Medicare.

Age

67 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment.

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

None.

Administrative Specification
Denominator

The eligible population.

Numerator

One or more eye exams for glaucoma by an eye care professional (i.e.,
ophthalmologist, optometrist) during the measurement year or the year prior to the
measurement year. A member is considered to have had an eye exam for glaucoma
if a submitted claim/encounter contains any code in Table GSO-A.

Table GSO-A: Codes to Identify Glaucoma Screening Eye Exams
CPT
92002, 92004, 92012, 92014, 92081-92083, 92135,
92140, 99202-99205, 99213-99215, 99242-99245

HCPCS
G0117, G0118, S0620,
S0621

ICD-9-CM Diagnosis
V80.1

ICD-9-CM Procedure
95.02, 95.03, 95.26

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Exclusion (optional)
Members who had a prior diagnosis of glaucoma or glaucoma suspect. Look for evidence of glaucoma as far
back as possible in the member’s history through December 31 of the measurement year. Refer to Table
GSO-B for codes to identify exclusions.

Table GSO-B: Codes to Identify Exclusions
Description
Glaucoma suspect
Glaucoma

ICD-9-CM Diagnosis
365.0
365.1-365.9

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table GSO-3: Data Elements for Glaucoma Screening in Older Adults
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









HEDIS 2010, Volume 2

Care for Older Adults (COA)
SUMMARY OF CHANGES TO HEDIS 2010
Added HCPCS G8427, G8428 to Table COA-C.
Clarified that a complete physical functional status assessment is required.
Clarified that a comprehensive pain assessment is required.

Description
The percentage of adults 65 years and older who had each of the following during the measurement year.
Advance care planning
Medication review
Functional status assessment
Pain screening

Definitions
Medication list

A list of the member’s medications in the medical record, which may include
prescriptions, over-the-counter (OTC) medications and herbal or supplemental
therapies.

Medication review

A review of all a member’s medications, including prescription medications, OTC
medications and herbal or supplemental therapies.

Eligible Population
Product line

Medicare SNP.

Ages

66 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in continuous enrollment of up to 45 days during the
measurement year.

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

None.

Administrative Specification
Denominator

The eligible population.

Numerators
Advance care
planning

Evidence of advance care planning during the measurement year (Table COA-A).

HEDIS 2010, Volume 2

Table COA-A: Codes to Identify Advance Care Planning
Description

CPT Category II

HCPCS

Advance care planning

1157F, 1158F

S0257

Medication
review

At least one medication review (Table COA-B) conducted by a prescribing practitioner
or clinical pharmacist during the measurement year and the presence of a medication
list in the medical record (Table COA-C), as documented through administrative data.
The claim/encounter for a member’s medication review and medication list must be on
the same date of service.

Table COA-B: Codes to Identify Medication Review
Description

CPT

CPT Category II

HCPCS*

Medication review

90862, 99605, 99606

1160F

G8427, G8428

Table COA-C: Code to Identify Medication List
Description

CPT Category II

HCPCS*

Medication list

1159F

G8427, G8428

*The HCPCS codes meet criteria for both medication review and medication list.
Functional status
assessment

At least one functional status assessment during the measurement year (Table COA-D).

Table COA-D: Codes to Identify Functional Status Assessment
Description
Functional status
assessment

CPT Category II

Functional evaluation

Pain screening

ICD-9-CM Procedure

1170F
93.01

At least one pain screening or pain management plan during the measurement year.
A member had a pain screening if a submitted claim/encounter contains any code in
Table COA-E.

Table COA-E: Codes to Identify Pain Screening
Description

CPT Category II

Pain screening

0521F, 1125F, 1126F

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population. The organization may reduce
the sample size using the current year’s administrative rate or the prior year’s audited,
product line-specific rate. Refer to the Guidelines for Calculations and Sampling for
information on reducing the sample size.

Numerators
Advance care
Planning

Evidence of advance care planning as documented through either administrative data
or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Advanced care planning is a discussion about preferences for resuscitation, lifesustaining treatment and end of life care. Evidence of advance care planning must
include either:
The presence of an advanced care plan in the medical record, or
Documentation of an advance care planning discussion with the provider and the
date on which it was discussed. The documentation of discussion must be
notated in the measurement year. Notation that the member has previously
executed an advance care plan meets criteria.
Examples of advance care plans include:
Advance directives. Directives pertaining to treatment preferences and the
designation of a surrogate decision maker in the event that a person should
become unable to make medical decisions on their own behalf. (e.g., living will,
power of attorney, health care proxy).
Actionable medical orders. Written instructions regarding initiation, continuation,
withholding or withdrawal of particular forms of life-sustaining treatment.
Living wills. Legal documents denoting preferences for life-sustaining treatment
and end-of-life care.
Surrogate decision maker. A written document designating someone else to
make future medical treatment choices.
Examples of an advance care planning discussion include either:
Notation in the medical record of a discussion with a provider or the initiation of a
discussion by a provider during the measurement year, or
Oral statements. Conversations with relatives or friends about life-sustaining
treatment and end-of-life care, documented in the medical record. Patient
designation of an individual who can make decisions on their behalf. Evidence of
oral statements must be noted in the medical record during the measurement
year.

Medication
Review

At least one medication review conducted by a prescribing practitioner or clinical
pharmacist during the measurement year and the presence of a medication list in the
medical record, as documented through either administrative data or medical record
review.

HEDIS 2010, Volume 2

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation must come from the same medical record and must include the
following.
A medication list in the medical record, and evidence of a medication review by a
prescribing practitioner or clinical pharmacist and the date on which it was
performed
Notation that the member is not taking any medication and the date on which it
was noted
A review of side effects for a single medication at the time of prescription alone is not
sufficient.
An outpatient visit is not required to meet criteria.

Functional
Status
Assessment

At least one functional status assessment during the measurement year, as
documented through either administrative data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation in the medical record must include evidence of a complete physical
functional status assessment and the date on which it was performed.
Notations for a complete physical functional status assessment may include the
following.
Functional independence
Loss of independent performance, Activities of Daily Living (ADL), social activities,
or Instrumental Activities of Daily Living (IADL)
The level of assistance needed to accomplish daily activities
Result of assessment using a standardized functional status assessment tool, not
limited to:
SF-36®
ADL list
Assessment of Living Skills and Resources (ALSAR)
Barthel ADL Index Physical Self-Maintenance (ADLS) Scale
Bayer Activities of Daily Living (B-ADL) Scale
Barthel Index
Extended Activities of Daily Living (EADL) Scale
Independent Living Scale (ILS)
Katz Index of Independence in Activities of Daily Living
Kenny Self-Care Evaluation
Klein-Bell Activities of Daily Living Scale
Kohlman Evaluation of Living Skills (KELS)
Lawton & Brody’s IADL scales

Pain Screening

At least one pain screening or a pain management plan during the measurement year,
as documented through either administrative data or medical record review.

HEDIS 2010, Volume 2

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation in the medical record must include evidence of a comprehensive pain
screening or a pain management plan and the date on which it was performed.
Evidence of a comprehensive pain screening may include the following.
Notation of a comprehensive pain assessment. Pain assessment associated with
an acute event (e.g., toothache, earache, localized pain from trauma) does not
meet criteria for a comprehensive pain assessment.
Results of a screening using a standardized pain screening tool, as in but not
limited to:
Multidimensional Pain Inventory
Faces Pain Scale
0–10 Numeric Rating Scales, verbal or visual
Verbal Descriptor Scale
Brief Pain Inventory (Short Form)
Evidence of a pain management plan may include the following.
Notation of no pain intervention and the rationale
Notation of plan for treatment of pain, which may include use of pain medications,
psychological support and patient/family education
Notation of plan for reassessment of pain, including reassessment time interval

Note
Refer to Appendix 3 for the definition of clinical pharmacist.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table COA-3: Data Elements for Care for Older Adults
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population

Administrative

Hybrid









Number of numerator events by administrative data in eligible population (before
exclusions)

Each of the 4 rates

Current year’s administrative rate (before exclusions)

Each of the 4 rates





Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS

Each of the 4 rates

Administrative rate on FSS

Each of the 4 rates






Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data

Each of the 4 rates

Numerator events by medical records

Each of the 4 rates
Each of the 4 rates

Reported rate

Each of the 4 rates

Each of the 4 rates

Lower 95% confidence interval

Each of the 4 rates

Each of the 4 rates

Upper 95% confidence interval

Each of the 4 rates

Each of the 4 rates

HEDIS 2010, Volume 2

Use of Spirometry Testing in the Assessment
and Diagnosis of COPD (SPR)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of members 40 years of age and older with a new diagnosis or newly active COPD who
received appropriate spirometry testing to confirm the diagnosis.

Definitions
Intake Period

A 12-month window that begins on July 1 of the year prior to the measurement year
and ends on June 30 of the measurement year. The Intake Period captures the first
COPD diagnosis.

IESD

Index Episode Start Date. The earliest date of service for any encounter during the
Intake Period with any diagnosis of COPD (Table SPR-A).
For an outpatient claim/encounter, the IESD is the date of service.
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of discharge.
For a transfer or readmission, the IESD is the discharge date of the original admission.

Negative
Diagnosis
History

A period of 730 days (2 years) prior to the IESD (inclusive), during which the member
had no claims/encounters containing any diagnosis of COPD (Table SPR-A). For an
inpatient (acute or nonacute) IESD, use the date of admission to determine the
Negative Diagnosis History.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

42 years or older as of December 31 of the measurement year.

Continuous
enrollment

730 days (2 years) prior to the IESD through 180 days after the IESD.

Allowable gap

One gap in enrollment of up to 45 days is allowed in each of the 12-month periods
prior to the IESD or in the 6-month period after the IESD, for a maximum of two gaps
total. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).

Anchor date

IESD.

Benefit

Medical.

HEDIS 2010, Volume 2

Event/
diagnosis
Step 1

The first COPD diagnosis. Follow the steps below to identify the eligible population for
the measure.
Identify all members who had any diagnosis of COPD (Table SPR-A) during the Intake
Period. If the member had more than one diagnosis of COPD, include only the first one.

Table SPR-A: Codes to Identify COPD
Description

ICD-9-CM Diagnosis

Chronic bronchitis

491

Emphysema

492

COPD

496

Step 2

Test for Negative Diagnosis History. Exclude members who had a claim/encounter with a
COPD diagnosis during the 730 days (2 years) prior to the IESD. For an inpatient (acute
or nonacute) IESD, use the date of admission to determine the Negative Diagnosis
History.

Step 3

Calculate continuous enrollment. Members must be continuously enrolled in the
organization 730 days (2 years) prior to the IESD through 180 days after the IESD.

Administrative Specification
Denominator

The eligible population.

Numerator

At least one claim/encounter with any code listed in Table SPR-B for spirometry in the
730 days (2 years) before the IESD to 180 days after the IESD.

Table SPR-B: Codes to Identify Spirometry Testing
Description
Spirometry

CPT
94010, 94014-94016, 94060, 94070, 94375, 94620

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table SPR-1/2/3: Data Elements for Use of Spirometry Testing in the Assessment
and Diagnosis of COPD
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









HEDIS 2010, Volume 2

Pharmacotherapy Management of COPD Exacerbation (PCE)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified in Step 2 that for ED visits resulting in an inpatient stay only the inpatient stay should be included.
Clarified that an ED visit for any diagnosis on or seven days after the Episode Date should be excluded in
step 4.

Description
The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient
discharge or ED encounter between January 1–November 30 of the measurement year and who were
dispensed appropriate medications. Two rates are reported.
1. Dispensed a systemic corticosteroid within 14 days of the event
2. Dispensed a bronchodilator within 30 days of the event
Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on
members. It is possible for the denominator to include multiple events for the same individual.

Definitions
Intake Period

An 11-month period that begins on January 1 of the measurement year and ends on
November 30 of the measurement year. The Intake Period captures eligible episodes of
treatment.

Episode Date

The date of service for any acute inpatient discharge or ED claim/encounter during the
Intake Period with a principal diagnosis of COPD.
For an acute inpatient claim/encounter, the Episode Date is the date of discharge.
For an ED claim/encounter, the Episode Date is the date of service.

Active
prescription

A prescription is considered active if the ―days supply‖ indicated on the date the
member filled the prescription is the number of days or more between that date and the
relevant Episode Date.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

40 years or older as of January 1 of the measurement year.

Continuous
enrollment

Episode Date through 30 days after the Episode Date.

Allowable gap

None.

Anchor date

Episode Date.

Benefits

Medical and pharmacy.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Event/
diagnosis

A COPD exacerbation as indicated by an acute inpatient discharge or ED encounter with a
principal diagnosis of COPD.
Follow the steps below to identify the eligible population.

Step 1

Identify all members who during the Intake Period had an acute inpatient discharge or an
ED visit with a primary diagnosis of COPD (Table PCE-A). Use Table PCE-B to identify
acute inpatient discharges and ED visits.

Table PCE-A: Codes to Identify COPD
Description

ICD-9-CM Diagnosis

Chronic bronchitis

491

Emphysema

492

COPD

496

Table PCE-B: Codes to Identify Visit Type
Description

CPT

Acute inpatient

UB Revenue
010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134, 0139, 0140-0144, 0149, 0150-0154,
0159, 016x, 020x-022x, 072x, 0987

ED*

99281-99285

045x, 0981

*Do not include ED visits that result in an inpatient admission.
Step 2

Determine all COPD Episode Dates. For each member identified in step 1, identify all
acute inpatient discharges and ED visits. Do not include ED visits that result in an inpatient
admission.

Step 3

Test for transfers. Exclude Episode Dates on which the member was transferred directly to
an acute or nonacute care facility for any diagnosis.

Step 4

Test for readmission and additional ED visits. Exclude Episode Dates for which the
member was readmitted to an acute or nonacute care facility for any diagnosis on or within
seven days after the Episode Date. Exclude Episode Dates for which the member had an
ED visit for any diagnosis on or seven days after the Episode Date.

Step 5

Calculate continuous enrollment. The member must be continuously enrolled without any
gaps in coverage from the Episode Date through 30 days after the Episode Date.
Note: All Episode Dates that were not excluded should remain in the denominator. The
denominator for this measure is based on acute inpatient discharges and ED visits, not
members.

Administrative Specification
Denominator

The eligible population.

Numerators
Systemic
corticosteroid

Dispensed prescription for systemic corticosteroid (Table PCE-C) on or 14 days after
the Episode Date. The organization may count systemic corticosteroids that are active
on the Episode Date.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table PCE-C: Systemic Corticosteroids
Description
Glucocorticoids

Prescription
betamethasone
dexamethasone

hydrocortisone
methylprednisolone

prednisolone
prednisone

triamcinolone

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Bronchodilator

Dispensed prescription for a bronchodilator (Table PCE-D) on or 30 days after the
Episode Date. The organization may count bronchodilators that are active on
the Episode Date.

Table PCE-D: Bronchodilators
Description

Prescription

Anticholinergic agents

albuterol-ipratropium

ipratropium

tiotropium

Beta 2-agonists

albuterol
arformoterol
budesonide-formoterol

fluticasone-salmeterol
formoterol
levalbuterol

metaproterenol
pirbuterol
salmeterol

Methylxanthines

dyphylline-guaifenesin
guaifenesin-theophylline
potassium iodide-theophylline

aminophylline
dyphylline
theophylline

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table PCE-1/2/3: Data Elements for Pharmacotherapy Management of
COPD Exacerbation
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Exclusions based on direct transfers to another facility*
Exclusions based on readmissions*







Numerator events by administrative data

Each of the 2 rates

Reported rate

Each of the 2 rates

Lower 95% confidence interval

Each of the 2 rates

Upper 95% confidence interval

Each of the 2 rates

*Reporting this additional data element is optional in IDSS.

HEDIS 2010, Volume 2

Cholesterol Management for Patients With Cardiovascular Conditions
(CMC)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that a calculated or direct LDL may be used for LDL-C screening and control.
Deleted CPT codes 99261–99263 from Table CMC-C.
Deleted LOINC code 24331-1 from Table CMC-D.

Description
The percentage of members 18–75 years of age who were discharged alive for AMI, coronary artery bypass
graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the
year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the
measurement year and the year prior to measurement year, who had each of the following during the
measurement year.
LDL-C screening
LDL-C control (<100 mg/dL)

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18–75 years as of December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/
diagnosis

Members are identified for the eligible population in two ways: by event or by
diagnosis. The organization must use both to identify the eligible population, but a
member only needs to be identified in one to be included in the measure.
Event. Discharged alive for AMI, CABG or PTCA on or between January 1 and
November 1 of the year prior to the measurement year. Refer to Table CMC-A for
codes to identify AMI, PTCA and CABG. The organization should include AMI and
CABG from inpatient claims/encounters only. All cases of PTCA should be included,
regardless of setting (e.g., inpatient, outpatient, ED).

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table CMC-A: Codes to Identify AMI, PTCA and CABG
Description

CPT

HCPCS

AMI (include only
inpatient claims)

ICD-9-CM Diagnosis

ICD-9-CM Procedure

410.x1

CABG (include only
inpatient claims)

33510-33514, 33516-33519,
33521-33523, 33533-33536

PTCA

33140, 92980, 92982, 92995

S2205-S2209

36.1, 36.2
00.66, 36.06, 36.07, 36.09

Diagnosis. Identify members as having IVD who met at least one of the following criteria
during both the measurement year and the year prior to the measurement year. Criteria
need not be the same across both years.
At least one outpatient visit (Table CMC-C) with any IVD diagnosis (Table
CMC-B), or
At least one acute inpatient claim/encounter (Table CMC-C) with any IVD diagnosis
(Table CMC-B)

Table CMC-B: Codes to Identify IVD
Description
IVD

ICD-9-CM Diagnosis
411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434, 440.1, 440.2, 440.4, 444, 445

Table CMC-C: Codes to Identify Visit Type
Description

CPT

UB Revenue

Outpatient

99201-99205, 99211-99215, 99217-99220, 99241-99245,
99341-99345, 99347-99350, 99384-99387, 99394-99397,
99401-99404, 99411, 99412, 99420, 99429, 99455, 99456

051x, 0520-0523, 0526-0529, 057x-059x, 077x,
0982, 0983

Acute inpatient

99221-99223, 99231-99233, 99238, 99239, 99251-99255,
99291

010x, 0110-0114, 0119, 0120-0124, 0129,
0130-0134, 0139, 0140-0144, 0149, 01500154, 0159, 016x, 020x-022x, 072x, 0987

Administrative Specification
Denominator

The eligible population.

Numerators
LDL-C
Screening

An LDL-C test performed any time during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in Table CMC-D.
The organization may use a calculated or direct LDL for LDL-C screening and control
indicators.

Table CMC-D: Codes to Identify LDL-C Screening
CPT
80061, 83700, 83701, 83704, 83721

CPT Category II
3048F, 3049F, 3050F

LOINC
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2,
49132-4

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

LDL-C Level
<100 mg/dL

Using automated laboratory data, the member is numerator compliant if the most
recent LDL-C level during the measurement year is <100 mg/dL. The member is
noncompliant if the automated result for the most recent LDL-C test is ≥100 mg/dL or
is missing, or if an LDL-C test was not done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-I and use the most recent code
during the measurement year to evaluate whether the member is numerator compliant.

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population for each product line. The
organization may reduce its sample size using the current year’s lowest administrative
rate or the prior year’s audited, product line-specific results for the two rates. Refer to
the Guidelines for Calculations and Sampling for information about sampling.

Numerators
LDL-C
Screening

An LDL-C test performed during the measurement year as determined by
administrative data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may use a calculated LDL for LDL-C screening and control
indicators.

LDL-C Level
<100 mg/dL

The most recent LDL-C level performed during the measurement year is <100 mg/dL,
as documented through automatic laboratory data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from the
administrative data.

Medical record

Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may calculate LDL-C levels from total cholesterol, HDL-C and
triglycerides using the Friedewald equation if the triglycerides are ≤400 mg/dL.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5)
If lipoprotein (a) is measured, this calculation is:
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5) – 0.3[lipoprotein (a)]
These formulae are used when all levels are expressed in mg/dL and cannot be used if
triglycerides are >400 mg/dL.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table CMC-1/2/3: Data Elements for Cholesterol Management for Patients With
Cardiovascular Conditions
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population

Administrative

Hybrid









Number of numerator events by administrative data in eligible population (before
exclusions)

Each of the 2 rates

Current year’s administrative rate (before exclusions)

Each of the 2 rates





Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS

Each of the 2 rates

Administrative rate on FSS

Each of the 2 rates






Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data

Each of the 2 rates

Numerator events by medical records

Each of the 2 rates
Each of the 2 rates

Reported rate

Each of the 2 rates

Each of the 2 rates

Lower 95% confidence interval

Each of the 2 rates

Each of the 2 rates

Upper 95% confidence interval

Each of the 2 rates

Each of the 2 rates

HEDIS 2010, Volume 2

Controlling High Blood Pressure (CBP)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that member-reported BP readings are not acceptable.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CBP-C ―Evidence of ESRD‖
description.
Added ICD-9-CM Diagnosis codes 678, 679 to Table CBP-C ―Pregnancy‖ description.
Deleted CPT code 90939 from Table CBP-C.

Description
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP
was adequately controlled (<140/90) during the measurement year. Use the Hybrid Method for this measure.

Definitions
Adequate control

Both a representative systolic BP <140 mm Hg and a representative diastolic BP
<90 mm Hg (BP in the normal or high-normal range).

Representative
BP

The most recent BP reading during the measurement year (as long as it occurred
after the diagnosis of hypertension was made). If multiple BP measurements occur
on the same date or are notated in the chart on the same date, the lowest systolic
and lowest diastolic BP reading should be used. If no BP is recorded during the
measurement year, assume that the member is ―not controlled.‖

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18–85 years as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in continuous enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a Medicaid beneficiary
for whom enrollment is verified monthly, the member may not have more than a onemonth gap in coverage (i.e., a member whose coverage lapses for 2 months [60
days] is not considered continuously enrolled).

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

Hypertensive. A member is considered hypertensive if there is at least one outpatient
encounter (Table CBP-B) with a diagnosis of hypertension (Table CBP-A) during the
first six months of the measurement year.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table CBP-A: Codes to Identify Hypertension
Description

ICD-9-CM Diagnosis

Hypertension

401

Table CBP-B: Codes to Identify Outpatient Visits
Description

CPT

Outpatient visits

99201-99205, 99211-99215, 99241-99245, 99384-99387, 99394-99397

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population for each product line whose
diagnosis of hypertension is confirmed by chart review. The organization may reduce
the sample size using the prior year’s audited, product line-specific rate. Refer to the
Guidelines for Calculations and Sampling for information on reducing the sample size.
To confirm the diagnosis of hypertension, the organization must find notation of one of
the following in the medical record on or before June 30 of the measurement year.
HTN

History of HTN

High BP (HBP)

Hypertensive vascular disease (HVD)

Elevated BP ( BP)

Hyperpiesia

Borderline HTN

Hyperpiesis

Intermittent HTN
The notation of hypertension may appear anytime on or before June 30 of the
measurement year, including prior to the measurement year. It does not matter if
hypertension was treated or is currently being treated. The notation indicating a
diagnosis of hypertension may be recorded in any of the following documents.
Problem list (this may include a diagnosis prior to June 30 of the measurement year
or an undated diagnosis; see Note at the end of this section)
Office note
Subjective, Objective, Assessment, Plan (SOAP) note
Encounter form
Telephone call record
Diagnostic report
Hospital discharge summary
Statements such as ―rule out HTN,‖ ―possible HTN,‖ ―white-coat HTN,‖ ―questionable
HTN‖ and ―consistent with HTN‖ are not sufficient to confirm the diagnosis if such
statements are the only notations of hypertension in the medical record.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Identifying the
medical record

The organization should use only the medical records of one practitioner or provider
team for both the confirmation of the diagnosis of hypertension and the representative
BP. All eligible BP measurements recorded in the records from one practitioner or
provider team (even if obtained by a different practitioner) should be considered (e.g.,
from a consultation note or other note relating to a BP reading from a health care
practitioner or provider team). If the organization cannot find the medical record, the
member remains in the measure denominator and is considered noncompliant for the
numerator.
The organization should use the following algorithm to find the appropriate medical
record to review.

Step 1

Identify the member’s primary care practitioner (PCP).
If the member had more than one PCP for the time period, identify the PCP who
most recently provided care to the member
If the member did not visit a PCP for the time period or does not have a PCP,
identify the practitioner who most recently provided care to the member
If a practitioner other than the member’s PCP manages the hypertension, the
organization may use the medical record of that practitioner, instead

Step 2

Use one medical record to both confirm the diagnosis for the denominator and identify
the representative BP level for the numerator. There are circumstances in which the
organization may need to go to a second medical record to either confirm the
diagnosis or obtain the BP reading, as in the following two examples.
If a member sees one PCP during the denominator confirmation period (on or before
June 30 of the measurement year) and another PCP after June 30, the diagnosis of
hypertension and BP reading may be identified through two different medical records.
If a member has the same PCP for the entire measurement year, but it is clear from
claims or medical record data that a specialist (e.g., cardiologist) manages the
member’s hypertension after June 30, the organization may use the PCP’s chart to
confirm the diagnosis and use the specialist’s chart to obtain the BP reading. For
example, if all recent claims coded with 401 came from the specialist, the organization
may elect to use this chart for the most recent BP reading. If the member did not have
any visits with the specialist prior to June 30 of the measurement year, the
organization must go to another medical record to confirm the diagnosis.

Numerator

The number of members in the denominator whose most recent BP is adequately
controlled during the measurement year. For a member’s BP to be controlled, both
the systolic and diastolic BP must be <140/90 (adequate control). To determine if a
member’s BP is adequately controlled, the organization must identify the
representative BP.

Administrative

None.

Medical record

Follow the steps below to determine representative BP.

Step 1

Identify the most recent BP reading noted during the measurement year. The reading
must occur after the date on which the diagnosis of hypertension was made or
confirmed. Do not include BP readings that meet the following criteria.
BPs taken during an acute inpatient stay or an ED visit
BPs taken during an outpatient visit which was for the sole purpose of having a
diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal
of a mole)

HEDIS 2010, Volume 2

BPs obtained the same day as a major diagnostic or surgical procedure (e.g., stress test,
administration of IV contrast for a radiology procedure, endoscopy)
BP readings reported by or taken by the member
Step 2

Identify the lowest systolic and lowest diastolic BP reading from the most recent BP notation
in the medical record. If multiple readings were recorded for a single date, use the lowest
systolic and lowest diastolic BP on that date as the representative BP. The systolic and
diastolic results do not need to be from the same reading.

Exclusions (optional)
Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) (Table
CBP-C) on or prior to December 31 of the measurement year. Documentation in the medical record must
include a dated note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets
the criteria for evidence of ESRD.
Exclude from the eligible population all members with a diagnosis of pregnancy (Table CBP-C) during the
measurement year.
Exclude from the eligible population all members who had an admission to a nonacute inpatient setting any
time during the measurement year. Refer to Table FUH-B for codes to identify nonacute care.

Table CBP-C: Codes to Identify Exclusions
Description
Evidence of
ESRD

CPT
36145, 36800, 36810,
36815, 36818, 36819,
36820, 36821, 3683136833, 50300, 50320,
50340, 50360, 50365,
50370, 50380, 90920,
90921, 90924, 90925,
90935, 90937, 90940,
90945, 90947, 9095790962, 90965, 90966,
90969, 90970, 90989,
90993, 90997, 90999,
99512

Pregnancy

HCPCS
G0257, G0308G0319, G0322,
G0323, G0326,
G0327, G0392,
G0393, S9339

ICD-9-CM
Diagnosis
585.5, 585.6,
V42.0, V45.1,
V56

ICD-9-CM
Procedure

UB
Revenue

UB Type
of Bill

POS

38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.6

0367,
080x,
082x-085x,
088x

72x

65

630-679, V22,
V23, V28

Note
The organization may use an undated notation of hypertension on problem lists. Problem lists generally
indicate established conditions; to discount undated entries might hinder confirmation of the denominator.
Organizations generally require an oversample of 10 percent–15 percent to meet the MRSS for confirmed
cases of hypertension.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table CBP-1/2/3: Data Elements for Controlling High Blood Pressure
Hybrid
Measurement year
Data collection methodology (Hybrid)
Eligible population
Number of numerator events by administrative data in eligible population (before exclusions)
Current year’s administrative rate (before exclusions)
Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of records excluded because of false-positive diagnoses
Number of administrative data records excluded
Number of medical record data records excluded
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data
Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval

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HEDIS 2010, Volume 2

Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of members 18 years of age and older during the measurement year who were hospitalized
and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement
year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after
discharge.

Definition
Treatment days
(covered days)

The actual number of calendar days covered with prescriptions within the specified
180-day measurement interval (i.e., a prescription of 90 days supply dispensed on
the 100th day will have 80 days counted in the 180-day interval).

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18 years and older as of December 31 of the measurement year.

Continuous
enrollment

Discharge date through 180 days after discharge.

Allowable gap

No more than one gap in enrollment of up to 45 days within the 180 days of the
event. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap
in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
continuously enrolled).

Anchor date

Discharge date.

Benefit

Medical and pharmacy.

Event/diagnosis

Discharged alive from an acute inpatient setting with an AMI (Table PBH-A) from
July 1 of the year prior to the measurement year through June 30 of the
measurement year.
If a member has more than one episode of AMI from July 1 of the year prior to the
measurement year through June 30 of the measurement year, the organization
should only include the first discharge.

Table PBH-A: Codes to Identify AMI
Description

ICD-9-CM Diagnosis

AMI

410.x1*

* An organization that does not have fifth-digit specificity must develop a methodology to ensure that only the first eligible episode of an AMI
is included in the measure.

HEDIS 2010, Volume 2

Transfers to acute facilities. Include hospitalizations in which the member was
transferred directly to another acute inpatient facility for any diagnosis. Count the
discharge from the subsequent acute inpatient facility, not the initial discharge. The
discharge date from the facility to which the member was transferred must occur on or
before June 30 of the measurement year.
Transfers to nonacute facilities. Exclude from the denominator hospitalizations in which
the member was transferred directly to a nonacute care facility for any diagnosis.
Readmissions. If the member was readmitted to an acute or nonacute care facility for
any diagnosis, include the member in the denominator and use the discharge date
from the original hospitalization.

Administrative Specification
Denominator

The eligible population.

Numerator

A 180-day course of treatment with beta-blockers.
Identify all members in the denominator population whose dispensed days supply is
≥135 days in the 180 days following discharge. Persistence of treatment for this
measure is defined as at least 75 percent of the days supply filled.
To determine continuity of treatment during the 180-day period, sum the number of
allowed gap days to the number of treatment days for a maximum of 180 days (i.e.,
135 treatment days + 45 gap days = 180 days); identify all prescriptions filled within
180 days of the Discharge Date.
To account for members who are on beta-blockers prior to admission, the organization
should factor those prescriptions into adherence rates if the actual treatment days fall
within the 180 days following discharge.

Table PBH-B: Beta-Blocker Medications
Description

Prescription

Noncardioselective beta-blockers

carteolol
carvedilol
labetalol

nadolol
penbutolol
pindolol

propranolol
timolol
sotalol

Cardioselective beta-blockers

acebutolol
atenolol

betaxolol
bisoprolol

metoprolol
nebivolol

Antihypertensive combinations

atenolol-chlorthalidone
bendroflumethiazide-nadolol
bisoprolol-hydrochlorothiazide

hydrochlorothiazide-metoprolol
hydrochlorothiazide-propranolol
hydrochlorothiazide-timolol

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

HEDIS 2010, Volume 2

Exclusion (optional)
Use administrative data to look as far back as possible in the member’s history through the end of the
continuous enrollment period for evidence of a contraindication to beta-blocker therapy. Refer to Table
PBH-C and Table PBH-D for codes and medications representing contraindications to beta-blocker
therapy.

Table PBH-C: Codes to Identify Exclusions
Description

ICD-9-CM Diagnosis

History of asthma

493

Hypotension

458

Heart block >1 degree

426.0, 426.12, 426.13, 426.2-426.4, 426.51-426.54, 426.7

Sinus bradycardia

427.81

COPD

491.2, 496, 506.4

Table PBH-D: Medications to Identify Exclusions (History of Asthma)
Description

Prescription

Bronchodilator combinations

budesonide-formoterol

Inhaled corticosteroids

beclomethasone
budesonide
flunisolide

fluticasone-salmeterol
fluticasone
mometasone
triamcinolone

fluticasone CFC free

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table PBH-1/2/3: Data Elements for Persistence of Beta-Blocker Treatment
After a Heart Attack
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval

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HEDIS 2010, Volume 2

Comprehensive Diabetes Care (CDC)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that HbA1c control (<7.0%) is only reported for the commercial and Medicaid product lines.
Deleted CPT codes 99261–99263, 99301–99303, 99311–99313, 99321–99323, 99331–99333 from Table
CDC-C.
Deleted CPT Category II code 3047F from Tables CDC-D, CDC-E, CDC-F and CDC-Q.
Clarified that a calculated or direct LDL may be used for LDL-C screening and control.
Deleted LOINC code 24331-1 from Table CDC-H.
Deleted LOINC codes 34535-5, 50561-0, 53525-2 from Table CDC-J.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CDC-K ―Evidence of treatment for
nephropathy‖ description.
Added LOINC code 53525-2 to Table CDC-K.
Deleted LOINC codes 24356-8, 24357-6, 50556-0, 50564-4 from Table CDC-K.
Deleted CPT code 90939 from Tables CDC-K, CDC-P.
Deleted CPT Category II code 3076F from Table CDC-N.
Clarified that member-reported BP readings are not acceptable.
Added ICD-9-CM Diagnosis code 249 to Table CDC-O ―Steroid induced‖ description.
Added CPT codes 90957–90962, 90965, 90966, 90969, 90970 to Table CDC-P ―ESRD‖ description.

Description
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the
following.
Hemoglobin A1c (HbA1c) testing

LDL-C screening

HbA1c poor control (>9.0%)

LDL-C control (<100 mg/dL)

HbA1c control (<8.0%)

Medical attention for nephropathy

HbA1c control (<7.0%) *

BP control (<130/80 mm Hg)

Eye exam (retinal) performed

BP control (<140/90 mm Hg)

* Additional exclusion criteria are required for this indicator. This indicator is only reported for the commercial and Medicaid
product lines.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18–75 years as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during the measurement year. To
determine continuous enrollment for a Medicaid beneficiary for whom enrollment is
verified monthly, the member may not have more than a 1-month gap in coverage (i.e.,
a member whose coverage lapses for 2 months [60 days] is not considered continuously
enrolled).

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/
diagnosis

There are two ways to identify members with diabetes: by pharmacy data and by claim/
encounter data. The organization must use both to identify the eligible population, but a
member only needs to be identified in one to be included in the measure. Members may
be identified as having diabetes during the measurement year or the year prior to the
measurement year.
Pharmacy data. Members who were dispensed insulin or oral hypoglycemics/antihyperglycemics during the measurement year or year prior to the measurement year on an
ambulatory basis (Table CDC-A).

Table CDC-A: Prescriptions to Identify Members With Diabetes
Description

Prescription

Alpha-glucosidase inhibitors

acarbose

miglitol

Amylin analogs

pramlinitide

Antidiabetic combinations

glimepiride-pioglitazone
glimepiride-rosiglitazone
glipizide-metformin

Insulin

insulin aspart
insulin aspart-insulin aspart protamine
insulin detemir
insulin glargine
insulin glulisine
insulin inhalation
insulin isophane beef-pork
insulin isophane human
insulin isophane pork
insulin isophane-insulin regular

Meglitinides

nateglinide

repaglinide

Miscellaneous antidiabetic
agents

exenatide

sitagliptin

Sulfonylureas

acetohexamide
chlorpropamide

glimepiride
glipizide

Thiazolidinediones

pioglitazone

rosiglitazone

glyburide-metformin
metformin-pioglitazone

metformin-rosiglitazone
metformin-sitagliptin

insulin lispro
insulin lispro-insulin lispro protamine
insulin regular beef-pork
insulin regular human
insulin regular pork
insulin zinc beef-pork
insulin zinc extended human
insulin zinc human
insulin zinc pork

glyburide
tolazamide

tolbutamide

HEDIS 2010, Volume 2

Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes;
members with diabetes on these medications are identified through diagnosis codes only. NCQA will post a
complete list of medications and NDC codes to www.ncqa.org by November 16, 2009.
Claim/encounter data. Members who had two face-to-face encounters with a diagnosis
of diabetes (Table CDC-B) on different dates of service in an outpatient setting or
nonacute inpatient setting, or one face-to-face encounter in an acute inpatient or ED
setting during the measurement year or the year prior to the measurement year. The
organization may count services that occur over both years. Refer to Table CDC-C for
codes to identify visit type.

Table CDC-B: Codes to Identify Diabetes
Description
Diabetes

ICD-9-CM Diagnosis
250, 357.2, 362.0, 366.41, 648.0

Table CDC-C: Codes to Identify Visit Type
Description

CPT

UB Revenue

Outpatient

92002, 92004, 92012, 92014, 99201-99205, 9921199215, 99217-99220, 99241-99245, 99341-99345,
99347-99350, 99384-99387, 99394-99397, 9940199404, 99411, 99412, 99420, 99429, 99455, 99456

051x, 0520-0523, 0526-0529, 057x-059x, 077x, 082x085x, 088x, 0982, 0983

Nonacute inpatient

99304-99310, 99315, 99316, 99318, 99324-99328,
99334-99337

0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525,
055x, 066x

Acute inpatient

99221-99223, 99231-99233, 99238, 99239, 9925199255, 99291

010x, 0110-0114, 0119, 0120-0124, 0129, 0130-0134,
0139, 0140-0144, 0149, 0150-0154, 0159, 016x,
020x-022x, 072x, 080x, 0987

ED

99281-99285

045x, 0981

Administrative Specification
Denominator
Required
exclusions for
the HbA1c
Control
<7% indicator

The eligible population.
For the HbA1c control <7% indicator, exclude members who meet any of the following
criteria.
65–75 years of age as of December 31 of the measurement year.
CABG or PTCA. Members discharged alive for CABG or PTCA in the
measurement year or the year prior to the measurement year. Refer to Table
CMC-A and use codes for PTCA and CABG only. CABG cases should be from
inpatient claims/encounters only. Include all cases of PTCA, regardless of
setting (e.g., inpatient, outpatient, ED).
IVD. Members who met at least one of the following criteria during both the
measurement year and the year prior to the measurement year. Criteria need
not be the same across both years.
At least one outpatient visit (Table CMC-C) with an IVD diagnosis (Table CMCB), or
At least one acute inpatient claim/encounter (Table CMC-C) with an IVD
diagnosis (Table CMC-B)

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Chronic heart failure (CHF). Members who had at least one encounter, in any
setting, with CHF. Refer to Table RCA-A and use codes for CHF only. Look as
far back as possible in the member’s history through December 31 of the
measurement year.
Prior MI. Members who had at least one encounter, in any setting, with any code
to identify MI (Table CDC-P). Look as far back as possible in the member’s
history through December 31 of the measurement year.
Chronic renal failure (CRF)/ESRD. Members who had at least one encounter, in
any setting, with any code to identify CRF/ESRD (Table CDC-P). Look as far
back as possible in the member’s history through December 31 of the
measurement year.
Dementia. Members who had at least one encounter, in any setting, with any
code to identify dementia (Table DDE-E). Look as far back as possible in the
member’s history through December 31 of the measurement year.
Blindness. Members who had at least one encounter, in any setting, with any
code to identify blindness (Table CDC-P). Look as far back as possible in the
member’s history through December 31 of the measurement year.
Amputation (lower extremity). Members who had at least one encounter, in any
setting, with any code to identify lower extremity amputation (Table CDC-P).
Look as far back as possible in the member’s history through December 31 of
the measurement year.

Table CDC-P: Codes to Identify Required Exclusions
Description

CPT

HCPCS

MI
CRF/ESRD

ICD-9-CM
Procedure

UB Revenue

UB Type
of Bill

POS

410, 412
36145, 36800-36821,
36831-36833, 9091990921, 90923-90925,
90935, 90937, 90940,
90945, 90947, 9095790962, 90965, 90966,
90969, 90970, 90989,
90993, 90997, 90999,
99512

Blindness
Amputation (lower
extremity)

ICD-9-CM
Diagnosis

G0257, G0311G0319, G0321G0323, G0325G0327, G0392,
G0393, S9339

585.4, 585.5,
585.6, V42.0,
V45.1, V56

38.95, 39.27,
39.42, 39.43,
39.53, 39.93,
39.94, 39.95,
54.98

080x, 082x085x, 088x

72x

65

369.0, 369.1,
369.2, 369.4,
369.6, 369.7
27290, 27295, 2759027592, 27594, 27596,
27598, 27880, 27881,
27882, 27884, 27886,
27888, 27889, 28800,
28805, 28810, 28820,
28825

84.1

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Numerators
HbA1c Testing

An HbA1c test performed during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in Table CDC-D.

Table CDC-D: Codes to Identify HbA1c Tests
CPT

CPT Category II

LOINC

83036, 83037

3044F, 3045F, 3046F

4548-4, 4549-2, 17856-6

HbA1c Poor
Control >9%

Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is >9.0% or is missing a result or if an HbA1c test was not done during
the measurement year. The member is not numerator compliant if the automated
result for the most recent HbA1c test during the measurement year is ≤9.0%.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-E and use the most recent code
during the measurement year to evaluate whether the member is numerator
compliant.
Note: For this indicator, a lower rate indicates better performance (i.e., low rates of
poor control indicate better care).

Table CDC-E: Codes to Identify HbA1c Levels >9%
Description
Numerator compliant (HbA1c >9.0%)
Not numerator compliant (HbA1c ≤9.0%)

HbA1c Control
<8%

CPT Category II
3046F
3044F, 3045F

Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is <8.0%. The member is not numerator compliant if the automated result
for the most recent HbA1c test is ≥8.0% or is missing a result, or if an HbA1c test was
not done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-Q and use the most recent code
during the measurement year to evaluate whether the member is numerator
compliant.

Table CDC-Q: Codes to Identify HbA1c Levels <8%
Description
Numerator compliant (HbA1c <8.0%)
Not numerator compliant (HbA1c ≥8.0%)

CPT Category II
3044F
3045F*, 3046F

* CPT Category II code 3045F indicates most recent HbA1c (HbA1c) level 7.0%–9.0% and is not specific enough to denote numerator
compliance for this indicator. For members with this code, the organization may use other sources (laboratory data, hybrid reporting
method) to determine if the HbA1c result was <8%.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

HbA1c
Control <7%

Use automated laboratory data to identify the most recent HbA1c test during the
measurement year. The member is numerator compliant if the most recent automated
HbA1c level is <7.0%. The member is not numerator compliant if the automated result for
the most recent HbA1c test is ≥7.0% or is missing a result, or if an HbA1c test was not
done during the measurement year.
An organization that uses CPT Category II codes to identify numerator compliance for this
indicator must search for all codes in Table CDC-F and use the most recent code during
the measurement year to evaluate whether the member is numerator compliant.
Note: This indicator uses the eligible population with additional eligible population criteria
(e.g., removing members with required exclusions).

Table CDC-F: Codes to Identify HbA1c Levels <7%
Description
Numerator compliant (HbA1c <7.0%)
Not numerator compliant (HbA1c ≥7.0%)

Eye Exam

CPT Category II
3044F
3045F, 3046F

An eye screening for diabetic retinal disease as identified by administrative data. This
includes diabetics who had one of the following.
A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) in the measurement year, or
A negative retinal exam (no evidence of retinopathy) by an eye care professional in
the year prior to the measurement year
Refer to Table CDC-G for codes to identify eye exams. For exams performed in the year
prior to the measurement year, a result must be available.

Table CDC-G: Codes to Identify Eye Exams*
CPT
67028, 67030, 67031, 67036, 67038-67043,
67101, 67105, 67107, 67108, 67110, 67112,
67113, 67121, 67141, 67145, 67208, 67210,
67218, 67220, 67221, 67227, 67228, 92002,
92004, 92012, 92014, 92018, 92019, 92225,
92226, 92230, 92235, 92240, 92250, 92260,
99203-99205, 99213-99215, 99242-99245

CPT Category II**
2022F, 2024F,
2026F, 3072F***

HCPCS
S0620, S0621,
S0625**, S3000

ICD-9-CM
Diagnosis
V72.0

ICD-9-CM
Procedure
14.1-14.5, 14.9,
95.02-95.04, 95.11,
95.12, 95.16

* Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to

determine that a dilated exam was performed.
** The organization does not need to limit CPT Category II codes or HCPCS S0625 to an optometrist or an ophthalmologist. These codes
indicate an eye exam was performed by an eye care professional.
*** CPT Category II code 3072F can only be used if the claim/encounter was during the measurement year because it indicates the member
had ―no evidence of retinopathy in the prior year.‖ Additionally, because the code definition itself indicates results were negative, an
automated result is not required.

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Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

LDL-C
Screening

An LDL-C test performed during the measurement year, as identified by claim/
encounter or automated laboratory data. Use any code listed in table CDC-H.
The organization may use a calculated or direct LDL for LDL-C screening and control
indicators.

Table CDC-H: Codes to Identify LDL-C Screening
CPT

CPT Category II

80061, 83700, 83701, 83704, 83721

3048F, 3049F, 3050F

LDL-C Control
<100 mg/dL

LOINC
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8,
39469-2, 49132-4

Use automated laboratory data to identify the most recent LDL-C test during the
measurement year. The member is numerator compliant if the most recent automated
LDL-C level is <100 mg/dL. If the automated result for the most recent LDL-C test
during the measurement year is ≥100 mg/dL or is missing, or if an LDL-C test was not
done during the measurement year, the member is not numerator compliant.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-I and use the most recent code
during the measurement year to evaluate whether the member is numerator compliant.
Use Table CDC-I to determine compliance.

Table CDC-I: Codes to Identify LDL-C Levels
Description

CPT Category II

Numerator compliant (LDL-C <100 mg/dL)
Not numerator compliant (LDL-C ≥100 mg/dL)

Medical
Attention for
Nephropathy

Nephropathy
screening test

3048F
3049F, 3050F

A nephropathy screening test or evidence of nephropathy, as documented through
administrative data.
Note: A process flow diagram is included at the end of this specification to help
implement this specification.
A nephropathy screening test during the measurement year (Table CDC-J).

Table CDC-J: Codes to Identify Nephropathy Screening Tests
Description
Nephropathy screening test

CPT
82042, 82043,
82044, 84156

CPT Category II
3060F, 3061F

LOINC
1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4,
2890-2, 9318-7, 11218-5, 12842-1, 13801-6, 14956-7, 149575, 14958-3, 14959-1, 13705-9, 14585-4, 18373-1, 20621-9,
21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2,
30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4,
40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1,
44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2,
53531-0, 53532-8

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Evidence of
nephropathy

Any of the following meet criteria for evidence of nephropathy.
A claim/encounter with a code to indicate evidence of treatment for nephropathy
(Table CDC-K) during the measurement year.
A nephrologist visit during the measurement year, as identified by the organization’s
specialty provider codes (no restriction on the diagnosis or procedure code
submitted).
A positive urine macroalbumin test in the measurement year, as documented by
claim/encounter or automated laboratory data. Refer to Table CDC-K for codes to
identify urine macroalbumin tests. ―Trace‖ urine macroalbumin test results are not
considered numerator-compliant.
Evidence of ACE inhibitor/ARB therapy during the measurement year. Members who
had a claim indicating therapy (Table CDC-K) or received an ambulatory
prescription or were dispensed an ambulatory prescription for ACE inhibitors or
ARBs during the measurement year are compliant. Table CDC-L lists the ACE
inhibitors/ARBs included in this measure.

HEDIS 2010, Volume 2

Table CDC-K: Codes to Identify Evidence of Nephropathy
Description

CPT

CPT
Category II*

Urine macroalbumin
test*

81000-81003, 81005

3062F

Evidence of treatment
for nephropathy

36145, 36800, 36810, 36815,
36818, 36819-36821, 3683136833, 50300, 50320, 50340,
50360, 50365, 50370, 50380,
90920, 90921, 90924, 90925,
90935, 90937, 90940, 90945,
90947, 90957-90962, 90965,
90966, 90969, 90970, 90989,
90993, 90997, 90999, 99512

3066F

ACE inhibitor/
ARB therapy

ICD-9-CM
Diagnosis

HCPCS

ICD-9-CM
Procedure

UB
Revenue

UB Type
of Bill

POS

LOINC
5804-0, 20454-5,
50561-0, 53525-2

G0257, G0314G0319, G0322,
G0323, G0326,
G0327, G0392,
G0393, S9339

250.4, 403, 404,
405.01, 405.11,
405.91, 580588, 753.0,
753.1, 791.0,
V42.0, V45.1,
V56

38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.4-55.6

0367, 080x,
082x-085x,
088x

72x

65

4009F

* A CPT Category II code indicates a positive result for urine macroalbumin; the organization must use automated laboratory data to confirm a positive result for tests identified by CPT or LOINC
codes.

Table CDC-L: ACE Inhibitors/ARBs
Description
Angiotensin converting
enzyme inhibitors
Angiotensin II
inhibitors
Antihypertensive
combinations

Prescription
benazepril
enalapril
captopril
fosinopril
candesartan
irbesartan
eprosartan
losartan
amlodipine-benazepril
amlodipine-olmesartan
amlodipine-valsartan
benazepril-hydrochlorothiazide
candesartan-hydrochlorothiazide
captopril-hydrochlorothiazide

lisinopril
perindopril
moexipril
quinapril
olmesartan
valsartan
telmisartan
enalapril-hydrochlorothiazide
eprosartan-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide-irbesartan
hydrochlorothiazide-lisinopril
hydrochlorothiazide-losartan

ramipril
trandolapril

hydrochlorothiazide-moexipril
hydrochlorothiazide-olmesartan
hydrochlorothiazide-quinapril
hydrochlorothiazide-telmisartan
hydrochlorothiazide-valsartan
trandolapril-verapamil

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 16, 2009.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

BP Control
<130/80 mm Hg

Use automated data to identify the most recent BP reading during the measurement
year.
The member is numerator compliant if the BP is <130/80 mm Hg. The member is not
compliant if the BP is ≥130/80 mm Hg or if there is no automated BP reading during
the measurement year. If there are multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date as the representative BP.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-M and use the most recent
codes during the measurement year to evaluate whether the member is numerator
compliant for both systolic and diastolic levels.

Table CDC-M: Codes to Identify Systolic and Diastolic BP Levels <130/80
CPT Category II
Systolic
Diastolic

Description
Numerator compliant (BP <130/80 mm Hg)

3074F

3078F

Not numerator compliant (BP ≥130/80 mm Hg)

3075F, 3077F

3079F, 3080F

BP Control
<140/90 mm Hg

Use automated data to identify the most recent BP reading during the measurement
year. Refer to Table CDC-N and use the most recent code to evaluate whether the
member is numerator compliant.
The member is numerator compliant if the BP is <140/90 mm Hg. The member is not
compliant if the BP is ≥140/90 mm Hg or if there is no automated BP reading during
the measurement year. If there are multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date as the representative BP.
An organization that uses CPT Category II codes to identify numerator compliance for
this indicator must search for all codes in Table CDC-N and use the most recent
codes during the measurement year to evaluate whether the member is numerator
compliant for both systolic and diastolic levels.

Table CDC-N: Codes to Identify Systolic and Diastolic BP Levels <140/90
CPT Category II
Systolic
Diastolic

Description
Numerator compliant (BP <140/90 mm Hg)

3074F, 3075F

3078F, 3079F

Not numerator compliant (BP ≥140/90 mm Hg)

3077F

3080F

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Hybrid Specification
Denominator

A systematic sample of 548 drawn from the eligible population for each product line. A
sample size of 548 is based on the goal of achieving a sample of at least 411 for the
HbA1c <7% denominator after required exclusions.
Members who meet the required exclusion criteria for the HbA1c <7% indicator
should not be substituted with members from the oversample. These members will
only be excluded when reporting the denominator for the HbA1c <7% indicator.
In other words, organizations should report the FSS for the HbA1c <7% indicator as
548 minus the required exclusions.

Required
exclusions for
HbA1c Good
Control <7%
Administrative

Refer to Administrative Specification to identify required exclusions from
administrative data.

Medical record

Exclude members who meet any of the following criteria.
65–75 years of age as of December 31 of the measurement year.
CABG or PTCA. Dated documentation of CABG or PTCA in the measurement
year or the year prior to the measurement year.
IVD. Documentation of an IVD diagnosis. Look as far back as possible in the
member’s history through December 31 of the measurement year. Appropriate
diagnoses include:
IVD
Ischemic heart disease
Angina
Coronary atherosclerosis
Coronary artery occlusion
Cardiovascular disease
Occlusion or stenosis of precerebral arteries (including basilar, carotid and
vertebral arteries)
Atherosclerosis of renal artery
Atherosclerosis of native arteries of the extremities
Chronic total occlusion of artery of the extremities
Arterial embolism and thrombosis
Atheroembolism
CHF. Documentation of CHF diagnosis. Look as far back as possible in the
member’s history through December 31 of the measurement year.
Prior MI. Documentation of prior MI. Look as far back as possible in the member’s
history through December 31 of the measurement year.
CRF/ESRD. Documentation of Stage 4 or 5 CRF or ESRD. Look as far back as
possible in the member’s history through December 31 of the measurement
year.

HEDIS 2010, Volume 2

Dementia. Documentation of dementia. Look as far back as possible in the
member’s history through December 31 of the measurement year.
Blindness. Documentation of blindness in one or both eyes. Look as far back as
possible in the member’s history through December 31 of the measurement
year.
Amputation (lower extremity). Documentation of lower extremity amputation. Look
as far back as possible in the member’s history through December 31 of the
measurement year.
Note: The organization must search the medical record for required exclusions before
it searches for a numerator hit.
Numerators
HbA1c Testing

An HbA1c test performed during the measurement year as identified by administrative
data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

At a minimum, documentation in the medical record must include a note indicating the
date on which the HbA1c test was performed and the result. The organization may
count notation of the following in the medical record.

HbA1c Poor
Control >9%

A1c

Hemoglobin A1c

HbA1c

Glycohemoglobin A1c

HgbA1c

The most recent HbA1c level (performed during the measurement year) is >9.0% or is
missing or was not done during the measurement year, as documented through
automated laboratory data or medical record review.
Note: For this indicator, a lower rate indicates better performance (i.e., low rates of
poor control indicate better care).

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

At a minimum, documentation in the medical record must include a note indicating the
date on which the HbA1c test was performed and the result.

HbA1c Control
<8%

The most recent HbA1c level (performed during the measurement year) is <8.0% as
identified by automated laboratory data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

At a minimum, documentation in medical record must include a note indicating the date
on which the HbA1c test was performed and the result.

HbA1c Good
Control <7%

The most recent HbA1c level (performed during the measurement year) is <7.0% as
identified by automated laboratory data or medical record review.
Note: This indicator uses the eligible population with additional eligible population
criteria (i.e., removing members with comorbid conditions.)

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

HEDIS 2010, Volume 2

Medical record
Eye Exam

At a minimum, documentation in medical record must include a note indicating the date
on which the HbA1c test was performed and the result.
An eye screening for diabetic retinal disease as identified by administrative data or
medical record review. This includes diabetics who had one of the following.
A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) in the measurement year, or
A negative retinal exam (no evidence of retinopathy) by an eye care professional in
the year prior to the measurement year

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

At a minimum, documentation in the medical record must include one of the following.
A note or letter prepared by an ophthalmologist, optometrist, PCP or other health
care professional indicating that an ophthalmoscopic exam was completed by an
eye care professional, the date on which the procedure was performed and the
results, or
A chart or photograph of retinal abnormalities indicating the date on which the
fundus photography was performed and evidence that an eye care professional
reviewed the results. Alternatively, results may be read by a qualified reading
center that operates under the direction of a medical director who is a retinal
specialist.

LDL-C
Screening

An LDL-C test performed during the measurement year as identified by claim/
encounter or automated laboratory data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

At a minimum, documentation in the medical record must include a note indicating the
date on which the LDL-C test was performed and the result. The organization may use
a calculated LDL for LDL-C screening and control indicators.

LDL-C Control
<100 mg/dL

The most recent LDL-C level performed during the measurement year is <100 mg/dL,
as documented through automated laboratory data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation in medical record must include, at a minimum, a note indicating the
date on which the LDL-C test was performed and the result.
The organization may calculate LDL-C levels from total cholesterol, HDL-C and
triglycerides using the Friedewald equation if the triglycerides are ≤400 mg/dL.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5)
If lipoprotein (a) is measured, use the following calculation.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5) – 0.3 [lipoprotein (a)]
These formulae are used when all levels are expressed in mg/dL and cannot be used if
triglycerides >400 mg/dL.

HEDIS 2010, Volume 2

Medical
Attention for
Nephropathy

A nephropathy screening test during the measurement year or evidence of
nephropathy during the measurement year as documented through either
administrative data or medical record review.
Note: A process flow diagram is included at the end of this specification to help
implement this specification.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Nephropathy screening test. At a minimum, documentation must include a note
indicating the date on which a urine microalbumin test was performed, and the result.
Any of the following meet the criteria for a urine microalbumin test.
24-hour urine for microalbumin
Timed urine for microalbumin
Spot urine for microalbumin
Urine for microalbumin/creatinine ratio
24-hour urine for total protein
Random urine for protein/creatinine ratio
Evidence of nephropathy. Any of the following meet the criteria for evidence of
nephropathy.
Documentation of a visit to a nephrologist.
Documentation of medical attention for any of the following (no restriction on
provider type).
Diabetic nephropathy
ESRD
CRF
Chronic kidney disease (CKD)
Renal insufficiency
Proteinuria
Albuminuria
Renal dysfunction
Acute renal failure (ARF)
Dialysis, hemodialysis or peritoneal dialysis
A positive urine macroalbumin test. At a minimum, documentation in the medical
record must include a note indicating the date on which the test was performed,
and a positive result. Any of the following meet the criteria for a positive urine
macroalbumin test.
Positive urinalysis (random, spot or timed) for protein
Positive urine (random, spot or timed) for protein
Positive urine dipstick for protein
Positive tablet reagent for urine protein
Positive result for albuminuria
Positive result for macroalbuminuria
Positive result for proteinuria
Positive result for gross proteinuria

HEDIS 2010, Volume 2

Note: ―Trace‖ urine macroalbumin test results are not considered numerator
compliant.
Evidence of ACE inhibitor/ARB therapy. Documentation in medical record must
include, at minimum, a note indicating that the member received an
ambulatory prescription for ACE inhibitors/ARBs within the measurement
year.
BP Control
<130/80 mm Hg

The most recent BP level (taken during the measurement year) is <130/80 mm Hg,
as documented through administrative data or medical record review.

BP Control
<140/90 mm Hg

The most recent BP level (taken during the measurement year) is <140/90 mm Hg,
as documented through administrative data or medical record review.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

To determine if BP is adequately controlled, the organization must identify the
representative BP following the steps below.

Identifying the
medical record

Step 1

The organization should use the medical record from which it abstracts data for the
other CDC indicators. If the organization does not abstract for other indicators, it
should use the medical record of the provider that manages the member’s diabetes.
If that medical record does not contain a BP, the organization may use the medical
record of another PCP or specialist from which the member receives care.
Identify the most recent BP reading notated during the measurement year. Do not
include BP readings that meet the following criteria.
BPs taken during an acute inpatient stay or an ED visit
BPs taken during an outpatient visit which was for the sole purpose of having a
diagnostic test or surgical procedure performed (e.g., sigmoidoscopy,
removal of a mole)
BPs obtained the same day as a major diagnostic or surgical procedure (e.g.,
stress test, administration of IV contrast for a radiology procedure,
endoscopy)
BP readings reported by or taken by the member

Step 2

Identify the lowest systolic and lowest diastolic BP reading from the most recent BP
notation in the medical record. If there are multiple BPs recorded for a single date,
use the lowest systolic and lowest diastolic BP on that date as the representative
BP. The systolic and diastolic results do not need to be from the same reading.

Exclusions (optional)
Members with a diagnosis of polycystic ovaries (Table CDC-O) who did not have any face-to-face encounters
with a diagnosis of diabetes (CDC-B), in any setting, during the measurement year or the year prior to the
measurement year. Diagnosis can occur at any time in the member’s history, but must have occurred by
December 31 of the measurement year.
Members with gestational or steroid-induced diabetes (CDC-O) who did not have any face-to-face encounters
with a diagnosis of diabetes (CDC-B), in any setting, during the measurement year or the year prior to the
measurement year. Diagnosis can occur during the measurement year or the year prior to the
measurement year, but must have occurred by December 31 of the measurement year.

Table CDC-O: Codes to Identify Exclusions
Description

ICD-9-CM Diagnosis
HEDIS 2010, Volume 2

Polycystic ovaries

256.4

Steroid induced

249, 251.8, 962.0

Gestational diabetes

648.8

Note
The organization may select data collection method (Administrative vs. Hybrid) at the indicator level, but the
method for screening and control rates must be consistent, as must the methodology for BP control
indicators.
Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals
who are legally blind but require a retinal exam and those who are completely blind and therefore do not
require an exam.

HEDIS 2010, Volume 2

Monitoring for Diabetic Nephropathy
Step 1

NO
Go to
Step 2

Is there documentation of
ESRD, chronic or acute renal
failure, renal insufficiency,
diabetic nephropathy
or dialysis?

Review for a urinalysis test that
indicates a protein test was run
or a dipstick was performed for
gross protein macroalbuminuria in 2009

Step 2

YES

Is the test
positive for
2009?

STOP!
Member is
compliant

YES

NO

Go to
Step 3
Was the test
done in 2009?
Step 3

STOP!
Member is
compliant

YES

STOP!
Member is
compliant

Review for a microalbumin
lab test
NO
Go to
Step 4

Step 4

Is there
evidence of
therapy in
2009?

Review for evidence of ACE
inhibitor/ARB therapy

YES

STOP!
Member is
compliant

NO
STOP!
Member is
noncompliant

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table CDC-1/2/3: Data Elements for Comprehensive Diabetes Care
Administrative

Hybrid

Measurement year

Each of the 10 rates

Each of the 10 rates

Data collection methodology (Administrative or Hybrid)

Each of the 10 rates

Each of the 10 rates

Eligible population

Each of the 10 rates

Each of the 10 rates

Number of numerator events by administrative data in eligible population
(before exclusions)

Each of the 10 rates

Current year’s administrative rate (before exclusions)

Each of the 10 rates

Minimum required sample size (MRSS) or other sample size

Each of the 10 rates

Oversampling rate

Each of the 10 rates

Final sample size (FSS)

Each of the 10 rates

Number of numerator events by administrative data in FSS

Each of the 10 rates

Administrative rate on FSS

Each of the 10 rates

Number of original sample records excluded because of valid data errors

Each of the 10 rates

Number of administrative data records excluded

Each of the 10 rates

Number of medical records excluded

Each of the 10 rates

Number of employee/dependent medical records excluded

Each of the 10 rates

Number of HbA1c <7 required exclusions

Each of the 10 rates

Records added from the oversample list

Each of the 10 rates

Denominator

Each of the 10 rates

Numerator events by administrative data

Each of the 10 rates

Numerator events by medical records

Each of the 10 rates
Each of the 10 rates

Reported rate

Each of the 10 rates

Each of the 10 rates

Lower 95% confidence interval

Each of the 10 rates

Each of the 10 rates

Upper 95% confidence interval

Each of the 10 rates

Each of the 10 rates

HEDIS 2010, Volume 2

Disease-Modifying Anti-Rheumatic Drug Therapy
for Rheumatoid Arthritis (ART)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 99301–99303, 99311–99313, 99321–99323, 99331–99333 from Table ART-B.
Added J codes J2910 ―Anti-rheumatics‖ description and J9310 ―Immunomodulators‖ description.
Added ICD-9-CM Diagnosis codes 678, 679 to Table ART-D ―Pregnancy‖ description.

Description
The percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least
one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days. To determine continuous
enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the
member may not have more than a 1-month gap in coverage (i.e., a member whose
coverage lapses for 2 months [60 days] is not considered continuously enrolled).

Anchor date

December 31 of the measurement year.

Benefits

Medical and pharmacy.

Event/diagnosis

Two face-to-face physician encounters with different dates of service in an outpatient
or nonacute inpatient setting on or between January 1 and November 30 of the
measurement year with any diagnosis of rheumatoid arthritis. A diagnosis code from
Table ART-A must be in conjunction with a visit type code in Table ART-B.

Table ART-A: Codes to Identify Rheumatoid Arthritis
Description
Rheumatoid arthritis

ICD-9-CM Diagnosis
714.0, 714.1, 714.2, 714.81

Table ART-B: Codes to Identify Visit Type
Description

CPT

UB Revenue

Outpatient

99201-99205, 99211-99215, 99241-99245, 99341-99345,
99347-99350, 99384-99387, 99394-99397, 99401-99404,
99411, 99412, 99420, 99429, 99455, 99456

051x, 0520-0523, 0526-0529, 057x-059x, 077x,
0982, 0983

Nonacute inpatient

99304-99310, 99315, 99316, 99318, 99324-99328,
99334-99337

0118, 0128, 0138, 0148, 0158, 019x, 0524,
0525, 055x, 066x

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Administrative Specification
Denominator

The eligible population.

Numerator

Members who had at least one ambulatory prescription dispensed for a DMARD
during the measurement year. Table ART-C lists the DMARDs included in this
measure.

Table ART-C: DMARDs
Description

Prescription

J Codes

5-Aminosalicylates

sulfasalazine

Alkylating agents

cyclophosphamide

Aminoquinolines

hydroxychloroquine

Anti-rheumatics

auranofin
aurothioglucose

gold sodium thiomalate
leflunomide

methotrexate
penicillamine

J1600, J2910, J9250, J9260

Immunomodulators

abatacept
adalimumab
anakinra

etanercept
golimumab
infliximab

rituximab

J0129, J0135, J1438, J1745,
J9310

Immunosuppressive agents

azathioprine

cyclosporine

Tetracyclines

minocycline

J7502, J7515, J7516

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Exclusions (optional)
Members diagnosed with HIV. Look for evidence of HIV diagnosis as far back as possible in the member’s
history through December 31 of the measurement year.
Members who have a diagnosis of pregnancy during the measurement year.

Table ART-D: Codes to Identify Exclusions
Description

ICD-9-CM Diagnosis

HIV

042, V08

Pregnancy

630-679, V22, V23, V28

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table ART-1/2/3: Data Elements for DMARD Therapy for Rheumatoid Arthritis
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Number of numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









HEDIS 2010, Volume 2

Osteoporosis Management in Women Who Had a Fracture (OMW)
SUMMARY OF CHANGES TO HEDIS 2010
Added ICD-9-CM Diagnosis codes 733.93–733.98 to Table OMW-A.
Deleted HCPCS S2362 from Table OMW-A.

Description
The percentage of women 67 years of age and older who suffered a fracture and who had either a bone
mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after
the fracture.

Definitions
Intake Period

A 12-month window that begins on July 1 of the year prior to the measurement year
and ends on June 30 of the measurement year. The Intake Period is used to capture
the first fracture.

IESD

Index Episode Start Date. The earliest date of service for any encounter during the
Intake Period with a diagnosis of fracture (Table OMW-A).
For an outpatient or ED claim/encounter, the IESD is date of service.
For an inpatient claim/encounter, the IESD is the date of discharge.
For direct transfers, the IESD is the discharge date from the second admission.

Negative
Diagnosis
History

A period of 60 days prior to the IESD, during which time the member had no diagnosis
of fracture using Table OMW-A. For fractures requiring an inpatient stay, use the date
of admission to determine Negative Diagnosis History. For direct transfers, use the first
admission to determine the Negative Diagnosis History.

Eligible Population
Product line

Medicare.

Age

Women 67 years and older as of December 31 of the measurement year.

Continuous
enrollment

12 months prior to the IESD through 6 months (180 days) after the IESD.

Allowable gap

No more than one gap in enrollment of up to 45 days during the continuous enrollment
period.

Anchor date

IESD.

Benefits

Medical and pharmacy.

Event/
diagnosis

The earliest fracture during the Intake Period.
Follow the steps below to identify the eligible population.

HEDIS 2010, Volume 2

Step 1

Identify all members who had a fracture (Table OMW-A) during the 12-month Intake Period. If
the member had more than one fracture, include only the first fracture.

Table OMW-A: Codes to Identify Fractures*
CPT
21800-21825, 22305-22328, 22520, 22521, 22523, 22524,
23500-23515, 23570-23630, 23665-23680, 24500-24587,
24620, 24635, 24650-24685, 25500-25652, 25680, 25685,
26600, 26605, 26607, 26608, 26615, 27193-27248, 27254,
27267-27269, 27500-27514, 27520-27540, 27750-27828,
28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436,
28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476,
28485, 29850, 29851, 29855, 29856

HCPCS
S2360

ICD-9-CM
Diagnosis
733.1, 733.93733.98, 805-806,
807.0-807.4,
808-815, 818825, 827, 828

ICD-9-CM Procedure
79.01-79.03, 79.05-79.07, 79.1179.13, 79.15-79.17, 79.21-79.23,
79.25-79.27, 79.31-79.33, 79.3579.37, 79.61- 79.63, 79.65-79.67,
81.65, 81.66

*Fractures of finger, toe, face and skull are not included in this measure.

Step 2

Test for Negative Diagnosis History. Exclude members with a fracture (Table OMW-A) during
the 60 days prior to the IESD. For fractures requiring an inpatient stay, use the admission date
to determine Negative Diagnosis History. For direct transfers, use the first admission to
determine the Negative Diagnosis History.

Step 3

Calculate continuous enrollment. Members must be continuously enrolled during the 12 months
prior to the fracture through 6 months (180 days) post-fracture.

Step 4

Exclude members who had a BMD test (Table OMW-B) or who received any osteoporosis
treatment (Table OMW-C) during the 365 days prior to the IESD.
For an inpatient claim/encounter, use the admission date to determine the 365 days prior to the
IESD.

Administrative Specification
Denominator

The eligible population.

Numerator

Appropriate testing or treatment for osteoporosis after the fracture defined by any of the
following criteria.
A BMD test (Table OMW-B) on the IESD or in the 180-day period after the IESD, or
A BMD test (Table OMW-B) during the inpatient stay for the fracture (applies only to
fractures requiring hospitalization), or
A dispensed prescription (Table OMW-C) to treat osteoporosis on the IESD or in the
180-day period after the IESD

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Comprehensive Diabetes Care

Table OMW-B: Codes to Identify Bone Mineral Density Test
CPT
76070, 76071, 76075-76078, 76977, 77078-77083, 78350, 78351

HCPCS

ICD-9-CM Diagnosis

ICD-9-CM Procedure

G0130

V82.81

88.98

Table OMW-C: FDA-Approved Osteoporosis Therapies
Description

Prescription

J Codes
J3488

Biphosphonates

alendronate
alendronate-cholecalciferol
calcium carbonate-risedronate

ibandronate
risedronate
zoledronic acid

Estrogens

conjugated estrogens
conjugated estrogens synthetic
esterified estrogens

estradiol
estradiol acetate
estradiol cypionate

estradiol valerate
estropipate
ethinyl estradiol

Miscellaneous
hormones

calcitonin

raloxifene

teriparatide

Sex hormone
combinations

conjugated estrogens—
medroxy-progesterone
estradiol-levonorgestrel

estradiol-norethindrone
estradiol-norgestimate
ethinyl estradiol-norethindrone

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table OMW-3: Data Elements for Osteoporosis Management in Women Who Had a Fracture
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Comprehensive Diabetes Care

Antidepressant Medication Management (AMM)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified Negative Diagnosis History for inpatient claims/encounters and transfers.
Deleted CPT codes 90871, 99261–99263 from Table AMM-B.

Description
The percentage of members 18 years of age and older who were diagnosed with a new episode of major
depression, treated with antidepressant medication, and who remained on an antidepressant medication
treatment. Two rates are reported.
Effective Acute Phase Treatment. The percentage of newly diagnosed and treated members who
remained on an antidepressant medication for at least 84 days (12 weeks).
Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated members who
remained on an antidepressant medication for at least 180 days (6 months).

Definitions
Intake Period

The 12-month window starting on May 1 of the year prior to the measurement year
and ending on April 30 of the measurement year.

IESD

Index Episode Start Date. The earliest encounter during the Intake Period with any
diagnosis of major depression (Table AMM-A) that meets the following criteria.
A 120-day Negative Diagnosis History
A 90-day Negative Medication History
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of
discharge.
For a direct transfer, the IESD is the discharge date from the facility to which the
member was transferred.

Negative
Diagnosis History

A period of 120 days (4 months) prior to the IESD, during which time the member
had no claims/encounters with any diagnosis of major depression (Table AMM-A)
or prior episodes of depression (Table AMM-C).
For an inpatient (acute or nonacute) claim/encounter, use the date of admission to
determine Negative Diagnosis History.
For direct transfers, use the first admission to determine Negative Diagnosis
History.

IPSD

Index Prescription Start Date. The earliest prescription dispensing date for an
antidepressant medication during the period of 30 days prior to the IESD (inclusive)
through 14 days after the IESD (inclusive).

Negative
Medication History

A period of 90 days (3 months) prior to the IPSD, during which time the member
had no pharmacy claims for either new or refill prescriptions for an antidepressant
medication (Table AMM-D).

HEDIS 2010, Volume 2

Treatment days

The actual number of calendar days covered with prescriptions within the specified
180-day measurement interval. For Effective Continuation Phase Treatment, a
prescription of 90 days supply dispensed on the 151st day will have 80 days counted
in the 231-day interval.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18 years and older as of April 30 of the measurement year.

Continuous
enrollment

120 days prior to the IESD through 245 days after the IESD.

Allowable gap

One gap in enrollment of up to 45 days. To determine continuous enrollment for a
Medicaid beneficiary for whom enrollment is verified monthly, the member may not
have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for
2 months [60 days] is not considered continuously enrolled).

Anchor date

IESD.

Benefits

Medical, pharmacy and mental health (inpatient and outpatient).

Event/diagnosis

The organization should follow the steps below to identify the eligible population, which
should be used for both rates.

Step 1

Identify all members who met at least one of the following criteria during the Intake
Period.
At least one principal diagnosis of major depression (Table AMM-A) in an
outpatient, ED, intensive outpatient or partial hospitalization setting (Table
AMM-B), or
At least two visits in an outpatient, ED, intensive outpatient or partial hospitalization
setting (Table AMM-B) on different dates of service with any diagnosis of major
depression (Table AMM-A), or
At least one inpatient (acute or nonacute) claim/encounter with any diagnosis of
major depression (Table AMM-A)

Table AMM-A: Codes to Identify Major Depression
Description
Major depression

ICD-9-CM Diagnosis
296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311

* Brief depressive reaction (309.0) is not used for diagnosis, since it includes grief reaction (believed to be the most common use of that

code). Additionally, other possible codes that could indicate a depression diagnosis (296.4–296.9, 309.0, 309.28) are not included in this list
because these codes are less specific in identifying members with major depression.

HEDIS 2010, Volume 2

Table AMM-B: Codes to Identify Visit Type
Description

CPT

HCPCS

ED

99281-99285

Outpatient, intensive
outpatient and partial
hospitalization

90804-90815, 98960-98962,
99078, 99201-99205, 9921199215, 99217-99220, 9924199245, 99341-99345, 9934799350, 99384-99387, 9939499397, 99401-99404, 99411,
99412, 99510

UB Revenue
045x, 0981

G0155, G0176, G0177, H0002,
H0004, H0031, H0034-H0037,
H0039, H0040, H2000, H2001,
H2010-H2020, M0064, S0201,
S9480, S9484, S9485

0510, 0513, 0515-0517, 05190523, 0526-0529, 077x, 0900,
0901, 0902-0905, 0907, 09110917, 0919, 0982, 0983

CPT
90801, 90802, 90816-90819, 90821-90824, 9082690829, 90845, 90847, 90849, 90853, 90857, 90862,
90870, 90875, 90876, 99221-99223, 99231-99233,
99238, 99239, 99251-99255

POS
WITH

03, 05, 07, 09, 11, 12, 13, 14, 15,
20, 22, 33, 49, 50, 52, 53, 71, 72

Step 2

Determine the IESD. For each member identified in step 1, identify the date of the earliest
encounter during the Intake Period with any diagnosis of major depression. If the member had
more than one encounter during the Intake Period, include only the first encounter.

Step 3

Test for Negative Diagnosis History. Exclude members who had a claim/encounter for any
diagnosis of major depression (Table AMM-A) or prior episodes of depression (Table AMM-C)
during the 120 days prior to the IESD.

Table AMM-C: Additional Codes to Identify Depression
Description
Depression

ICD-9-CM Diagnosis
296.26, 296.36, 296.4-296.9, 309.0, 309.28

Step 4

Identify the IPSD. The IPSD is the date of the earliest dispensing event for an antidepressant
medication (Table AMM-D) during the period of 30 days prior to the IESD (inclusive) through
14 days after the IESD (inclusive). Exclude members who did not fill a prescription for an
antidepressant medication during this period.

Step 5

Test for Negative Medication History. Exclude members who filled a prescription for an
antidepressant medication 90 days (3 months) prior to the IPSD.

Step 6

Calculate continuous enrollment. Members must be continuously enrolled for 120 days prior to
the IESD to 245 days after the IESD.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Administrative Specification
Denominator

The eligible population.

Numerators
Effective Acute
Phase Treatment

At least 84 days (12-weeks) of continuous treatment with antidepressant medication
(Table AMM-D) during the 114-day period following the IPSD (inclusive). The
continuous treatment allows gaps in medication treatment up to a total of 30 days
during the 114-day period.
Allowable medication changes or gaps include:
Washout period gaps to change medication
Treatment gaps to refill the same medication
Regardless of the number of gaps, there may be no more than 30 gap days. The
organization may count any combination of gaps (e.g., two washout gaps of 15 days
each, or two washout gaps of 10 days each and one treatment gap of 10 days).

Table AMM-D: Antidepressant Medications
Description

Prescription

Miscellaneous antidepressants

bupropion

Monoamine oxidase inhibitors

isocarboxazid
phenelzine

selegiline
tranylcypromine

Phenylpiperazine antidepressants

nefazodone

trazodone

Psychotherapeutic combinations

amitriptyline-chlordiazepoxide
amitriptyline-perphenazine

fluoxetine-olanzapine

SSNRI antidepressants

desvenlafaxine

duloxetine

venlafaxine

SSRI antidepressants

citalopram
escitalopram

fluoxetine
fluvoxamine

paroxetine
sertraline

Tetracyclic antidepressants

maprotiline

mirtazapine

Tricyclic antidepressants

amitriptyline
amoxapine
clomipramine

desipramine
doxepin
imipramine

nortriptyline
protriptyline
trimipramine

Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.
Effective
Continuation
Phase Treatment

At least 180 days (6 months) of continuous treatment with antidepressant
medication (Table AMM-D) during the 231-day period following the IPSD (inclusive).
The continuous treatment allows gaps in medication treatment up to a total of 51
days during the 231-day period.
Allowable medication changes or gaps include the following.
Washout period gaps to change medication
Treatment gaps to refill the same medication
Regardless of the number of gaps, gap days may total no more than 51. The
organization may count any combination of gaps (e.g., two washout gaps, each 25
days or two washout gaps of 10 days each and one treatment gap of 10 days).

HEDIS 2010, Volume 2

Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each
date of service; others may be comparable to inpatient billing, with an admission date, a discharge date
and units of service. Organizations whose billing methods are comparable to inpatient billing may count
each unit of service as an individual visit. The unit of service must have occurred during the time frame
specified (e.g., during the Intake Period).

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table AMM-1/2/3: Data Elements for Antidepressant Medication Management
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population





Numerator events by administrative data

Each of the 2 rates

Reported rate

Each of the 2 rates

Lower 95% confidence interval

Each of the 2 rates

Upper 95% confidence interval

Each of the 2 rates

HEDIS 2010, Volume 2

Follow-Up After Hospitalization for Mental Illness (FUH)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 90871, 99261–99263 from Table FUH-C.

Description
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of
selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial
hospitalization with a mental health practitioner. Two rates are reported.
1. The percentage of members who received follow-up within 30 days of discharge
2. The percentage of members who received follow-up within 7 days of discharge

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

6 years and older as of the date of discharge.

Continuous
enrollment

Date of discharge through 30 days after discharge.

Allowable gap

No gaps in enrollment.

Anchor date

None.

Benefits

Medical and mental health (inpatient and outpatient).

Event/
diagnosis

Discharged alive from an acute inpatient setting (including acute care psychiatric
facilities) with a principal mental health diagnosis (Table FUH-A) on or between
January 1 and December 1 of the measurement year.
The denominator for this measure is based on discharges, not members. Include all
discharges for members who have more than one discharge on or between January 1
and December 1 of the measurement year.

Table FUH-A: Codes to Identify Mental Health Diagnosis
ICD-9-CM Diagnosis
295–299, 300.3, 300.4, 301, 308, 309, 311–314

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Mental health
readmission or
direct transfer

If the discharge is followed by readmission or direct transfer to an acute facility for any
mental health principal diagnosis (Tables MPT-A, MPT-B) within the 30-day follow-up
period, count only the readmission discharge or the discharge from the facility to which
the member was transferred. Although rehospitalization might not be for a selected
mental health disorder, it is probably for a related condition.
Exclude both the initial discharge and the readmission/direct transfer discharge if the
readmission/direct transfer discharge occurs after December 1 of the measurement
year.
Exclude discharges followed by readmission or direct transfer to a nonacute facility for
any mental health principal diagnosis (Tables MPT-A, MPT-B) within the 30-day followup period. These discharges are excluded from the measure because readmission or
transfer may prevent an outpatient follow-up visit from taking place. Refer to Table
FUH-B for codes to identify nonacute care.

Non-mental
health
readmission or
direct transfer

Exclude discharges in which the patient was transferred directly or readmitted within
30 days after discharge to an acute or nonacute facility for a non-mental health
principal diagnosis. This includes any ICD-9-CM Diagnosis code or DRG code other
than those in Tables MPT-A and MPT-B. These discharges are excluded from the
measure because rehospitalization or transfer may prevent an outpatient follow-up visit
from taking place.

Table FUH-B: Codes to Identify Nonacute Care
Description

HCPCS

UB Revenue

UB Type of Bill

POS

Hospice

0115, 0125, 0135, 0145, 0155,
0650, 0656, 0658, 0659

81x, 82x

34

SNF

019x

21x, 22x, 28x

31, 32

Hospital transitional care, swing bed
or rehabilitation

18x

Rehabilitation

0118, 0128, 0138, 0148, 0158

Respite

0655

Intermediate care facility

54

Residential substance abuse
treatment facility
Psychiatric residential treatment
center

T2048, H0017-H0019

1002

55

1001

56

Comprehensive inpatient rehabilitation
facility

61

Other nonacute care facilities that do not use the UB revenue or type of bill codes for billing (e.g., ICF, SNF)

HEDIS 2010, Volume 2

Administrative Specification
Denominator

The eligible population.

Numerators
30-Day
Follow-Up

An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
FUH-C) with a mental health practitioner within 30 days after discharge. Include
outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on
the date of discharge.

7-Day
Follow-Up

An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
FUH-C) with a mental health practitioner within 7 days after discharge. Include
outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on
the date of discharge.

Table FUH-C: Codes to Identify Visits
CPT

HCPCS

Follow-up visits identified by the following CPT or HCPCS codes must be with a mental health practitioner.
90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 9921799220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 9939399397, 99401-99404, 99411, 99412, 99510

G0155, G0176, G0177, H0002, H0004, H0031, H0034H0037, H0039, H0040, H2000, H2001, H2010-H2020,
M0064, S0201, S9480, S9484, S9485

CPT

POS

Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner.
90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847,
90849, 90853, 90857, 90862, 90870, 90875, 90876

WITH

03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33,
49, 50, 52, 53, 71, 72

99221-99223, 99231-99233, 99238, 99239, 99251-99255

WITH

52, 53

UB Revenue
The organization does not need to determine practitioner type for follow-up visits identified by the following UB revenue codes.
0513, 0900-0905, 0907, 0911-0917, 0919
Visits identified by the following revenue codes must be with a mental health practitioner or in conjunction with any diagnosis
code from Table FUH-A.
0510, 0515-0517, 0519-0523, 0526-0529, 077x, 0982, 0983

Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each
date of service; others may be comparable to inpatient billing, with an admission date, a discharge date
and units of service. Organizations whose billing methods are comparable to inpatient billing may count
each unit of service as an individual visit. The unit of service must have occurred during the time frame
required for the rate (e.g., within 30 days after discharge or within 7 days after discharge).
Refer to Appendix 3 for the definition of mental health practitioner.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table FUH-1/2/3: Data Elements for Follow-Up After Hospitalization for Mental Illness
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population





Numerator events by administrative data

Each of the 2 rates

Reported rate

Each of the 2 rates

Lower 95% confidence interval

Each of the 2 rates

Upper 95% confidence interval

Each of the 2 rates

HEDIS 2010, Volume 2

Annual Monitoring for Patients on Persistent Medications (MPM)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified numerator criteria for Rates 1–3.
Clarified codes that identified a lab panel in Table MPM-A.
Deleted LOINC codes 24320-4, 24321-2, 24326-1, 24322-0, 24323-8, 24362-6, 34554-6, 34555-3,
45064-3, 45065-0, 45066-8, 50261-7 from Table MPM-A.
Deleted LOINC codes 34540-5, 34545-4 from Table MPM-E.

Description
The percentage of members 18 years of age and older who received at least 180 treatment days of
ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one
therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report
each of the four rates separately and as a total rate.
Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARB)
Annual monitoring for members on digoxin
Annual monitoring for members on diuretics
Annual monitoring for members on anticonvulsants
Total rate (the sum of the four numerators divided by the sum of the four denominators)
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

18 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).

Anchor date

December 31 of the measurement year.

HEDIS 2010, Volume 2

Benefits

Medical and pharmacy.

Event/
diagnosis

Members on persistent medications—defined as members who received at least 180
treatment days of ambulatory medication in the measurement year. Refer to Additional
Eligible Population Criteria for each rate.
Treatment days are the actual number of calendar days covered with prescriptions
within the measurement year (i.e., a prescription of 90 days supply dispensed on
December 1 of the measurement year counts as 31 treatment days).

Administrative Specification
For each product line, report each of the four rates separately and as a combined rate. The total rate is the
sum of the four numerators divided by the sum of the four denominators.

Rate 1: Annual Monitoring for Members on ACE Inhibitors or ARBs
Additional
eligible
population
criteria

Members who received at least 180 treatment days of ACE inhibitors or ARBs, during the
measurement year. Refer to Table CDC-L to identify ACE inhibitors and ARBs.

Numerator

At least one serum potassium and either a serum creatinine or a blood urea nitrogen
therapeutic monitoring test in the measurement year (Table MPM-A). The member must
meet one of the following criteria to be compliant.

Note: Members may switch therapy with any medication listed in Table CDC-L during the
measurement year and have the days supply for those medications count toward the total
180 treatment days (i.e., a member who received 90 days of ACE inhibitors and 90 days
of ARBs meets the denominator definition for rate 1).

A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The tests do not need to occur on the same service date, only within the
measurement year.

HEDIS 2010, Volume 2

Table MPM-A: Codes to Identify Physiologic Monitoring Tests
Description
Lab panel
Serum potassium
(K+)
Serum creatinine
(SCr)

Blood urea
nitrogen (BUN)

CPT

LOINC

80047, 80048, 80050,
80053, 80069
80051, 84132
82565, 82575

84520, 84525

2824-1, 2823-3, 6298-4, 12812-4, 12813-2, 22760-3, 29349-8, 32713-0, 34548-8, 39789-3,
39790-1, 41656-0, 51618-7
2160-0, 2163-4, 2164-2, 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0,
13447-8, 13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 26752-6, 31045-8,
33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1, 38483-4, 39955-0, 39956-8,
39957-6, 39958-4, 39959-2, 39960-0, 39961-8, 39962-6, 39963-4, 39964-2, 39965-9,
39966-7, 39967-5, 39968-3, 39969-1, 39970-9, 39971-7, 39972-5, 39973-3, 39974-1,
39975-8, 39976-6, 40112-5, 40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2,
40119-0, 40120-8, 40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3,
40128-1, 40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2,
40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5, 40269-3,
40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3, 51619-5, 51620-3
3094-0, 6299-2, 11064-3, 11065-0, 12964-3, 12965-0, 12966-8, 14937-7, 44734-2,
49071-4

Rate 2: Annual Monitoring for Members on Digoxin
Additional eligible
population criteria

Members who received at least 180 treatment days of digoxin (Table MPM-B)
during the measurement year.

Table MPM-B: Drugs to Identify Members on Digoxin
Description
Inotropic agents

Numerator

Prescription
digoxin

At least one serum potassium and either a serum creatinine or a blood urea
nitrogen therapeutic monitoring test in the measurement year (Table MPM-A). The
member must meet one of the following criteria to be compliant.
A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The two tests do not need to occur on the same service date, only within the
measurement year.

Rate 3: Annual Monitoring for Members on Diuretics
Additional eligible
population criteria

Members who received at least 180 treatment days of a diuretic (Table MPM-C),
during the measurement year.
Note: Members may switch therapy with any medication listed in Table MPM-C
during the measurement year and have the days supply for those medications
count toward the total 180 treatment days.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table MPM-C: Drugs to Identify Members on Diuretics
Description

Prescription

Antihypertensive
combinations

aliskiren-hydrochlorothiazide
amiloride-hydrochlorothiazide
amlodipine-hydrochlorothiazidevalsartan
atenolol-chlorthalidone
benazepril-hydrochlorothiazide
bendroflumethiazide-nadolol
bisoprolol-hydrochlorothiazide
candesartan-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorthalidone-clonidine
enalapril-hydrochlorothiazide
eprosartan-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide-irbesartan

Loop diuretics

bumetanide
ethacrynic acid

furosemide
torsemide

Potassium-sparing
diuretics

amiloride
eplerenone

spironolactone
triamterene

Thiazide diuretics

bendroflumethiazide
chlorothiazide
chlorthalidone
hydrochlorothiazide

hydroflumethiazide
indapamide
methyclothiazide
metolazone

Numerator

hydrochlorothiazide-lisinopril
hydrochlorothiazide-losartan
hydrochlorothiazide-methyldopa
hydrochlorothiazide-metoprolol
hydrochlorothiazide-moexipril
hydrochlorothiazide-olmesartan
hydrochlorothiazide-propranolol
hydrochlorothiazide-quinapril
hydrochlorothiazide-spironolactone
hydrochlorothiazide-telmisartan
hydrochlorothiazide-timolol
hydrochlorothiazide-triamterene
hydrochlorothiazide-valsartan
polythiazide-prazosin

polythiazide
trichlormethiazide

At least one serum potassium and either a serum creatinine or a blood urea
nitrogen therapeutic monitoring test in the measurement year (Table MPM-A). The
member must meet one of the following criteria to be compliant.
A code for a lab panel test during the measurement year
A code for a serum potassium and a code for serum creatinine during the
measurement year
A code for serum potassium and a code for blood urea nitrogen during the
measurement year
Note: The two tests do not need to occur on the same service date, only within the
measurement year.

HEDIS 2010, Volume 2

Rate 4: Annual Monitoring for Members on Anticonvulsants
Additional eligible
population
criteria

Members who received at least 180 treatment days for an anticonvulsant (Table
MPM-D) during the measurement year.
Note: Members who are on multiple anticonvulsant drugs count toward the
denominator multiple times if they meet the persistent medications criteria for each
drug taken during the measurement year (i.e., a member who received at least 180
days of phenytoin and 180 days of valproic acid is counted twice in the denominator
for Rate 4, once for each drug).

Table MPM-D: Drugs to Identify Members on Anticonvulsants
Description

Drugs

Barbiturate anticonvulsants

phenobarbital

Dibenzazepine anticonvulsants

carbamazepine

Hydantoin anticonvulsants

phenytoin

Miscellaneous anticonvulsants

divalproex sodium

valproic acid

At least one drug serum concentration level monitoring test for the prescribed drug in
the measurement year (Table MPM-E).

Numerator

If a member received only one type of anticonvulsant, the drug serum concentration
level test must be for the specific drug taken as a persistent medication (i.e., a
member on phenytoin received a drug serum test for phenytoin).
If a member persistently received multiple types of anticonvulsants, each
anticonvulsant medication and drug monitoring test combination is counted as a
unique event (i.e., a member on both phenytoin and valproic acid with at least 180
treatment days for each drug in the measurement year must separately show
evidence of receiving drug serum concentration tests for each drug [Table MPM-E]
to be considered numerator-compliant for each drug).

Table MPM-E: Codes to Identify Drug Serum Concentration Monitoring Tests
Description

CPT

LOINC

Drug serum concentration for phenobarbital

80184

3948-7, 3951-1, 10547-8, 14874-2, 34365-7

Drug serum concentration for phenytoin

80185, 80186

3968-5, 3969-3, 14877-5, 32109-1, 40460-8

Drug serum concentration for valproic acid or
divalproex sodium

80164

4086-5, 4087-3, 4088-1, 14946-8, 18489-5, 21590-5, 32119-0,
32283-4

Drug serum concentration for carbamazepine

80156, 80157

3432-2, 3433-0, 9415-1, 14056-6, 14639-9, 18270-9, 29147-6,
29148-4, 32058-0, 32852-6, 47097-1

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Exclusion (optional)
Members from each eligible population rate who had an inpatient (acute or nonacute) claim/encounter during
the measurement year.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table MPM-1/2/3: Data Elements for Annual Monitoring for Patients on Persistent Medications
Administrative
Measurement year
Data collection methodology (Administrative)




Eligible population

For each of the 4 rates and total

Numerator events by administrative data

For each of the 4 rates and total

Reported rate

For each of the 4 rates and total

Lower 95% confidence interval

For each of the 4 rates and total

Upper 95% confidence interval

For each of the 4 rates and total

HEDIS 2010, Volume 2

Potentially Harmful Drug-Disease Interactions in the Elderly (DDE)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 90960–90962, 90966, 90970 to Table DDE-H ―Chronic renal failure‖ description.
Deleted CPT code 90939 from Table DDE-H.

Description
The percentage of Medicare members 65 years of age and older who have evidence of an underlying
disease, condition or health concern and who were dispensed an ambulatory prescription for a
contraindicated medication, concurrent with or after the diagnosis.
Report each of the three rates separately and as a total rate.
A history of falls and a prescription for tricyclic antidepressants, antipsychotics or sleep agents
Dementia and a prescription for tricyclic antidepressants or anticholinergic agents
CRF and prescription for nonaspirin NSAIDs or Cox-2 Selective NSAIDs
Total rate (the sum of the three numerators divided by the sum of the three denominators)
Members with more than one disease or condition can appear in the measure multiple times (i.e., in each
indicator for which they qualify). For all three rates, a lower rate represents better performance.
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Definitions
IESD

Index Episode Start Date. The earliest diagnosis, procedure or prescription between
January 1 of the year prior to the measurement year and December 1 of the measurement
year.
For an outpatient claim/encounter, the IESD is the date of service.
For an inpatient claim/encounter, the IESD is the discharge date.
For dispensed prescriptions, the IESD is the dispense date.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Eligible Population
Product line

Medicare.

Age

67 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year and the year prior to the measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of
continuous enrollment.

Anchor date

Enrolled as of December 31 of the measurement year.

Benefit

Medical and pharmacy.

Event/diagnosis

Members with at least one disease or condition or procedure in the measurement
year or the year prior to the measurement year. Refer to Additional Eligible
Population Criteria for each rate.

Administrative Specification
Report each rate separately and as a combined rate. The total rate is the sum of the three numerators divided
by the sum of the three denominators.

Rate 1: Drug-Disease Interactions—History of Falls and Tricyclic Antidepressants,
Antipsychotics or Sleep Agents
Additional eligible
population
criteria
Step 1

An accidental fall or hip fracture on or between January 1 of the year prior to the
measurement year and December 1 of the measurement year.
Follow the steps below to identify the eligible population.
Identify members who had an accidental fall or hip fracture (Table DDE-A) on or
between January 1 of the year prior to the measurement year and December 1 of
the measurement year. Identify the IESD for each member.

Table DDE-A: Codes to Identify Falls or Hip Fractures
Description

CPT

Falls

ICD-9-CM Diagnosis
E880, E884, E885.9, E887, E888

Hip fracture*

27230, 27232, 27235, 27236, 27238, 27240, 27244-27246, 27248, 27254,
27267-27269, 27767-27769

820, V54.13

*Hip fracture may be used as a proxy for identifying falls.

Step 2

Exclude members with a diagnosis of psychosis (Table DDE-B) on or between
January 1 of the year prior to the measurement year and December 1 of the
measurement year.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

195

Table DDE-B: Codes to Identify Psychosis
Description

ICD-9-CM Diagnosis

Dementias (with delirium or delusions)

290.11, 290.12, 290.20, 290.3, 290.41, 290.42, 290.8, 290.9

Transient mental disorders due to conditions classified elsewhere

293

Dementia in conditions classified elsewhere with behavioral disturbance

294.11

Schizophrenic disorders

295

Episodic mood disorders with psychotic behavior

296.x4

Delusional disorders

297

Other nonorganic psychoses

298

Numerator

Dispensed an ambulatory prescription for a tricyclic antidepressant (Table DDE-C) or
an antipsychotic or sleep agent (Table DDE-D) on or between the IESD and December
31 of the measurement year.

Table DDE-C: Tricyclic Antidepressants
Description

Prescription

Psychotherapeutic combinations

amitriptyline-chlordiazepoxide

Tricyclic antidepressants

amitriptyline
amoxapine
clomipramine

amitriptyline-perphenazine

desipramine
doxepin
imipramine

nortriptyline
protriptyline
trimipramine

Table DDE-D: Antipsychotics and Sleep Agents
Description

Prescription

Miscellaneous antipsychotic agents

aripiprazole
clozapine
haloperidol

loxapine
molindone
olanzapine

Miscellaneous anxiolytics, sedatives
and hypnotics

eszopiclone
ramelteon

zaleplon
zolpidem

Phenothiazine antipsychotics

prochlorperazine
chlorpromazine

fluphenazine
mesoridazine

Psychotherapeutic combinations

fluoxetine-olanzapine

Thioxanthenes

thiothixene

paliperidone
pimozide
quetiapine

risperidone
ziprasidone

perphenazine
thioridazine

trifluoperazine

HEDIS 2010, Volume 2

196

Rate 2: Drug-Disease Interactions—Dementia and Tricyclic Antidepressants or
Anticholinergic Agents
Additional eligible
population criteria

A diagnosis of dementia (Table DDE-E) or a dispensed dementia medication
(Table DDE-F) on or between January 1 of the year prior to the measurement year
and December 1 of the measurement year. Identify the IESD for each member.

Table DDE-E: Codes to Identify Dementia
ICD-9-CM Diagnosis
290, 291.2, 292.82, 294.0, 294.1, 294.8, 331.0, 331.1, 331.82

Table DDE-F: Medications for Dementia
Description

Prescription

Cholinesterase inhibitors

donepezil
galantamine

Miscellaneous central nervous system agents

memantine

Numerator

rivastigmine
tacrine

Dispensed an ambulatory prescription for a tricyclic antidepressant (Table DDE-C),
or anticholinergic agent (Table DDE-G) on or between the IESD and December 31
of the measurement year.

HEDIS 2010, Volume 2

197

Table DDE-G: Anticholinergic Agents
Description

Prescription

Anticholinergic antiemetics

cyclizine
dimenhydrinate

meclizine
scopolamine

trimethobenzamide

Anticholinergic antiParkinson agents

benztropine

trihexyphenidyl

Anticholinergics/
antispasmodics

belladonna

dicyclomine

hyoscyamine

propantheline

Antihistamines

azatadine
brompheniramine
chlorpheniramine

clemastine
cyproheptadine
dexchlorpheniramine

diphenhydramine
hydroxyzine hydrochloride
hydroxyzine pamoate

triprolidine

Phenothiazine antiemetics

prochlorperazine

promethazine

Skeletal muscle relaxants

carisoprodol
chlorzoxazone

cyclobenzaprine
metaxalone

Upper respiratory
combinations

APAP/diphenhydramine/pseudoephedrine
atropine/CPM/hyoscyamine/PSE/scopolamine
brompheniramine/carbetapentane/
phenylephrine
brompheniramine/dextromethorphphenylephrine
brompheniramine/dextromethorphan/PSE
brompheniramine/DM/guaifenesin/
phenylephrine
brompheniramine/DM/guaifenesin/PSE
brompheniramine/DM/phenylephrine
brompheniramine/hydrocodone/phenylephrine
brompheniramine/hydrocodone/pseudo-ephedrine
brompheniramine-phenylephrine
brompheniramine-pseudoephedrine
carbetapentane/chlorpheniramine/
phenylephrine
carbetapentane/CPM/ephedrine/phenylephrine
carbetapentane/diphenhydramine/
phenylephrine
carbetapentane-chlorpheniramine

carbetapentane-diphenhydramine
chlorpheniramine/codeine/PE/K iodide
chlorpheniramine/codeine/pseudoephedrine
chlorpheniramine/dextromethorp/phenylephrine
chlorpheniramine/dextromethorphan/PSE
chlorpheniramine/dihydrocodeine/phenylephrine
chlorpheniramine/dihydrocodeine/PSE
chlorpheniramine/DM/guaifenesin/
phenylephrine
chlorpheniramine/DM/methscopolamine
chlorpheniramine/DM/phenylephrine
chlorpheniramine/guaifenesin/phenylephrine
chlorpheniramine/hydrocodone/phenylephrine
chlorpheniramine/hydrocodone/PSE
chlorpheniramine/methscopolamine/PE
chlorpheniramine/methscopolamine/PSE
chlorpheniramine/PE/phenyltoloxamine
chlorpheniramine/phenylephrine/pyrilamine
chlorpheniramine-hydrocodone
chlorpheniramine-methscopolamine

chlorpheniramine-phenylephrine
chlorpheniramine-pseudoephedrine
codeine/phenylephrine/promethazine
codeine/pseudoephedrine/triprolidine
codeine-promethazine
dexchlorpheniramine/dextrometho/PE/pyrilamine
dexchlorpheniramine/dextromethorphan/PE
dexchlorpheniramine/dextromethorphan/PSE
dexchlorpheniramine/hydrocodone/phenylephrine
dexchlorpheniramine/methscopolamine/PE
dexchlorpheniramine/methscopolamine/PSE
dexchlorpheniramine-pseudoephedrine
dextromethorphan/diphenhydramine/PE
dextromethorphan-promethazine
diphenhydramine/hydrocodone/phenylephrine
diphenhydramine-phenylephrine
hydrocodone/pseudoephedrine/triprolidine
phenylephrine-promethazine
pseudoephedrine-triprolidine

Urinary antispasmodics

butabarbital/hyoscyamine/phenazopyridine
flavoxate

hyoscyamine/methenam/m-blue/phenyl salicyl
oxybutynin

tolterodine

methocarbamo
orphenadrine

HEDIS 2010, Volume 2

Rate 3: Drug-Disease Interactions—CRF and Nonaspirin NSAIDs or Cox-2 Selective NSAIDs
Additional eligible
population
criteria

A diagnosis of CRF (Table DDE-H) on or between January 1 of the year prior to the
measurement year and December 1 of the measurement year. Identify the IESD for
each member.

Table DDE-H: Codes to Identify CRF
Description
Chronic renal
failure

CPT

HCPCS

36145, 36800, 36810,
36815, 36818, 36819-36821,
36831-36833, 50300, 50320,
50340, 50360, 50365,
50370, 50380, 90921,
90925, 90935, 90937,
90940, 90945, 90947,
90960-90962, 90966, 90970,
90989, 90993, 90997,
90999, 99512

G0257, G0317G0319, G0323,
G0327, G0392,
G0393, S9339

Numerator

ICD-9-CM
Diagnosis
585.5, 585.6,
V42.0, V45.1,
V56

ICD-9-CM
Procedure

UB
Revenue

38.95, 39.27,
39.42, 39.43,
39.53, 39.9339.95, 54.98,
55.6

0367,
080x,
082x-085x,
088x

UB
Type
of Bill
72x

POS
65

Dispensed an ambulatory prescription for an NSAID or Cox-2 selective NSAID
(Table DDE-I) on or between the IESD and December 31 of the measurement year.

Table DDE-I: NSAIDs and Cox-2 Selective NSAIDs
Description

Prescription

Cox-2 inhibitors

celecoxib

Nonsteroidal antiinflammatory agents

diclofenac potassium
diclofenac sodium
etodolac
fenoprofen
flurbiprofen

ibuprofen
indomethacin
ketoprofen
ketorolac
meclofenamate

mefenamic acid
meloxicam
nabumetone
naproxen
naproxen sodium

oxaprozin
piroxicam
sulindac
tolmetin

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table DDE-3: Data Elements for Potentially Harmful Drug-Disease Interactions in the Elderly
Administrative
Measurement year
Data collection methodology (Administrative)




Eligible population

For each of the 3 rates and total

Numerator events by administrative data

For each of the 3 rates and total

Reported rate

For each of the 3 rates and total

Lower 95% confidence interval

For each of the 3 rates and total

Upper 95% confidence interval

For each of the 3 rates and total

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Use of High-Risk Medications in the Elderly (DAE)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of Medicare members 65 years of age and older who received at least one high risk
medication
The percentage of Medicare members 65 years of age and older who received at least two different high risk
medications
For both rates, a lower rate represents better performance.
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
16, 2009.

Eligible Population
Product line

Medicare.

Age

65 years and older as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during the measurement year.

Anchor date

Enrolled as of December 31 of the measurement year.

Benefits

Medical and pharmacy.

Event/diagnosis

None.

Administrative Specification
Denominator

The eligible population.

Numerator 1

At least one prescription dispensed for any high-risk medication (Table DAE-A)
during the measurement year.

Numerator 2

At least two prescriptions dispensed for different high risk medications (Table
DAE-A) during the measurement year.
Note: Identify different drugs using the Drug ID field located in the NDC list on
NCQA’s Web site (www.ncqa.org).

HEDIS 2010, Volume 2

200

Table DAE-A: High-Risk Medications
Description

Prescription

Antianxiety (includes
combination drugs)

aspirin-meprobamate

meprobamate

Antiemetics

scopolamine

trimethobenzamide

Analgesics (includes
combination drugs)

acetaminophen-diphenhydramine
diphenhydramine-magnesium salicylate

ketorolac

Antihistamines (includes
combination drugs)

APAP/dextromethorphan/diphenhydramine
APAP/diphenhydramine/phenylephrine
APAP/diphenhydramine/pseudoephedrine
acetaminophen-diphenhydramine
atropine/CPM/hyoscyamine/PE/PPA/scopolamine
carbetapentane/diphenhydramine/phenylephrine
codeine/phenylephrine/promethazine
codeine-promethazine
cyproheptadine
dexchlorpheniramine
dexchlorpheniramine/dextromethorphan/PSE
dexchlorpheniramine/guaifenesin/PSE
dexchlorpheniramine/hydrocodone/phenylephrine

dexchlorpheniramine/methscopolamine/PSE
dexchlorpheniramine-pseudoephedrine
dextromethorphan-promethazine
diphenhydramine
diphenhydramine/hydrocodone/phenylephrine
diphenhydramine-magnesium salicylate
diphenhydramine-phenylephrine
diphenhydramine-pseudoephedrine
hydroxyzine hydrochloride
hydroxyzine pamoate
phenylephrine-promethazine
promethazine
tripelennamine

Antipsychotic, typical

mesoridazine

thioridazine

Amphetamines

amphetaminedextroamphetamine
benzphetamine
dexmethylphenidate

dextroamphetamine
diethylpropion
methamphetamine
methylphenidate

Barbiturates

amobarbital
butabarbital
mephobarbital

pentobarbital
phenobarbital
secobarbital

Long-acting benzodiazepines
(includes combination drugs)

amitriptyline-chlordiazepoxide
chlordiazepoxide

Calcium channel blockers

nifedipine—short-acting only

Gastrointestinal antispasmodics

dicyclomine

Belladonna alkaloids
(includes combination drugs)

atropine
atropine/CPM/hyoscyamine/PE/scopolamine
atropine/hyoscyamine/PB/scopolamine
atropine-difenoxin
atropine-diphenoxylate
atropine-edrophonium
belladonna
belladonna/caffeine/ergotamine/pentobarbital

Skeletal muscle relaxants
(includes combination drugs)

ASA/caffeine/orphenadrine
ASA/carisoprodol/codeine
aspirin-carisoprodol
aspirin-meprobamate

aspirin-methocarbamol
carisoprodol
chlorzoxazone
cyclobenzaprine

metaxalone
methocarbamol
orphenadrine

Oral estrogens (includes
combination drugs)

conjugated estrogen
conjugated estrogenmedroxyprogesterone

esterified estrogen
esterified estrogenmethyltestosterone

estropipate

pemoline
phendimetrazine
phentermine

chlordiazepoxide-clidinium
diazepam

flurazepam

propantheline
belladonna/ergotamine/phenobarbital
butabarbital/hyoscyamine/phenazopyridine
digestive enzymes/hyoscyamine/ phenyltoloxamine
hyoscyamine
hyoscyamine/methenam/m-blue/phenyl salicyl
hyoscyamine-phenobarbital

HEDIS 2010, Volume 2

201

Table DAE-A: High-Risk Medications (continued)
Description

Prescription

Oral hypoglycemics

chlorpropamide

Narcotics (includes combination drugs)

ASA/caffeine/propoxyphene
acetaminophen-pentazocine
acetaminophen-propoxyphene
belladonna-opium
meperidine

meperidine-promethazine
naloxone-pentazocine
pentazocine
propoxyphene hydrochloride
propoxyphene napsylate

Vasodilators

cyclandelate
dipyridamole—short-acting only

ergot mesyloid
isoxsuprine

Others (including androgens and anabolic
steroids, thyroid drugs, urinary antiinfectives)

methyltestosterone
nitrofurantoin
nitrofurantoin macrocrystals

nitrofurantoin macrocrystals-monohydrate
thyroid desiccated

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table DAE-3: Data Elements for Use of High-Risk Medications in the Elderly
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population





Numerator events by administrative data

For each of the 2 rates

Reported rate

For each of the 2 rates

Lower 95% confidence interval

For each of the 2 rates

Upper 95% confidence interval

For each of the 2 rates

HEDIS 2010, Volume 2

202

Medication Reconciliation Post-Discharge (MRP)
SUMMARY OF CHANGES TO HEDIS 2010
Added definition of ―medication reconciliation.‖
Clarified medical record documentation for evidence of medication reconciliation.

Description
The percentage of discharges from January 1–December 1 of the measurement year for members 65 years
of age and older for whom medications were reconciled on or within 30 days of discharge.

Definition
Medication
reconciliation

A type of review in which the discharge medications are reconciled with the current
medication list in the outpatient medical record.

Eligible Population
Product line

Medicare SNP.

Ages

66 years and older as of December 31 of the measurement year.

Continuous
enrollment

Date of discharge through 30 days after discharge.

Allowable gap

None.

Anchor date

Date of discharge.

Benefit

Medical.

Event/diagnosis

An acute or nonacute inpatient discharge on or between January 1 and December 1
of the measurement year.
The denominator for this measure is based on discharges, not members. Include all
discharges for members who have one or more discharges on or between January
1 and December 1 of the measurement year.

Readmission or
direct transfer

If the discharge is followed by a readmission or direct transfer to an acute or
nonacute facility within the 30-day follow-up period, count only the readmission
discharge or the discharge from the facility to which the member was transferred.
Exclude both the initial discharge and the readmission/direct transfer discharge if
the readmission/direct transfer discharge occurs after December 1 of the
measurement year.

HEDIS 2010, Volume 2

203

Administrative Specification
Denominator

The eligible population.

Numerator

Medication reconciliation (Table MRP-A) conducted by a prescribing practitioner or
clinical pharmacists on or within 30 days of discharge. A member had a medication
reconciliation if a claim/encounter contains a code in Table MRP-A.

Table MRP-A: Codes to Identify Medication Reconciliation
Description

CPT Category II

Medication reconciliation

1111F

Hybrid Specification
Denominator

A systematic sample drawn from the eligible population. The organization may
reduce the sample size using the current year’s administrative rate or the prior year’s
audited, product line-specific rate. Refer to the Guidelines for Calculations and
Sampling for information on reducing the sample size.
The denominator is based on episodes, not members. Members may appear more
than once in the sample.

Numerator

Medication reconciliation conducted by a prescribing practitioner or clinical
pharmacist, as documented through either administrative data or medical record
review on or within 30 days of discharge.

Administrative

Refer to Administrative Specification to identify positive numerator hits from
administrative data.

Medical record

Documentation in the medical record must include evidence of medication
reconciliation, and the date on which it was performed. The following evidence meets
criteria.
Notation that the medications prescribed or ordered upon discharge were
reviewed, or
Notation that no medications were prescribed or ordered upon discharge
Only documentation in the outpatient chart meets the intent of the measure, but an
outpatient visit is not required. A medication list in a discharge summary obtained
from the hospital or inpatient chart should not be used as evidence of medication
reconciliation, but the intent of the measure is met if the discharge summary is in the
outpatient chart.

Note
The denominator is based on the discharge date found in administrative/claims data. This date must be used,
regardless of subsequent data errors or corrections found during medical record review.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table MRP-3: Data Elements for Medication Reconciliation Post-Discharge
Measurement year
Data collection methodology (Administrative or Hybrid)
Eligible population

Administrative

Hybrid









Number of numerator events by administrative data in eligible population (before
exclusions)



Current year’s administrative rate (before exclusions)

















Minimum required sample size (MRSS) or other sample size
Oversampling rate
Final sample size (FSS)
Number of numerator events by administrative data in FSS
Administrative rate on FSS
Number of original sample records excluded because of valid data errors
Number of employee/dependent medical records excluded
Records added from the oversample list
Denominator
Numerator events by administrative data



Numerator events by medical records
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval





HEDIS 2010, Volume 2

Medicare Health Outcomes Survey (HOS)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.

Description
This measure provides a general indication of how well a Medicare organization manages the physical and
mental health of its members. The survey measures each member’s physical and mental health status at the
beginning and the end of a two-year period.
A two-year change score is calculated and each member’s physical and mental health status is categorized
as better, the same or worse than expected, taking into account risk adjustment factors. Organization-specific
results are assigned as percentages of members whose health status was better, the same or worse than
expected.

HEDIS 2010, Volume 2

Fall Risk Management (FRM)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.

Description
The following components of this measure assess different facets of fall risk management.
Discussing
Fall Risk

The percentage of Medicare members 75 years of age and older or 65–74 years of age
with balance or walking problems or a fall in the past 12 months, who were seen by a
practitioner in the past 12 months and who discussed falls or problems with balance or
walking with their current practitioner.

Managing
Fall Risk

The percentage of Medicare members 65 years of age and older who had a fall or had
problems with balance or walking in the past 12 months, who were seen by a practitioner
in the past 12 months and who received fall risk intervention from their current
practitioner.

HEDIS 2010, Volume 2

Management of Urinary Incontinence in Older Adults (MUI)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.

Description
The following components of this measure assess the management of urinary incontinence in older adults.
Discussing Urinary
Incontinence

The percentage of Medicare members 65 years of age and older who reported
having a problem with urine leakage in the past six months and who discussed
their urine leakage problem with their current practitioner.

Receiving Urinary
Incontinence
Treatment

The percentage of Medicare members 65 years of age and older who reported
having a urine leakage problem in the past six months and who received treatment
for their current urine leakage problem.

HEDIS 2010, Volume 2

Osteoporosis Testing in Older Women (OTO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.

Description
The percentage of Medicare women 65 years of age and older who report ever having received a bone
density test to check for osteoporosis.

HEDIS 2010, Volume 2

Physical Activity in Older Adults (PAO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 6: Specifications for the Medicare Health Outcomes Survey.

Description
The following components of this measure assess different facets of promoting physical activity in older
adults.
Discussing
Physical Activity

The percentage of Medicare members 65 years of age and older who had a doctor’s
visit in the past 12 months and who spoke with a doctor or other health provider
about their level of exercise or physical activity.

Advising
Physical Activity

The percentage of Medicare members 65 years of age and older who had a doctor’s
visit in the past 12 months and who received advice to start, increase or maintain
their level exercise or physical activity.

HEDIS 2010, Volume 2

Flu Shots for Older Adults (FSO)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.

Description
The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year
who received an influenza vaccination between September 1 of the measurement year and the date on which
the Medicare CAHPS survey was completed.

HEDIS 2010, Volume 2

Medical Assistance With Smoking and Tobacco Use Cessation (MSC)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.

Description
The following components of this measure assess different facets of providing medical assistance with
smoking and tobacco use cessation.
Advising Smokers
and Tobacco Users
to Quit

A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users and who received advice to quit
during the measurement year.

Discussing Cessation
Medications

A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users and who discussed or were
recommended medications to quit during the measurement year.

Discussing Cessation
Strategies

A rolling average represents the percentage of members 18 years of age and
older who are current smokers or tobacco users who discussed or were provided
cessation methods or strategies during the measurement year.

HEDIS 2010, Volume 2

Pneumonia Vaccination Status for Older Adults (PNU)
SUMMARY OF CHANGES TO HEDIS 2010
This measure is collected using survey methodology. Detailed specifications and summary of changes are
contained in HEDIS 2010, Volume 3: Specifications for Survey Measures.

Description
The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year
who have ever received a pneumococcal vaccine

HEDIS 2010, Volume 2

Adults’ Access to Preventive/Ambulatory Health Services (AAP)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of members 20 years and older who had an ambulatory or preventive care visit. The
organization reports three separate percentages for each product line.
Medicaid and Medicare members who had an ambulatory or preventive care visit during the
measurement year
Commercial members who had an ambulatory or preventive care visit during the measurement year or
the two years prior to the measurement year

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Ages

20–65 years and older as of December 31 of the measurement year. Report three age
stratifications and a total rate.
20–44 years

45–64 years

65 years and older

Total

Total. The total rate is the sum of the three numerators divided by the sum of the three
denominators.
Continuous
enrollment

Medicaid and Medicare: The measurement year.

Allowable gap

No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for
whom enrollment is verified monthly, the member may not have more than a 1-month
gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).

Anchor date

December 31 of the measurement year.

Benefit

Medical.

Event/diagnosis

None.

Commercial: The measurement year and the two years prior to the measurement year.

HEDIS 2010, Volume 2

Administrative Specification
Denominator

The eligible population (report each age stratification separately).

Numerator

Medicaid and Medicare: One or more ambulatory or preventive care visits (Table
AAP-A) during the measurement year.
Commercial: One or more ambulatory or preventive care visits (Table AAP-A) during
the measurement year or the two years prior to the measurement year.

Table AAP-A: Codes to Identify Preventive/Ambulatory Health Services
Description

CPT

Office or other outpatient
services

99201-99205, 99211-99215,
99241-99245

Home services

99341-99345, 99347-99350

Nursing facility care

99304-99310, 99315, 99316,
99318

Domiciliary, rest home or
custodial care services

99324-99328, 99334-99337

Preventive medicine

99385-99387, 99395-99397,
99401-99404, 99411, 99412,
99420, 99429

Ophthalmology and
optometry

92002, 92004, 92012, 92014

HCPCS

ICD-9-CM Diagnosis

UB Revenue
051x, 052x, 0982,
0983

G0344

077x

General medical
examination

V70.0, V70.3, V70.5,
V70.6, V70.8, V70.9

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table AAP-1/2/3: Data Elements for Adults’ Access to Preventive/Ambulatory
Health Services
Administrative
Measurement year
Data collection methodology (Administrative)




Eligible population

For each age stratification and total

Numerator events by administrative data

For each age stratification and total

Reported rate

For each age stratification and total

Lower 95% confidence interval

For each age stratification and total

Upper 95% confidence interval

For each age stratification and total

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment (IET)
SUMMARY OF CHANGES TO HEDIS 2010
Deleted CPT codes 99261–99263 from Table IET-B.

Description
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD)
dependence who received the following.
Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD
admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the
diagnosis.
Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or
more additional services with an AOD diagnosis within 30 days of the initiation visit.

Definitions
Intake Period

January 1–November 15 of the measurement year. The Intake Period is used to
capture new episodes of AOD.

Index Episode

The earliest inpatient, intensive outpatient, partial hospitalization, outpatient,
detoxification or ED encounter during the Intake Period with a diagnosis of AOD.
For ED visits that result in an inpatient stay, the inpatient stay is the Index Episode.

IESD

Index Episode Start Date. The earliest date of service for any inpatient, intensive
outpatient, partial hospitalization, outpatient, detoxification or ED encounter during the
Intake Period with any diagnosis of AOD.
For an outpatient, intensive outpatient, partial hospitalization, detoxification or ED (not
resulting in an inpatient stay) claim/encounter, the IESD is the date of service.
For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of
discharge.
For an ED visit that results in an inpatient stay, the IESD is the date of the inpatient
discharge.
For direct transfers, the IESD is the discharge date from the second admission.

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Negative
Diagnosis
History

A period of 60 days prior to the IESD, during which the member had no claims/
encounters with any diagnosis of AOD dependence.
For an inpatient claim/encounter, use the admission date to determine the Negative
Diagnosis History.
For ED visits that result in an inpatient stay, use the ED date of service to determine
the Negative Diagnosis History.
For direct transfers, use the first admission to determine the Negative Diagnosis
History.

Eligible Population
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Age

13 years and older as of the December 31 of the measurement year. Report two age
stratifications and a total rate.
13-17 years
18+ years
Total
The total rate is the sum of the two numerators divided by the sum of the two
denominators.

Continuous
enrollment

60 days prior to the IESD through 44 days after the IESD (inclusive).

Allowable gap

None.

Anchor date

None.

Benefits

Medical and chemical dependency (inpatient and outpatient).
Note: Members with detoxification-only chemical dependency benefits do not meet
these criteria.
New episode of AOD during the Intake Period.

Event/
diagnosis

Follow the steps below to identify the eligible population, which is the denominator for
both rates.
Step 1

Identify the Index Episode. Identify all members in the specified age range who during
the Intake Period had one of the following.
An outpatient visit, intensive outpatient encounter or partial hospitalization (Table
IET-B) with a diagnosis of AOD (Table IET-A)
A detoxification visit (Table IET-C)
An ED visit (Table IET-D) with a diagnosis of AOD (Table IET-A)

HEDIS 2010, Volume 2

An inpatient discharge with a diagnosis of AOD as identified by either of the
following.
An inpatient facility code in conjunction with a diagnosis of AOD (IET-A)
An inpatient facility code in conjunction with an AOD procedure code (IET-E)
For members with more than one episode of AOD, use the first episode.
For members whose first episode was an ED visit that resulted in an inpatient stay, use
the inpatient discharge.
Select the IESD.

Table IET-A: Codes to Identify AOD Dependence
ICD-9-CM Diagnosis
291-292, 303.00-303.02, 303.90-303.92, 304.00-304.02, 304.10-304.12, 304.20-304.22, 304.30-304.32, 304.40-304.42, 304.50-304.52,
304.60-304.62, 304.70-304.72, 304.80-304.82, 304.90-304.92, 305.00-305.02, 305.20-305.22, 305.30-305.32, 305.40-305.42, 305.50305.52, 305.60-305.62, 305.70-305.72, 305.80-305.82, 305.90-305.92, 535.3, 571.1

Table IET-B: Codes to Identify Outpatient, Intensive Outpatient and Partial
Hospitalization Visits
CPT

HCPCS

90804-90815, 98960-98962, 99078, 9920199205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 9938499387, 99394-99397, 99401-99404, 99408,
99409, 99411, 99412, 99510

UB Revenue

G0155, G0176, G0177, G0396, G0397, H0001, H0002,
H0004, H0005, H0007, H0015, H0016, H0020, H0022,
H0031, H0034-H0037, H0039, H0040, H2000, H2001,
H2010-H2020, H2035, H2036, M0064, S0201, S9480,
S9484, S9485, T1006, T1012

0510, 0513, 0515-0517,
0519-0523, 0526-0529,
077x, 0900, 0902-0907,
0911-0917, 0919, 0944,
0945, 0982, 0983

CPT

POS

90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876

90816-90819, 90821-90824, 90826-90829, 99221-99223, 99231-99233, 99238, 99239,
99251-99255

WITH
WITH

03, 05, 07, 09, 11, 12, 13,
14, 15, 20, 22, 33, 49, 50,
52, 53, 57, 71, 72
52, 53

Table IET-C: Codes to Identify Detoxification Visits
HCPCS

ICD-9-CM Procedure

UB Revenue

H0008-H0014

94.62, 94.65, 94.68

0116, 0126, 0136, 0146, 0156

Table IET-D: Codes to Identify Emergency Department Visits
CPT

UB Revenue

99281-99285

045x, 0981

Table IET-E: Codes to Identify AOD Procedures
ICD-9-CM Procedure
94.61, 94.63, 94.64, 94.66, 94.67, 94.69

______________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Step 2

Test for Negative Diagnosis History. Exclude members who had a claim/encounter with
any diagnosis of AOD (Table IET-A) during the 60 days prior to the IESD.
For an inpatient IESD, use the admission date to determine the Negative Diagnosis
History.
For an ED visit that results in an inpatient stay, use the ED date of service to determine
the Negative Diagnosis History.

Step 3

Calculate continuous enrollment. Members must be continuously enrolled without any
gaps 60 days prior to the IESD through 44 days after the IESD.

Administrative Specification
Denominator

The eligible population.

Numerator
Initiation of
AOD Treatment

Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive
outpatient encounter or partial hospitalization within 14 days of diagnosis.
If the Index Episode was an inpatient discharge, the inpatient stay is considered
initiation of treatment and the member is compliant
If the Index Episode was an outpatient, intensive outpatient, partial hospitalization,
detoxification or ED visit, the member must have an inpatient admission,
outpatient visit, intensive outpatient encounter or partial hospitalization (Table
IET-B) with any AOD diagnosis (Table IET-A) within 14 days of the IESD
(inclusive)
If the initiation encounter is an inpatient admission, the admission date (not the
discharge date) must be within 14 days of the IESD (inclusive)
Do not count Index Episodes that include detoxification codes (including inpatient
detoxification) as being initiation of treatment
Exclude from the denominator members whose initiation encounter is an inpatient stay
with a discharge date after December 1 of the measurement year.

Engagement of
AOD Treatment

Initiation of AOD treatment and two or more inpatient admissions, outpatient visits,
intensive outpatient encounters or partial hospitalizations (Table IET-B) with any AOD
diagnosis (Table IET-A) within 30 days after the date of the Initiation encounter
(inclusive). Multiple engagement visits may occur on the same day, but they must be with
different providers in order to be counted.
For members who initiated treatment via an inpatient stay, use the discharge date as the
start of the 30-day engagement time period.
If the engagement encounter is an inpatient admission, the admission date (not the
discharge date) must be within 30 days of the Initiation encounter (inclusive).
Do not count engagement encounters that include detoxification codes (including
inpatient detoxification)

HEDIS 2010, Volume 2

Note
Organizations may have different methods for billing intensive outpatient encounters and partial
hospitalizations. Some organizations may bill comparable to outpatient billing, with separate claims for
each date of service; others may bill comparable to inpatient billing, with an admission date, a discharge
date and units of service. Organizations that bill comparable to inpatient billing may count each unit of
service as an individual visit. The unit of service must have occurred during the time frame required for the
rate (e.g., within 14 days of the IESD or within 30 days after the date of the initiation encounter).

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table IET-1/2/3: Data Elements for Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment
Administrative
Measurement year
Data collection methodology (administrative)




Eligible population

For each age stratification and total

Numerator events by administrative data

For each age stratification and total

Reported rate

For each age stratification and total

Lower 95% confidence interval

For each age stratification and total

Upper 95% confidence interval

For each age stratification and total

HEDIS 2010, Volume 2

Call Abandonment (CAB)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of calls received by the organization’s Member Services call centers (during operating hours)
during the measurement year that were abandoned by the caller before being answered by a live voice.
Lower rates represent better performance.

Definitions
Abandonment

The caller dials directly into the organization’s Member Services call center or
selects the Member Services option, is placed in the call queue and hangs up the
phone, disconnecting from the call center before being answered by a Member
Services representative.

Call

Telephone contact initiated by an external caller that connects to the organization
Member Services call center. For calls transferred from other parts of the
organization telephone system, measure time from after the call is transferred into
the call center and the member chooses the option to speak to a Member Services
representative and is placed in the call queue.

Member Services
operating hours

Hours of live call-center operation indicated by membership materials (e.g., ID card,
summary organization descriptions, enrollment materials).

Member Services
representative

An employee at the organization’s Member Services call center responsible for
answering calls regarding enrollment, benefits and claims processing.

Member Services
call center

An entity within the organization or under contract with the organization that is
responsible for handling the organization’s network Member Services inquiries
regarding enrollment, benefits and claims processing.

Queue

A sequence of calls waiting to be handled by a Member Services representative. The
wait time on a queued call is calculated by Automatic Call Distribution (ACD), which
tracks incoming calls.

Calculation
Product lines

Commercial, Medicaid, Medicare (report each product line separately).
Note: An organization that uses the same systems, policies and procedures and
staff to answer calls for all product lines may report the same rate for all product lines
if it is not possible for it to report data by individual product line.

Denominator

The number of calls received by the organization’s Member Services call center
(during hours of operation) during the measurement year where the member called
directly into Member Services or selected a Member Services option and was put in
the call queue.
Exclude calls to the organization’s benefit contractor (e.g., mental health, dental,
vision, pharmacy) when the contractor has its own call center.

HEDIS 2010, Volume 2

Numerator

The number of calls abandoned by the caller or the system before being answered
by a live voice.
Note: Calls abandoned within 30 seconds remain in the measure and are compliant
for the numerator. Calls sent directly to voicemail should also remain in the measure
and are considered compliant.

Formulas

For an organization with one call center that answers all the organization’s calls and
has the organization as its only client, report the measure as specified.
For an organization with one call center that answers all the organization’s calls and
also has multiple clients, if the call center is unable to report abandonment data for
the organization, report abandonment for the entire volume of calls the center
handles.
For an organization with multiple call centers, each of which answers a portion of the
total amount of calls for the organization and has the organization as its only client,
report the measure as a weighted average (see the formula below).

Definitions

Let N1

= The total number of Member Services calls received by call center 1.

Let N2

= The total number of Member Services calls received by call center 2.

Let PCAB1 = The rate for the Call Abandonment HEDIS measure for call center 1.
Let PCAB2 = The rate for the Call Abandonment HEDIS measure for call center 2.
Set-up calculations

Pooled analysis

Let W1

= The weight assigned to call center 1. This result is calculated by the
formula W1 = N1/(N1+N2).

Let W2

= The weight assigned to call center 2. This result is calculated by the
formula W2 = N2/(N1+N2).

The pooled result from the two rates is calculated as:
PCA pooled = W1*PCAB1+ W2*PCAB2

Note
If during peak call periods (or any regular business hours), the organization blocks calls by immediately giving
members a busy signal and keeping the calls from reaching the call queue, the auditor assesses the
percentage of blocked calls and its impact on the measure.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table CAB-1/2/3: Data Elements for Call Abandonment
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









HEDIS 2010, Volume 2

Call Answer Timeliness (CAT)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The percentage of calls received by the organization’s Member Services call centers (during operating hours)
during the measurement year that were answered by a live voice within 30 seconds.

Definitions
Call

Telephone contact initiated by an external caller connects with the organization’s
Member Services call center. For calls transferred from other parts of the
organization’s telephone system, measure time from after the call is transferred
into the Member Services call center, the member chooses the option to speak to
a Member Services representative and is placed in the call queue.

Member Services
operating hours

Hours of live call-center operation indicated by membership materials (e.g., ID
card, summary organization descriptions, enrollment materials).

Member Services
representative

An employee at the organization’s Member Services call center responsible for
answering calls regarding enrollment, benefits and claims processing.

Member Services
call center

An entity within the organization or under contract with the organization that is
responsible for handling the organization’s network Member Services inquiries
regarding enrollment, benefits and claims processing.

Queue

A sequence of calls waiting to be handled by the Member Services representative.
The wait time on a queued call is calculated by ACD, which tracks incoming calls.

Calculation
Product lines

Commercial, Medicaid, Medicare (report each product line separately).
Note: An organization that uses the same systems, policies and procedures and
staff to answer calls for all product lines may report the same rate for all product
lines if it is not possible for it to report data by individual product line.

Denominator

The number of calls received by the Member Services call centers (during hours of
operation) during the measurement year, where the member called directly into
Member Services or selected a Member Services option and was put in the call
queue. Exclude calls to a benefits contractor (e.g., mental health, dental, vision,
pharmacy) that uses its own call center.

Numerator

The number of calls answered by a live voice within 30 seconds.
Time measured begins when the member is placed in the call queue and is waiting
to speak to a Member Services representative.
Note: Calls abandoned within 30 seconds remain in the measure and are
noncompliant for the numerator. Calls sent directly to voicemail should also remain
in the measure and are considered noncompliant.

HEDIS 2010, Volume 2

Formulas

For an organization with one call center that answers all the organization’s calls and
has the organization as its only client, report the measure as specified.
For an organization with one call center that answers all the organization’s calls and
also has multiple clients, if the call center is unable to report timeliness data for the
specific organization, report timeliness for the entire volume of calls the center handles.
For an organization with multiple call centers, each of which answers a portion of the
total calls for the organization and has the organization as its only client, report the
measure as a weighted average (see the formula below).

Definitions

Let N1 = The total number of Member Services calls received by call center 1.
Let N2 = The total number of Member Services calls received by call center 2.
Let PCAT1 = The rate for the Call Answer Timeliness HEDIS measure for call center 1.
Let PCAT2 = The rate for the Call Answer Timeliness HEDIS measure for call center 2.

Set-up
calculations

Pooled analysis

Let W1

= The weight assigned to call center 1. This result is calculated by the
formula W1 = N1/(N1+N2).

Let W2

= The weight assigned to call center 2. This result is calculated by the
formula W2 = N2/(N1+N2).

The pooled result from the two rates is calculated as:
PCAT pooled = W1*PCAT1+ W2*PCAT2

Note
If during peak call periods (or any regular business hours), the organization blocks calls by immediately giving
members a busy signal and keeping the calls from reaching the call queue, the auditor assesses the
percentage of blocked calls and its impact on the measure.

Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table CAT-1/2/3: Data Elements for Call Answer Timeliness
Administrative
Measurement year
Data collection methodology (Administrative)
Eligible population
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval









HEDIS 2010, Volume 2

Total Membership (TLM)
SUMMARY OF CHANGES TO HEDIS 2010
Retired the Years in Business portion of the measure.
Renamed the measure.
Clarified Total Membership count.

Description
The number of members enrolled as of December 31 of the measurement year.

Calculation
For each product line the licensed organization offers (i.e., HMO, POS, PPO or FFS), report the number of
members enrolled as of December 31 of the measurement year by product line (i.e., commercial, Medicaid,
Medicare or other**). The total category should equal the licensed organization’s total membership as of
December 31 of the measurement year. The organization should complete this measure once and report the
information for each HEDIS submission.
Include all products and product lines (i.e., across all books of business), even if they were not included in a
HEDIS submission. Include:
Special Needs Plans (SNP) in the Medicare count
ASO members in either the commercial HMO, POS or PPO count, as appropriate
EPO members in either the HMO, POS or PPO count, as appropriate
CHIP members in the Medicaid product line.

Table TLM-1/2/3: Total Membership*
Organization Name: _____________________________________________

Product/Product Line
HMO
Medicaid
Commercial
Medicare
Other

Total Number of Members

Total HMO:

__________________
__________________
__________________
__________________
__________________

Total PPO:

__________________
__________________
__________________
__________________
__________________

Total:

__________________

PPO
Medicaid
Commercial
Medicare
Other

Product/Product Line
POS
Medicaid
Commercial
Medicare
Other

Total Number of Members

Total POS:

__________________
__________________
__________________
__________________
__________________

Total FFS:

__________________
__________________
__________________
__________________
__________________

FFS
Medicaid
Commercial
Medicare
Other

*Total number of members in each category as of December 31 of the measurement year.

HEDIS 2010, Volume 2

Frequency of Selected Procedures (FSP)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT codes 22856, 22861, 22864, 27267–27269 to Table FSP-A.
Added ICD-9-CM Procedure codes 80.53, 80.54 to table FSP-A (―back surgery‖ description).
Deleted CPT codes 63035, 63043, 63044, 63048, 63057, 63066, 63076, 63078, 63082, 63086, 63088,
63091, 63103 from Table FSP-A.
Removed CMS-DRGs from Table FSP-A.

Description
This measure summarizes the utilization of frequently performed procedures that often show wide regional
variation and have generated concern regarding potentially inappropriate utilization.

Calculations
Product lines

Report the following tables for each applicable product line.
Table FSP-1a

Total Medicaid*

Table FSP-2

Commercial—by Product or Combined HMO/POS

Table FSP-3

Medicare

* Report this measure for Total Medicaid only; reporting by eligibility category will
result in small numbers.
Member months

For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.

Procedures

Use Table FSP-A to identify procedures for reporting. Report counts for the
procedures as specified regardless of the site of care (e.g., inpatient or ambulatory
setting). Report the number of procedures rather than the number of members who
received the procedures. Do not double-count the same procedure. The two
examples below illustrate scenarios counted as one procedure.

Count as one
procedure…

If the date of service for two procedures is the same and both codes indicate
CABG
If the date of service for a procedure falls between the admission and
discharge dates for an inpatient stay where the procedure was performed
For example, if a CABG was billed by a surgeon on March 4 of the
measurement year and the facility bill shows a CABG for an admission
that started on March 2 and lasted until March 7 of the measurement
year, combine these to count one CABG

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Myringotomy

Report myringotomy or myringotomy and adenoidectomy. Report toward both
measures, myringotomy and tonsillectomy occurring on the same date of service.
Report as two separate procedures, two myringotomies performed on the same
date of service by the same provider.
Do not report adenoidectomy performed alone.

Tonsillectomy

Report tonsillectomy or tonsillectomy and adenoidectomy. Report toward both
measures myringotomy and tonsillectomy occurring on the same date of service.
Do not report adenoidectomy performed alone.

Nonobstetric D&C

Report nonobstetric D&C.
Do not report obstetric D&C or termination of pregnancy D&C.
Do not report a nonobstetric D&C performed in conjunction with (i.e., on the same
date of service as) a hysterectomy. These services are reported under
hysterectomy.

Hysterectomy
Cholecystectomy
Back surgery

Report abdominal and vaginal hysterectomy separately.
Report open and closed (laparoscopic) cholecystectomy separately.
Report all spinal fusion and disc surgery, including codes relating to laminectomy
with and without disc removal.

Coronary
angioplasty
(PTCA)

Report all PTCAs performed separately. Do not report angioplasty or cardiac
catheterization performed in conjunction with (i.e., on the same date of service as)
a CABG in the angioplasty or the cardiac catheterization rate; report only the
CABG.

Cardiac
catheterization

Report all cardiac catheterizations performed separately. Do not report a cardiac
catheterization performed in conjunction with (i.e., on the same date of service as)
an angioplasty in the cardiac catheterization rate; report only the angioplasty.
Do not report angioplasty or cardiac catheterization performed in conjunction with
(i.e., on the same date of service as) a CABG in the angioplasty or the cardiac
catheterization rate; report only the CABG.

CABG

Coronary artery bypass graft. Report each CABG only once for each date of
service per patient, regardless of the number of arteries involved or the number or
types of grafts involved.
Do not report angioplasty or cardiac catheterization performed in conjunction with
(i.e., on the same date of service as) a CABG in the angioplasty or the cardiac
catheterization rate; report only the CABG.

Prostatectomy
Reduction of
fracture of femur

Report the number of prostatectomies.
Report the number of reductions of fracture of the femur.

HEDIS 2010, Volume 2

Total hip
replacement

Report the number of total hip replacements.

Total knee
replacement

Report the number of total knee replacements.

Partial excision of
large intestine
Carotid
endarterectomy

Report the number of partial excisions of the large intestine.

Report the number of carotid endarterectomies.

Mastectomy

Report the number of mastectomies. Report bilateral mastectomy procedures as
two procedures, even if performed on the same date.

Lumpectomy

Report the number of lumpectomies. Report multiple lumpectomies on the same
date of service as one lumpectomy procedure per patient.

Table FSP-A: Codes to Identify Selected Procedures
Description
Myringotomy or myringotomy
with adenoidectomy
Tonsillectomy or tonsillectomy
with adenoidectomy
Nonobstetric dilation and
curettage
Hysterectomy (abdominal)
Hysterectomy (vaginal)
Cholecystectomy (open)
Cholecystectomy (closed/
laparoscopic)

CPT

HCPCS

ICD-9-CM
Procedure

69433, 69436

20.01

42820, 42821, 42825, 42826, 42860

28.2-28.4

58120

69.09

51925, 58150, 58152, 58180, 58200, 58210, 58240,
58541-58544, 58548, 58570-58573, 58951, 58953,
58954, 58956, 59135, 59525
58260, 58262, 58263, 58267, 58270, 58275, 58280,
58285, 58290-58294, 58550, 58552-58554
47600, 47605, 47610, 47612, 47620
47562-47564

68.3, 68.4, 68.6,
68.8, 68.9

Back surgery

22220, 22222, 22224, 22532, 22533, 22548, 22554,
22556, 22558, 22590, 22595, 22600, 22610, 22612,
22630, 22830, 22856, 22857, 22861, 22862, 22864,
22865, 63001, 63003, 63005, 63011, 63012, 6301563017, 63020, 63030, 63040, 63042, 63045-63047,
63050, 63051, 63055, 63056, 63064, 63075, 63077,
63081, 63085, 63087, 63090, 63101-63102

Coronary angioplasty (PTCA)

MS—
DRG

68.5, 68.7
51.21, 51.22
51.23, 51.24
S2348,
S2350

03.02, 03.09,
80.5, 81.0, 81.3,
81.6, 84.6, 84.8

453-460

92980, 92982, 92995

00.66, 36.06,
36.07, 36.09

246-251

Cardiac catheterization

93501, 93510, 93511, 93514, 93524, 93526-93529,
93539-93545

37.21-37.23,
88.55-88.57

216-218,
222-225,
286, 287

CABG

33510-33514, 33516-33519, 33521-33523, 3353333536

36.1, 36.2

231-236

S2205S2209

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table FSP-A: Codes to Identify Selected Procedures (continued)
Description
Prostatectomy

Reduction of fracture of
femur
Total hip replacement
Total knee replacement
Partial excision of large
intestine
Carotid endarterectomy
Mastectomy

Lumpectomy

CPT

HCPCS

ICD-9-CM Procedure

52601, 52612, 52614, 52620,
52630, 52647, 52648, 55801,
55810, 55812, 55815, 55821,
55831, 55840, 55842, 55845,
55866
27230, 27232, 27235, 27236,
27238, 27240, 27244-27246,
27248, 27267-27269
27130, 27132, 27134
27446, 27447, 27486, 27487

60.2-60.6

44140, 44141, 44143-44147,
44160, 44204-44208
34001, 35001, 35301, 35501,
35601
Bilateral: 19303-19307 with a
modifier .50 code
Unilateral: 19303-19307

45.7

19120, 19125, 19301, 19302

MS—DRG
665-667

79.05, 79.15, 79.25, 79.35
00.70, 81.51, 81.53
00.80, 81.54, 81.55

38.12
Bilateral: 85.42, 85.44, 85.46,
85.48
Unilateral: 85.41, 85.43, 85.45,
85.47
85.2

NA (no MS-DRGs
are specific to total
mastectomy)
584, 585

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table FSP-1: Frequency of Selected Procedures
Member Months
Age

Male

Female

_____________

0-9

_____________

5-19

_____________

10-19

_____________

15-44

_____________

20-44

_____________

30-64

_____________

45-64

_____________

Procedure
Myringotomy
Tonsillectomy
D&C
Hysterectomy, abdominal
Hysterectomy, vaginal

0-4
5-19
0-9
10-19
15-44
45-64
15-44
45-64
15-44
45-64

15-44
45-64
30-64

Cholecystectomy, closed
(laparoscopic)

15-44
45-64
20-44

Back surgery
45-64

Mastectomy
Lumpectomy

15-44
45-64
15-44
45-64

_____________

_____________

Number of Procedures

Procedures/
1,000 Member Months

Male and Female

___________________
___________________

___________________
___________________

Male and Female

___________________
___________________

___________________
___________________

Female

___________________
___________________

___________________
___________________

Female

___________________
___________________

___________________
___________________

Female

___________________
___________________

___________________
___________________

Male

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Female

___________________
___________________

___________________
___________________

___________________

___________________

___________________

___________________

Age

30-64
Cholecystectomy, open

Total

0-4

Sex

Female
Male
Female

Female

HEDIS 2010, Volume 2

Table FSP-2: Frequency of Selected Procedures
Age

Male

Member Months
Female

0-4

___________

0-9

___________

5-19

___________

10-19

___________
_____________

15-44
20-44

_____________

30-64

_____________

45-64

_____________

_____________

65+

_____________

_____________

Procedure
Myringotomy
Tonsillectomy
D&C

Hysterectomy, abdominal

0-4
5-19
0-9
10-19
15-44
45-64
15-44
45-64
15-44
45-64

Procedures/
1,000 Member Years

___________________

___________________

___________________

___________________

Male and Female

___________________
___________________

___________________
___________________

Female

___________________
___________________

___________________
___________________

Female

___________________
___________________
___________________

___________________
___________________
___________________

Female

___________________
___________________
___________________

___________________
___________________
___________________

Male

___________________

___________________

Female

___________________
___________________

___________________
___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________
___________________

___________________
___________________

Male

___________________

___________________

Female

___________________

___________________

Sex
Male and Female

65+
30-64
15-44
Cholecystectomy, open

45-64
65+
30-64
15-44

Cholecystectomy, closed
(laparoscopic)

45-64
65+

_____________

Number of Procedures

Age

65+
Hysterectomy, vaginal

Total

HEDIS 2010, Volume 2

Table FSP-2: Frequency of Selected Procedures (continued)
Procedure

20-44

Back surgery

45-64

65+

45-64
PTCA
65+

45-64
Cardiac catheterization
65+

45-64
CABG
65+

Prostatectomy

Mastectomy

Number of Procedures

Procedures/
1,000 Member Years

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________
___________________

___________________
___________________

Female

___________________
___________________
___________________

___________________
___________________
___________________

Female

___________________
___________________
___________________

___________________
___________________
___________________

Age

45-64
65+
15-44
45-64

Sex

65+
Lumpectomy

15-44
45-64
65+

HEDIS 2010, Volume 2

Table FSP-3: Frequency of Selected Procedures
Member Months
Male

Age

Procedure

Female

<65

_____________

_____________

65-74

_____________

_____________

75-84

_____________

_____________

85+

_____________

_____________

Number of Procedures

Procedures/
1,000 Member Years

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Age
<65

65-74
CABG
75-84

85+

<65

65-74
PTCA
75-84

85+

<65

65-74
Cardiac catheterization
75-84

85+

Sex

HEDIS 2010, Volume 2

Table FSP-3: Frequency of Selected Procedures (continued)
Procedure

Number of Procedures

Procedures/
1,000 Member Years

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Age
<65

65-74
Carotid endarterectomy
75-84

85+

<65

65-74
Cholecystectomy, open
75-84

85+

<65

65-74
Cholecystectomy, closed
(laparoscopic)
75-84

85+

<65
65-74
Back surgery
75-84
85+

Sex

HEDIS 2010, Volume 2

Table FSP-3: Frequency of Selected Procedures (continued)
Procedure

Number of Procedures

Procedures/
1,000 Member Years

___________________

___________________

___________________

___________________

___________________

___________________

85+

___________________

___________________

<65

___________________

___________________

___________________

___________________

___________________

___________________

85+

___________________

___________________

<65

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Age

Sex

<65
Hysterectomy (abdominal)

Hysterectomy (vaginal)

Prostatectomy

65-74
75-84

65-74
75-84

65-74
75-84

Female

Female

Male

85+
<65
65-74
Reduction of fracture of femur
75-84
85+
<65
65-74
Total hip replacement
75-84
85+
<65

65-74
Total knee replacement
75-84

85+

HEDIS 2010, Volume 2

Table FSP-3: Frequency of Selected Procedures (continued)
Procedure

Number of Procedures

Procedures/
1,000 Member Years

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

Male

___________________

___________________

Female

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

85+

___________________

___________________

<65

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Age
<65

65-74
Partial excision of large
intestine
75-84

85+

Sex

<65
Mastectomy

Lumpectomy

65-74
75-84

65-74
75-84
85+

Female

Female

HEDIS 2010, Volume 2

Inpatient Utilization—General Hospital/Acute Care (IPU)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Tables IPU-A and IPU-B.
Added ICD-9-CM Diagnosis codes 678–679 to Table IPU-B ―Maternity‖ description.

Description
This measure summarizes utilization of acute inpatient care and services in the following categories.
Total inpatient
Medicine
Surgery
Maternity

Calculations
Product lines

Member months

Report the following tables for each applicable product line.
Table IPU-1a

Total Medicaid

Table IPU-1b

Medicaid/Medicare Dual-Eligibles

Table IPU-1c

Medicaid—Disabled

Table IPU-1d

Medicaid—Other Low Income

Table IPU-2

Commercial—by Product or Combined HMO/POS

Table IPU-3

Medicare

For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.
Maternity rates are reported per 1,000 male and per 1,000 female total member
months in order to capture deliveries as a percentage of the total inpatient
discharges.

Discharges

Refer to the codes in Table IPU-A to identify total inpatient discharges, then use
Table IPU-B to separate discharges into Maternity, Surgery and Medicine.

HEDIS 2010, Volume 2

Table IPU-A: Codes to Identify Total Inpatient Discharges
Principal ICD-9-CM Diagnosis

MS—DRG

001-289, 317-999, V01-V29, V40-V86
OR

001-013, 020-042, 052-103, 113-117, 121-125, 129-139, 146-159, 163-168,
175-208, 215-264, 280-316, 326-358, 368-395, 405-425, 432-446, 453-517,
533-566, 573-585, 592-607, 614-630, 637-645, 652-675, 682-700, 707-718,
722-730, 734-750, 754-761, 765-770, 774-782, 789-795, 799-804, 808-816,
820-830, 834-849, 853-858, 862-872, 901-909, 913-923, 927-929, 933-935,
939-941, 947-951, 955-959, 963-965, 969-970, 974-977, 981-989, 998, 999
WITH

UB Type of Bill
11x, 12x, 41x, 84x

OR

Any acute inpatient facility code

Days

Count all days associated with the identified discharges. Report days for total inpatient,
maternity, surgery and medicine.

ALOS

Refer to the Specific Instructions for Use of Services Tables for the formula. Calculate
average length of stay for total inpatient, medicine, surgery and maternity.

Total inpatient

Use Table IPU-A to identify acute inpatient discharges.
The Total Inpatient should be the sum of the three categories (Medicine, Surgery,
Maternity) and any MS-DRGs defined as ―principal diagnosis invalid as discharge
diagnosis or ungroupable.‖
Use Table IPU-B to identify maternity, surgery and medicine inpatient discharges.

Medicine

DRGs are the preferred method to identify medical discharges. An organization that
uses ICD-9-CM Diagnosis codes must identify total acute inpatient discharges, remove
maternity related discharges and remove all discharges accompanied by UB revenue
code 036X.
Report MS-DRGs 789–795 under Medicine if newborn care is rendered after the baby
has been discharged home from delivery and is subsequently rehospitalized.

Surgery

DRGs are the preferred method to identify surgical discharges. An organization that
uses ICD-9-CM Diagnosis codes must identify total inpatient, remove maternity-related
discharges and include the remaining discharges accompanied by UB revenue code
036X.

Maternity

Include birthing center deliveries in this measure and count them as one day of stay.
Refer to Table IPU-B for ICD-9-CM Principal Diagnosis codes, UB Revenue, UB Type
of Bill and DRG codes.

HEDIS 2010, Volume 2

Table IPU-B: Codes to Identify Medicine, Surgery and Maternity Inpatient Discharges
Description

Principal ICD-9CM Diagnosis

UB Revenue

Medicine

Total—Maternity—
Surgery

Surgery

Total—Maternity*

036x

Maternity

630-676, 678-679,
V24.0

0112, 0122, 0132,
0142, 0152, 07200722, 0724

UB Type
of Bill

MS—DRG
052-103, 121-125, 146-159, 175-208, 280-316, 368-395,
432-446, 533-566, 592-607, 637-645, 682-700, 722-730,
754-761, 789-795, 808-816, 834-849, 862-872, 913-923,
933-935, 947-951, 963-965, 974-977
001-013, 020-042, 113-117, 129-139, 163-168, 215-264,
326-358, 405-425, 453-517, 573-585, 614-630, 652-675,
707-718, 734-750, 799-804, 820-830, 853-858, 901-909,
927-929, 939-941, 955-959, 969-970, 981-989

84x

765-770, 774-782

* If the organization uses ICD-9-CM Diagnosis codes to report this measure, all discharges reported in the Surgery group must be in
conjunction with UB revenue code 036x.

Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude claims and
encounters that contain any of the following codes.

Table IPU-C: Codes to Identify Exclusions
Principal ICD-9-CM Diagnosis

Secondary ICD-9-CM Diagnosis

WITH

960-979

291-292, 303-305

Table IPU-1: Inpatient Utilization—General Hospital/Acute Care
Age

Member Months

<1

_____________

1-9

_____________

10-19

_____________

20-44

_____________

45-64

_____________

65-74

_____________

75-84

_____________

85+

_____________

Unknown

_____________
Total:

_____________

HEDIS 2010, Volume 2

Table IPU-1: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges

Discharges/1,000
Member Months

Days

Days/1,000 Member
Months

Average Length
of Stay

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Age
Total Inpatient

Total:

_______

___________

___________

___________

_______

___________

___________

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Medicine

Total:

_______

___________

___________

___________

_______

___________

___________

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Surgery

Total:

___________

_______
___________

_______

___________
___________

___________

HEDIS 2010, Volume 2

Table IPU-1: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges

Discharges/1,000
Member Months

Days

Days/1,000 Member
Months

Average Length of
Stay

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

Unknown

___________

Age
Maternity*

Total:

___________

_______
___________

___________

_______

___________

___________

*The maternity category is calculated using member months for members 10–64 years.

Table IPU-2/3: Inpatient Utilization—General Hospital/Acute Care
Age

Member Months

<1

_____________

1-9

_____________

10-19

_____________

20-44

_____________

45-64

_____________

65-74

_____________

75-84

_____________

85+

_____________

Unknown

_____________
Total:

_____________

Discharges

Discharges/1,000
Member Years

Days

Days/1,000 Member
Years

Average Length of
Stay

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Age
Total Inpatient

Total:

___________

_______
___________

_______

___________
___________

___________

HEDIS 2010, Volume 2

Table IPU-2/3: Inpatient Utilization—General Hospital/Acute Care (continued)
Discharges

Discharges/1,000
Member Years

Days

Days/1,000 Member
Years

Average Length
of Stay

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Age
Medicine

Total:

_______

___________

___________

___________

_______

___________

___________

<1

___________

___________

_______

___________

___________

1-9

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

65-74

___________

___________

_______

___________

___________

75-84

___________

___________

_______

___________

___________

85+

___________

___________

_______

___________

___________

Unknown

___________

Surgery

Total:

_______

___________

___________

___________

_______

___________

___________

10-19

___________

___________

_______

___________

___________

20-44

___________

___________

_______

___________

___________

45-64

___________

___________

_______

___________

___________

Unknown

___________

Maternity

Total:

___________

_______
___________

_______

___________
___________

___________

HEDIS 2010, Volume 2

Ambulatory Care (AMB)
SUMMARY OF CHANGES TO HEDIS 2010
Added CPT code 99461 to Table AMB-A.

Description
This measure summarizes utilization of ambulatory care in the following categories.
Outpatient Visits
ED Visits
Ambulatory Surgery/Procedures
Observation Room Stays

Calculations
Product lines

Report the following tables for each applicable product line.
Table AMB-1a

Total Medicaid

Table AMB-1b

Medicaid/Medicare Dual-Eligibles

Table AMB-1c

Medicaid—Disabled

Table AMB-1d

Medicaid—Other Low Income

Table AMB-2

Commercial—by Product or Combined HMO/POS

Table AMB-3

Medicare

Member months

For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.

Counting multiple
services

For ambulatory surgery/procedures that occur on the same date of service as an
ED visit, report as a single ED visit.
For Observation Room visits that occur on the same date of service as an
ambulatory surgery/procedure, report as a single ambulatory surgery/procedure.
For Observation Room visits that occur on the same date of service as an ED visit,
report as a single ED visit.
For all other combinations of multiple ambulatory services falling in different
categories on the same day, report each service that meets the criteria in the
appropriate category.

____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Outpatient visits

Use Table AMB-A to identify outpatient visits. Count each occurrence of the CPT
codes listed in Table AMB-A if rendered by different practitioners (a CPT code may
count more than once on the same date of service if rendered by different
practitioners).
Report services without regard to practitioner type, training or licensing. Include
office-based surgical procedures (use the Ambulatory Surgery/Procedures codes in
Table AMB-C and include surgeries conducted at the practitioner’s office).

Table AMB-A: Codes to Identify Outpatient Visits
Description

CPT

UB Revenue

Office or other outpatient visits

99201-99205, 99211-99215, 99241-99245

Home visits
Nursing facility care
Domiciliary or rest home care
Preventive medicine

99341-99345, 99347-99350
99304-99310, 99315, 99316, 99318
99324-99328, 99334-99337
99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420,
99429
99432, 99461
92002, 92004, 92012, 92014

Newborn care
Ophthalmology and optometry

ED visits

051x, 052x,
0982, 0983

Use Table AMB-B to identify ED visits. Count once each visit to an ED that does not
result in an inpatient stay, regardless of the intensity or duration of the visit. Count
multiple ED visits on the same date of service as one visit.

Table AMB-B: Codes to Identify ED Visits
CPT

UB Revenue

99281-99285

045x, 0981
OR

CPT
10040-69979

Ambulatory
surgery/
procedures

WITH

POS
23

Use Table AMB-C to identify ambulatory surgeries/procedures. Identify encounters
using Option A or Option B. Option A is the preferred method for this measure,
though when necessary, the organization should use Option A and Option B.
Report only ambulatory surgeries/procedures performed at a hospital outpatient
facility or at a free-standing surgery center. Do not report office-based surgeries/
procedures in this category; report them under Outpatient Visits. Count multiple
ambulatory surgeries/procedures on the same date of service as one ambulatory
surgery/procedure.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table AMB-C: Codes to Identify Ambulatory Surgery/Procedures
Option A
CPT

POS

All codes included in the CMS 2009 ASC Approved HCPCS Codes and Payment Rates file* and
92953, 92970, 92971, 92975, 92980, 92982, 92986, 92990, 92992, 92993, 92995, 92996, 9350193533, 93600-93652

22, 24

WITH

Option B
ICD-9-CM Procedure
01-86, 88.4, 88.5, 98.5

WITH

UB Revenue

WITH

0320, 0321, 0323, 036x, 0480, 0481, 049x, 075x, 079x

UB Type of Bill
13x, 83x

* The CMS 2009 ASC Approved HCPCS Codes and Payment Rates files are available on the CMS Web site
(http://www.cms.hhs.gov/ASCPayment/) under the Addenda Updates section. Use the file that was valid at the end of the measurement
year.

Observation
Room stays

Use Table AMB-D to identify Observation Room stays.
Count once, each observation visit that does not result in an inpatient stay, regardless
of the intensity or duration of the visit. Count multiple observation visits on the same
date of service as one visit.

Table AMB-D: Codes to Identify Observation Room Stays
CPT

UB Revenue

99217-99220

0762

Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude from all categories
claims and encounters that contain any code in Table AMB-E.

Table AMB-E: Codes to Identify Exclusions
CPT

Principal ICD-9-CM Diagnosis

90801-90899

290-316

Principal ICD-9-CM Diagnosis
960-979

WITH

ICD-9-CM Procedure
94.26, 94.27, 94.6

Secondary ICD-9-CM Diagnosis
291-292, 303-305

Note
This measure provides a reasonable proxy for professional ambulatory encounters. It is neither a strict
accounting of all ambulatory resources nor an effort to be all-inclusive.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table AMB-1: Ambulatory Care
Age

Member Months

<1

______________

1-9

______________

10-19

______________

20-44

______________

45-64

______________

65-74

______________

75-84

______________

85+

______________

Unknown

______________

Total:

Outpatient Visits

ED Visits

______________

Ambulatory Surgery/
Procedures
Procedures/
1,000
Member
Procedures
Months

Observation Room Stays

Visits

Visits/1,000
Member
Months

Visits

Visits/1,000
Member
Months

Stays

Stays/
1,000 Member
Months

<1

_____

_______

_____

_______

_______

______

______

_______

1-9

_____

_______

_____

_______

_______

______

______

_______

10-19

_____

_______

_____

_______

_______

______

______

_______

20-44

_____

_______

_____

_______

_______

______

______

_______

45-64

_____

_______

_____

_______

_______

______

______

_______

65-74

_____

_______

_____

_______

_______

______

______

_______

75-84

_____

_______

_____

_______

_______

______

______

_______

85+

_____

_______

_____

_______

_______

______

______

_______

Unknown

_____

Total:

_____

Age

_____
_______

_____

_______
_______

_______

______
______

______

_______

HEDIS 2010, Volume 2

Table AMB-2/3: Ambulatory Care
Age

Member Months

<1

______________

1-9

______________

10-19

______________

20-44

______________

45-64

______________

65-74

______________

75-84

______________

85+

______________

Unknown

______________
Total:

______________

Ambulatory Surgery/
Procedures
Procedures/
1,000
Member
Procedures
Years

Observation Room
Stays

Outpatient Visits
Visits/
1,000
Member
Visits
Years

ED Visits
Visits/
1,000
Member
Visits
Years

Stays

Stays/
1,000 Member
Years

<1

_____

_______

_____

_______

______

_______

______

_______

1-9

_____

_______

_____

_______

______

_______

______

_______

10-19

_____

_______

_____

_______

______

_______

______

_______

20-44

_____

_______

_____

_______

______

_______

______

_______

45-64

_____

_______

_____

_______

______

_______

______

_______

65-74

_____

_______

_____

_______

______

_______

______

_______

75-84

_____

_______

_____

_______

______

_______

______

_______

85+

_____

_______

_____

_______

______

_______

______

_______

Unknown

_____

Age

Total:

_____

_____
_______

_____

______
_______

______

______
_______

______

_______

HEDIS 2010, Volume 2

Inpatient Utilization—Nonacute Care (NON)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
This measure summarizes utilization of nonacute inpatient care in hospice, nursing home, rehabilitation, SNF,
transitional care and respite.

Calculations
Product lines

Report the following tables for each applicable product line.
Table NON-1a

Total Medicaid

Table NON-1b

Medicaid/Medicare Dual-Eligibles

Table NON-1c

Medicaid—Disabled

Table NON-1d

Medicaid—Other Low Income

Table NON-2

Commercial—by Product or Combined HMO/POS

Table NON-3

Medicare

Member months

For each product line and table, report all member months for the measurement
year. IDSS automatically produces member years data for the commercial and
Medicare product lines. Refer to Specific Instructions for Use of Services Tables
for more information.

Discharges

Refer to the codes listed in Table NON-A to report discharges for nonacute
inpatient care.

Table NON-A: Codes to Identify Nonacute Care
Description

UB Revenue

UB Type of Bill

Hospice

0115, 0125, 0135, 0145, 0155, 0650, 0656, 0658, 0659

81x, 82x

SNF

019x

21x, 22x, 28x

Hospital transitional care, swing bed
or rehabilitation

18x

Rehabilitation

0118, 0128, 0138, 0148, 0158

Respite

0655

Other nonacute care facilities that do not use the UB revenue or type of bill codes for billing (e.g., ICF, SNF)

Days

Count all days associated with the identified discharges.

ALOS

Refer to Specific Instructions for Use of Services Tables for the formula.

Total nonacute
inpatient care

Use the codes in Table NON-A to identify nonacute care. Include care from any
institution that provides long-term/specialty nonacute care.

HEDIS 2010, Volume 2

Exclusions (required)
The measure does not include mental health or chemical dependency services. Exclude claims and
encounters that contain any of the following codes.

Table NON-B: Codes to Identify Exclusions
CPT

Principal ICD-9-CM Diagnosis

ICD-9-CM Procedure

90801-90899

290-316

94.26, 94.27, 94.6

Principal ICD-9-CM Diagnosis
960-979

WITH

Secondary ICD-9-CM Diagnosis
291-292, 303-305

Table NON-1: Inpatient Utilization—Nonacute Care
Age

Member Months

<1

______________

1-9

______________

10-19

______________

20-44

______________

45-64

______________

65-74

______________

75-84

______________

85+

______________

Unknown

______________
Total:

______________

Discharges

Discharges/1,000
Member Months

Days

Days/1,000
Member Months

Average Length
of Stay

<1

_____________

_____________

_______

_____________

____________

1-9

_____________

_____________

_______

_____________

____________

10-19

_____________

_____________

_______

_____________

____________

20-44

_____________

_____________

_______

_____________

____________

45-64

_____________

_____________

______

_____________

____________

65-74

_____________

_____________

_______

_____________

____________

75-84

_____________

_____________

_______

_____________

____________

85+

_____________

_____________

_______

_____________

____________

Unknown

_____________

Age

Total:

_____________

_______
_____________

_______

____________
_____________

____________

____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table NON-2/3: Inpatient Utilization—Nonacute Care
Age

Member Months

<1

______________

1-9

______________

10-19

______________

20-44

______________

45-64

______________

65-74

______________

75-84

______________

85+

______________

Unknown

______________
Total:

______________

Discharges

Discharges/1,000
Member Years

Days

Days/1,000
Member Years

Average Length
of Stay

<1

____________

_____________

_______

_____________

____________

1-9

_____________

_____________

_______

_____________

____________

10-19

_____________

_____________

_______

_____________

____________

20-44

_____________

_____________

_______

_____________

____________

45-64

_____________

_____________

_______

_____________

____________

65-74

_____________

_____________

_______

_____________

____________

75-84

_____________

_____________

_______

_____________

____________

85+

_____________

_____________

_______

_____________

____________

Unknown

_____________

Age

Total:

_____________

_______
_____________

_______

____________
_____________

____________

HEDIS 2010, Volume 2

Mental Health Utilization (MPT)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Table MPT-B.
Deleted CPT codes 90871, 99261-99263 from Table MPT-C.
Added CPT codes 96102, 96103, 96105, 96119, 96120, 96125 to Table MPT-D.
Deleted CPT code 90871 from Table MPT-D.

Description
The number and percentage of members receiving the following mental health services during the
measurement year.
Any services
Inpatient
Intensive outpatient or partial hospitalization
Outpatient or ED

Calculations
Product lines

Report the following tables for each applicable product line.
Table MPT-1a

Total Medicaid

Table MPT-1b

Medicaid/Medicare Dual-Eligibles

Table MPT-1c

Medicaid—Disabled

Table MPT-1d

Medicaid—Other Low Income

Table MPT-2

Commercial—by Product or Combined HMO/POS

Table MPT-3

Medicare

Count members who received inpatient, intensive outpatient, partial hospitalization,
outpatient and ED mental health services in each column. Count members only
once in each column, regardless of number of visits.
Count members in the Any Services column only if they had at least one inpatient,
intensive outpatient, partial hospitalization, outpatient or ED claim/encounter during
the measurement year.
For members who have had more than one encounter, count only the first visit in
the measurement year and report the member in the respective age category as of
the date of service or discharge.
Benefit

Mental health.

____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Member months

For each product line and table, report all member months during the measurement
year for members with the benefit. IDSS automatically produces member years data
for the commercial and Medicare product lines. Refer to Specific Instructions for
Use of Services Tables for more information.
Because some organizations may offer different benefits for inpatient and outpatient
mental health services, denominators in the columns of the member months table
may vary. The denominator in the Any column should include all members with any
mental health benefit.

Inpatient

Include inpatient care at either a hospital or treatment facility with mental health as
the principal diagnosis.
Use one of the following criteria to identify inpatient services.
An inpatient facility code in conjunction with a principal mental health diagnosis
(Table MPT-A), or
DRGs (Table MPT-B)
Include discharges associated with residential care and rehabilitation.

Table MPT-A: Codes to Identify Mental Health Diagnosis
ICD-9-CM Diagnosis
290, 293-302, 306-316

Note: DSM-IV codes mirror ICD-9-CM codes. A health plan that has access only to DSM-IV codes should use
and document them. Follow the specifications outlined above for ICD-9-CM codes.

Table MPT-B: Codes to Identify Inpatient Services
MS—DRG
876, 880-887; exclude discharges with ICD-9-CM Principal
Diagnosis code 317-319

Intensive outpatient and partial
hospitalization

Report intensive outpatient and partial hospitalization claims/encounters (Table
MPT-C) in conjunction with a principal mental health diagnosis (Table MPT-A).
Count services provided by physicians and nonphysician practitioners.
Exclude any services the health plan knows to be inpatient based on type of bill,
place of service or location of service codes.

HEDIS 2010, Volume 2

Table MPT-C: Codes to Identify Intensive Outpatient and Partial Hospitalization Services
HCPCS

UB Revenue

Visits identified by the following HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental health
practitioner (the organization does not need to determine practitioner type).
H0035, H2001, H2012, S0201, S9480

0905, 0907, 0912, 0913,

CPT

POS

90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853, 90857,
90862, 90870, 90875, 90876

WITH

52, 53*

WITH

52, 53*

Visits identified by the following CPT/POS codes must be with a mental health practitioner.
99221-99223, 99231-99233, 99238, 99239, 99251-99255

* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an intensive outpatient or partial hospitalization setting.

Report outpatient and ED claims/encounters (Table MPT-D) in conjunction with a
principal mental health diagnosis (Table MPT-A). Count services provided by
physicians and nonphysicians.

Outpatient
and ED

Only include observation stays and ED visits that do not result in an inpatient stay.

Table MPT-D: Codes to Identify Outpatient and ED Services
CPT

HCPCS

UB Revenue

Visits identified by the following CPT, HCPCS, UB Revenue and CPT/POS codes may be with a mental health or non-mental
health practitioner (the organization does not need to determine practitioner type).
90804-90815, 96101-96103, 96105, 96110,
96111, 96116, 96118-96120, 96125CPT

G0155, G0176, G0177, H0002, H0004, H0031,
H0034, H0036, H0037, H0039, H0040, H2000,
H2010, H2011, H2013-H2020, M0064, S9484,
S9485

90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876

WITH

CPT

0513, 0900-0904, 0911, 09140919

POS
03, 05, 07, 09, 11, 12, 13, 14,
15, 20, 22, 23, 33, 49, 50, 53*,
71, 72

UB Revenue

Visits identified by the following CPT and UB Revenue codes must be with a mental health practitioner.
98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 9928199285, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411,
99412, 99420, 99510

045x, 0510, 0515-0517, 0519-0523, 05260529, 0762, 077x, 0981-0983

* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an outpatient setting.

____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table MPT-1/2/3: Mental Health Utilization
Member Months (Any Services)
Male
Female

Age

Total

Male

Member Months (Inpatient)
Female

Total

0-12

_________

_________

_________

_________

_________

________

13-17

_________

_________

_________

_________

_________

________

18-64

_________

_________

_________

_________

_________

________

65+

_________

_________

_________

_________

_________

________

Unknown

_________

_________

_________

_________

_________

________

_________

_________

_________

_________

_________

________

Total:

Member Months (Intensive Outpatient/Partial Hospitalization)
Age
Male
Female
Total

Member Months (Outpatient/ED)
Male
Female
Total

0-12

_________

_________

_________

_________

_________

________

13-17

_________

_________

_________

_________

_________

________

18-64

_________

_________

_________

_________

_________

________

65+

_________

_________

_________

_________

_________

________

Unknown

_________

_________

_________

_________

_________

________

_________

_________

_________

_________

_________

________

Total:

Age
0-12

Any Services
Number
Percent

Inpatient
Number
Percent

Intensive
Outpatient/Partial
Hospitalization
Number
Percent

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

______

______

______

______

______

______

______

______

Female

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Sex

Total:
13-17

Total:
18-64

Total:
65+

Total:
Unknown

Total:
Total

Total:

Outpatient/ED
Number
Percent

HEDIS 2010, Volume 2

Identification of Alcohol and Other Drug Services (IAD)
SUMMARY OF CHANGES TO HEDIS 2010
Removed CMS-DRGs from Table IAD-B.
Deleted CPT codes 90871, 99261-99263 from Table IAD-C.
Added CPT codes 96102, 96103, 96105, 96119, 96120, 96125 to Table IAD-D.
Deleted CPT code 90871 from Table IAD-D.

Description
This measure summarizes the number and percentage of members with an alcohol and other drug (AOD)
claim who received the following chemical dependency services during the measurement year.
Any services
Inpatient
Intensive outpatient or partial hospitalization
Outpatient or ED

Calculations
Product lines

Report the following tables for each applicable product line.
Table IAD-1a

Total Medicaid

Table IAD-1b

Medicaid/Medicare Dual-Eligibles

Table IAD-1c

Medicaid—Disabled

Table IAD-1d

Medicaid—Other Low Income

Table IAD-2

Commercial—by Product or Combined HMO/POS

Table IAD-3

Medicare

Count members who received inpatient, intensive outpatient, partial hospitalization,
outpatient and ED chemical dependency services in each column. Count members
in each column only once, regardless of number of visits.
Count members in the Any Services column only if they had at least one inpatient,
intensive outpatient, partial hospitalization, outpatient or ED claim/encounter during
the measurement year.
For members who had more than one encounter, count only the first visit in the
measurement year and report the member in the respective age category as of the
date of service or discharge.
Benefit

Chemical dependency.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2009, Volume 2

Member months

For each product line, report all member months during the measurement year for
members with the benefit. IDSS automatically produces member years data for the
commercial and Medicare product lines. Refer to Specific Instructions for Use of
Services Tables for more information.
Because some organizations may offer different benefits for inpatient and outpatient
chemical dependency services, denominators in the columns of the member
months table may vary. The denominator in the Any column should include all
members with any chemical dependency benefit.
Include inpatient care, including inpatient detoxification, at either a hospital or
treatment facility with any diagnosis of chemical dependency.

Inpatient

Use one of the following criteria to identify inpatient services.
An inpatient facility code in conjunction with any diagnosis of chemical
dependency (Table IAD-A), or
A code in Table IAD-B
Include discharges associated with residential care and rehabilitation.

Table IAD-A: Codes to Identify Chemical Dependency Diagnosis
ICD-9-CM Diagnosis
291-292, 303-304, 305.0, 305.2-305.9, 535.3, 571.1

Table IAD-B: Codes to Identify Inpatient Services
ICD-9-CM Procedure

MS—DRG

94.6x WITH an inpatient facility code

894-897

Intensive outpatient and partial
hospitalization

Report intensive outpatient and partial hospitalization claims/encounters (Table
IAD-C) in conjunction with any chemical dependency diagnosis (Table IAD-A).
Count services provided by physician and nonphysician practitioners.
Intensive outpatient and partial hospitalization are reported separate from outpatient
and ED services because these programs represent a significant number of
services rendered.
Exclude any services the health plan knows to be inpatient based on type of bill,
place of service or location of service codes.

HEDIS 2010, Volume 2

Table IAD-C: Codes to Identify Intensive Outpatient and Partial Hospitalization Services
HCPCS

UB Revenue

Visits identified by the following HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental health
practitioner (i.e., the organization does not need to determine practitioner type).
H0015, H0035, H2001, H2012, S0201, S9480

0905-0907, 0912, 0913

CPT

POS

90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853,
90857, 90862, 90870, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 9925199255

WITH

52, 53*

*POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an intensive outpatient or partial hospitalization setting.

Outpatient
and ED

Report outpatient and ED claims/encounters (Table IAD-D) in conjunction with any
chemical dependency diagnosis (Table IAD-A).
Count services provided by physicians and nonphysician practitioners.
Only include observation stays and ED visits that do not result in an inpatient stay.

Table IAD-D: Codes to Identify Outpatient and ED Services
CPT

HCPCS

UB Revenue

Visits identified by the following CPT, HCPCS, UB revenue and CPT/POS codes may be with a mental health or non-mental
health practitioner (i.e., the organization does not need to determine practitioner type).
90804-90815, 96101-96103, 96105, 96110, 96111,
96116, 96118-96120, 96125, 98960-98962, 99078,
99201-99205, 99211-99215, 99217-99220, 9924199245, 99281-99285, 99341-99345, 99347-99350,
99381-99387, 99391-99397, 99401-99404, 99408,
99409, 99411, 99412, 99420, 99510

G0155, G0176, G0177, G0396, G0397, H0001,
H0002, H0004, H0005, H0007, H0012-H0014,
H0016, H0020, H0022, H0031, H0034, H0036,
H0037, H0039, H0040, H0049, H0050, H2000,
H2010, H2011, H2013-H2020, H2035, H2036,
M0064, S9475, S9484, S9485, T1006, T1012

CPT
90801, 90802, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875,
90876

045x, 0510, 0513, 05150517, 0519-0523, 05260529, 0762, 077x, 09000904, 0911, 0914-0919,
0944, 0945, 0981-0983

POS
WITH

03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 23,
33, 49, 50, 53*, 57, 71, 72

* POS 53 identifies visits that occur in an outpatient, intensive outpatient or partial hospitalization setting. If the organization uses POS 53 for
reporting, it must have a system to confirm the visit was in an outpatient setting.

_____________
Current Procedural Terminology © 2009 American Medical Association. All rights reserved.

HEDIS 2010, Volume 2

Table IAD-1/2/3: Identification of Alcohol and Other Drug Services
Member Months (Any Services)
Male
Female

Age

Total

Male

Member Months (Inpatient)
Female

Total

0-12

_________

_________

_________

_________

_________

________

13-17

_________

_________

_________

_________

_________

________

18-24

_________

_________

_________

_________

_________

________

25-34

_________

_________

_________

_________

_________

________

35-64

_________

_________

_________

_________

_________

________

65+

_________

_________

_________

_________

_________

________

Unknown

_________

_________

_________

_________

_________

________

_________

_________

_________

_________

_________

________

Total:

Member Months (Intensive Outpatient/Partial Hospitalization)
Age
Male
Female
Total

Member Months (Outpatient/ED)
Male
Female
Total

0-12

_________

_________

_________

_________

_________

________

13-17

_________

_________

_________

_________

_________

________

18-24

_________

_________

_________

_________

_________

________

25-34

_________

_________

_________

_________

_________

________

35-64

_________

_________

_________

_________

_________

________

65+

_________

_________

_________

_________

_________

________

Unknown

_________

_________

_________

_________

_________

________

_________

_________

_________

_________

_________

________

Total:

Age
0-12

Any Services
Number
Percent

Inpatient
Number
Percent

Intensive
Outpatient/Partial
Hospitalization
Number
Percent

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

______

______

______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Sex

Total:
13-17

Total:
18-24

Total:
25-34

Total:

Outpatient/ED
Number
Percent

HEDIS 2010, Volume 2

Table IAD-1/2/3: Identification of Alcohol and Other Drug Services (continued)

Age
35-64

Any Services
Number
Percent

Inpatient
Number
Percent

Intensive
Outpatient/Partial
Hospitalization
Number
Percent

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

______

______

______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Sex

Total:
65+

Total:
Unkno
wn

Total

Total:

Total:

Outpatient/ED
Number
Percent

HEDIS 2010, Volume 2

Outpatient Drug Utilization (ORX)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age, during
measurement year. The following data are reported.
Total cost of prescriptions
Average cost of prescriptions PMPM
Total number of prescriptions
Average number of prescriptions PMPY

Calculations
Product lines

Report the following tables for each applicable product line.
Table ORX-1a

Total Medicaid

Table ORX-1b

Medicaid/Medicare Dual-Eligibles

Table ORX-1c

Medicaid—Disabled

Table ORX-1d

Medicaid—Other Low Income

Table ORX-2

Commercial—by Product or Combined HMO/POS

Table ORX-3

Medicare

Age

Age as of the date the prescription is dispensed.

Benefit

Pharmacy.

Member
months

Report all member months for the measurement year for members with the benefit.
Refer to Specific Instructions for Use of Services Tables.

Prescription

One 30-day (or less) supply of pharmaceuticals.* Supplies (e.g., syringes) do not count
toward this measure.
* To calculate dispensing events for prescriptions longer than 30 days, divide the days
supply by 30 and round up to convert. For example, a 100-day prescription is equal to
4 dispensing events (100/30 = 3.33, rounded up to 4).

Formulas

Total cost of prescriptions = Discounted ingredient cost + dispensing or professional
fees + administrative fees – formulary or other rebates.
The plan may be responsible for part of the total prescription cost and the member may
be responsible for the remainder of the total cost. The total cost of prescriptions may be
alternatively calculated as:
Total cost of prescriptions = plan cost + member cost.

HEDIS 2010, Volume 2

Average total cost of prescriptions per member per month = [Discounted ingredient
costs (before member copayments or deductibles) + dispensing or professional fees +
administrative fees – formulary or other rebates]/member months for members with a
pharmacy benefit.
Alternatively, average total cost of prescriptions = [plan costs + member costs]/ member
months for members with a pharmacy benefit. For example, the average wholesale price
for prescription ―X‖ is $50. The plan negotiates a 20 percent discount with the pharmacy.
There is a $5 dispensing fee and member copay is $4. Assuming no administrative
fees or other rebates or formularies, the discounted ingredient cost is $40 ($50 average
wholesale price less the 20 percent discount). The total cost of prescriptions is $45 ($40
discounted ingredient cost + $5 dispensing fee). While the cost to the member is $4 and
the plan cost is $41 (for a total of $45), the breakdown of total prescription cost between
the plan and the member is not reported.
Average total number of prescriptions per member per year = [Total number of
prescriptions/member months for members with a pharmacy benefit] 12 months.

Note
Results of this measure might be affected by differences in pharmacy benefits across health plans.
A health plan that dispenses rebates on a lump-sum basis should average the rebates over the total number
of prescriptions.

Table ORX-1/2/3: Outpatient Drug Utilization
Age

Member Months

0-9

______________

10-17

______________

18-34

______________

35-49

______________

50-64

______________

65-74

______________

75-84

______________

85+

______________

Unknown

______________

Total:

______________

HEDIS 2010, Volume 2

Table ORX-1/2/3: Outpatient Drug Utilization (continued)
Total Cost of
Prescriptions

Average Cost of
Prescriptions PMPM

Total Number of
Prescriptions

Average Number of
Prescriptions PMPY

0-9

______________

______________

______________

______________

10-17

______________

______________

______________

______________

18-34

______________

______________

______________

______________

35-49

______________

______________

______________

______________

65-74

______________

______________

______________

______________

75-84

______________

______________

______________

______________

85+

______________

______________

______________

______________

Unknown

______________

Total:

______________

Age

50-64

______________
______________

______________

______________

HEDIS 2010, Volume 2

Antibiotic Utilization (ABX)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
This measure summarizes the following data on outpatient utilization of antibiotic prescriptions during the
measurement year, stratified by age and gender.
Total number of antibiotic prescriptions
Average number of antibiotic prescriptions per member per year (PMPY)
Total days supplied for all antibiotic prescriptions
Average days supplied per antibiotic prescription
Total number of prescriptions for antibiotics of concern
Average number of prescriptions PMPY for antibiotics of concern
Percentage of antibiotics of concern for all antibiotic prescriptions
Average number of antibiotics PMPY reported by drug class:
For selected ―antibiotics of concern‖
For all other antibiotics
Note: NCQA will provide a list of NDC codes for antibiotic medications on its Web site (www.ncqa.org) by
November 16, 2009.

Measure Attributes
Product lines

Report the following tables for each applicable product line.
Table ABX-1a

Total Medicaid

Table ABX-1b

Medicaid/Medicare Dual-Eligibles

Table ABX-1c

Medicaid—Disabled

Table ABX-1d

Medicaid—Other Low Income

Table ABX-2

Commercial—by Product or Combined HMO/POS

Table ABX-3

Medicare

Report the information in Tables ABX-1/2/3 (a–c) by age and sex.
Age

Age as of the date the prescription is dispensed.

Benefit

Pharmacy.

Member months

Report all member months for the measurement year for members with the benefit.
IDSS automatically produces member years data for all product lines: Medicaid,
commercial and Medicare. Refer to Specific Instructions for Use of Services Tables.

Antibiotic
prescription

A dispensed antibiotic for any duration.

HEDIS 2010, Volume 2

Calculations
Total number
of antibiotic
prescriptions

Total number of all antibiotic prescriptions for the measurement year of any
duration of the medication.

Average number
of antibiotic
prescriptions PMPY

Annual total number of antibiotic prescriptions PMPY = [Total number of antibiotic
prescriptions in the year/member months for members with a pharmacy benefit]
12 months.

Total days supplied
for all antibiotic
prescriptions

Count the number of days supplied for all antibiotic prescriptions during the
measurement year. Organizations should identify the number of days supplied for
each antibiotic prescription and sum the days for all antibiotic prescriptions during
the measurement year.

Average number
of days supplied
per antibiotic
prescription

Average number of days supplied per prescription = [Total days supplied for
all antibiotics prescription in the year/Total number of antibiotic prescriptions in
the year].

Table ABX-A: Antibiotic Medications
Description
Antibiotics of concern

All other antibiotics

Prescription
amoxicillin-clavulanate
azithromycin
aztreonam
clarithromycin
cefaclor
cefdinir
cefditoren
cefepime
cefixime
cefotaxime
cefotetan
cefoxitin
amikacin
amoxicillin
ampicillin
ampicillin-sulbactam
carbenicillin
cefadroxil
cefazolin
cephalexin
cephradine
daptomycin
doxycycline
erythromycin
erythromycin estolate
erythromycin ethylsuccinate
erythromycin lactobionate
erythromycin stearate

cefpodoxime
cefprozil
ceftazidime
ceftibuten
ceftizoxime
ceftriaxone
cefuroxime
clindamycin
chloramphenicol
ciprofloxacin
dalfopristin-quinupristin
gatifloxacin
erythromycin-sulfisoxazole
fosfomycin
gentamicin
kanamycin
lincomycin
metronidazole
minocycline
nafcillin
nitrofurantoin
nitrofurantoin macrocrystals
dicloxacillin
oxacillin
penicillin G benzathine
penicillin G potassium
penicillin G procaine
penicillin G sodium

gemifloxacin
levofloxacin
lomefloxacin
moxifloxacin
loracarbef
linezolid
norfloxacin
ofloxacin
sparfloxacin
telithromycin
vancomycin
penicillin V potassium
piperacillin
piperacillin-tazobactam
rifampin
sulfadiazine
sulfamethoxazole-trimethoprim
sulfasalazine
sulfisoxazole
tetracycline
ticarcillin
ticarcillin-clavulanate
streptomycin
tobramycin
trimethoprim

HEDIS 2010, Volume 2

Calculations for Antibiotics of Concern
Total number of
prescriptions for
antibiotics of concern

Total number of all prescriptions for antibiotics of concern during the
measurement year. Table ABX-B contains all antibiotics of concern.

Average number of
prescriptions PMPY for
antibiotics of concern

Annual total number of prescriptions for antibiotics of concern per member per
year = [Annual number of prescriptions for antibiotics of concern/member
months for members with a pharmacy benefit] 12 months.

Percentage of
antibiotics of concern
of all antibiotic
prescriptions

Percentage of prescriptions for antibiotics of concern of all antibiotic
prescriptions = [Total number of prescriptions for antibiotics of concern in the
year/Total number of antibiotic prescriptions in the year].

Table ABX-B: Antibiotics of Concern by NCQA Drug Class
Description

Prescription

Quinolone

ciprofloxacin
gatifloxacin
gemifloxacin

levofloxacin
lomefloxacin
moxifloxacin

norfloxacin
ofloxacin
sparfloxacin

Azithromycin and clarithromycin

azithromycin

clarithromycin

Cephalosporin (second, third,
fourth generation)

cefaclor
cefdinir
cefditoren
cefepime
cefixime
cefotaxime

cefotetan
cefoxitin
cefpodoxime
cefprozil
ceftazidime
ceftibuten

ceftizoxime
ceftriaxone
cefuroxime
loracarbef

Amoxicillin/clavulanate

amoxicillin-clavulanate

Ketolide

telithromycin

Clindamycin

clindamycin

Miscellaneous antibiotics of
concern

aztreonam
chloramphenicol

dalfopristin-quinupristin
linezolid

vancomycin

Calculations for Reporting by Drug Class
Antibiotic utilization
by drug class

For each product line, report the utilization of antibiotic prescriptions by drug class
in Tables ABX-1/2/3(b) and (c) for the following.
Antibiotics of concern
All other antibiotics

Antibiotics of
concern

Report the utilization of antibiotics of concern by the following antibiotic drug
classes in Table ABX-1/2/3(b).
Amoxicillin/clavulanate
Azithromycin and clarithromycin
Cephalosporin (includes second-, third- and fourth-generation cephalosporins)
Clindamycin

HEDIS 2010, Volume 2

Ketolide
Quinolone
Miscellaneous antibiotics of concern
Refer to Table ABX-B for a list of antibiotics of concern and therapeutic classes.
All other antibiotics

Report the utilization of all other antibiotics by the following antibiotic drug classes
in Table ABX-1/2/3(c).
Absorbable sulfonamide
Aminoglycoside
Cephalosporin (includes first generation only)
Lincosamide (other than clindamycin)
Macrolide (other than azithromycin and clarithromycin)
Penicillin (other than amoxicillin/clavulanate)
Tetracycline
Miscellaneous antibiotics
Refer to Table ABX-C for a list of all other antibiotics of concern and therapeutic
classes.

Table ABX-C: All Other Antibiotics by NCQA Drug Class
Description

Prescription

Absorbable sulfonamide

sulfadiazine
sulfamethoxazole-trimethoprim

sulfasalazine
sulfisoxazole

Aminoglycoside

amikacin
gentamicin

kanamycin
streptomycin

Cephalosporin (first generation)

cefadroxil
cefazolin

cephalexin
cephradine

Lincosamide (other than clindamycin)

lincomycin

Macrolide (other than azithromycin and
clarithromycin)

erythromycin
erythromycin estolate
erythromycin ethylsuccinate

erythromycin lactobionate
erythromycin stearate
erythromycin-sulfisoxazole

Penicillin (other than amoxicillin/
clavulanate)

ampicillin
ampicillin-sulbactam
amoxicillin
carbenicillin
dicloxacillin
nafcillin
oxacillin
penicillin G benzathine

penicillin G potassium
penicillin G procaine
penicillin G sodium
penicillin V potassium
piperacillin
piperacillin-tazobactam
ticarcillin
ticarcillin-clavulanate

Tetracyclines

doxycycline

minocycline

Miscellaneous antibiotics

daptomycin
fosfomycin
metronidazole
nitrofurantoin

nitrofurantoin macrocrystals
rifampin
trimethoprim

tobramycin

tetracycline

HEDIS 2010, Volume 2

Table ABX-1/2/3: Plan Member Months
Age

Male

Member Months
Female

Total

0-9

_________

_________

_________

10-17

_________

_________

_________

18-34

_________

_________

_________

35-49

_________

_________

_________

50-64

_________

_________

_________

65-74

_________

_________

_________

85+

_________

_________

_________

Unknown

_________

_________

_________

_________

_________

_________

75-84

Total:

Table ABX-1/2/3(a): Antibiotic Utilization
Age
0-9

Total Antibiotic
Scrips

Average Scrips
for Antibiotics
PMPY

Total Days
Supplied for All
Antibiotic Scrips

Average Days
Supplied per Antibiotic Scrip

Total Scrips for
Antibiotics of
Concern

Average Scrips
for Antibiotics of
Concern PMPY

% of Antibiotics of
Concern of All
Antibiotic Scrips

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Sex

Total:

10-17

Total:

18-34

Total:

HEDIS 2010, Volume 2

Table ABX-1/2/3(a): Antibiotic Utilization (continued)
Age
35-49

Total Antibiotic
Scrips

Average Scrips
for Antibiotics
PMPY

Total Days
Supplied for All
Antibiotic Scrips

Average Days
Supplied per Antibiotic Scrip

Total Scrips for
Antibiotics of
Concern

Average Scrips
for Antibiotics of
Concern PMPY

% of Antibiotics of
Concern of All
Antibiotic Scrips

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Male

__________

___________

___________

___________

___________

___________

_________%

Female

__________

___________

___________

___________

___________

___________

_________%

__________

___________

___________

___________

___________

___________

_________%

Sex

Total:

50-64

Total:

65-74

Total:

75-84

Total:

85+

Total:

Unknown

Total:
Total

Total:

HEDIS 2010, Volume 2

Table ABX-1/2/3(b): Antibiotics of Concern Utilization by Drug Class

Age

0-9

10-17

18-34

35-49

50-64

65-74

75-84

Total
Azithromycin &
Clarithromycin
Scrips

Avg
Scrips
for
Azithromycin &
Clarithromycin
PMPY

Total
Amoxicillin/
Clavulanate
Scrips

Avg
Scrips
PMPY
for
Amoxicillin/
Clavulanate
PMPY

Total
Quinolone
Scrips

Avg
Scrips
for
Quinolone
PMPY

Total
Cephalosporin
Scrips

Avg
Scrips
for
Cephalosporin
PMPY

Male

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

Total:

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

Total:

_______

_______

_______

_______

Male

_______

_______

_______

Female

_______

_______

Total:

_______

_______

Male

_______

Female
Total:

Total
Misc
Antibiotics
of
Concern
Scrips

Avg
Scrips
for Misc
Antibiotics
of
Concern
PMPY

Total
Ketolide
Scrips

Avg
Scrips
for
Ketolide
PMPY

Total
Clindamycin
Scrips

Avg
Scrips
for
Clindamycin
PMPY

_______

_______

______

______

______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Total:

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Total:

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Male

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Female

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Total:

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

Sex

HEDIS 2010, Volume 2

Table ABX-1/2/3(b): Antibiotics of Concern Utilization by Drug Class (continued)

Age

85+

Unknown

Total:

Total
Azithromycin &
Clarithromycin
Scrips

Avg
Scrips
for
Azithromycin &
Clarithromycin
PMPY

Total
Amoxicillin/
Clavulanate
Scrips

Avg
Scrips
PMPY
for
Amoxicillin/
Clavulanate
PMPY

Total
Quinolone
Scrips

Avg
Scrips
for
Quinolone
PMPY

Total
Cephalosporin
Scrips

Avg
Scrips
for
Cephalosporin
PMPY

Male

_______

_______

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

_______

_______

Total:

_______

_______

_______

_______

_______

_______

Male

_______

_______

_______

_______

_______

Female

_______

_______

_______

_______

Total:

_______

_______

_______

_______

Male

_______

_______

_______

Female

_______

_______

_______

_______

Sex

Total:

Total
Misc
Antibiotics
of
Concern
Scrips

Avg
Scrips
for Misc
Antibiotics
of
Concern
PMPY

Total
Ketolide
Scrips

Avg
Scrips
for
Ketolide
PMPY

Total
Clindamycin
Scrips

Avg
Scrips
for
Clindamycin
PMPY

_______

_______

______

______

______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

_______

_______

_______

_______

_______

_______

_______

______

______

______

_______

_______

HEDIS 2010, Volume 2

Table ABX-1/2/3(c): All Other Antibiotic Utilization by Drug Class

Age

Total
Aminoglycoside
Scrips

Avg
Scrips
for
Aminoglycoside
PMPY

Total
1st Gen
Cephalosporins
Scrips

Avg
Scrips
for 1st
Gen
Cephalosporins
PMPY

Total
Lincosamide
Scrips

Avg
Scrips
for
Lincosamide
PMPY

Total
Macrolides
(not
azith.,
clar.)
Scrips

Avg
Scrips
for
Macrolides
(not
azith. ,
clar.)
PMPY

______

_____

______

______

_____

______

_____

______

______

______

_____

______

______

_____

______

_____

Tot.

______

______

_____

______

______

_____

______

M

______

______

_____

______

______

_____

F

______

______

_____

______

______

Tot.
M

______

______

_____

______

F

______

______

_____

______

______

_____

Tot.

______

______

M

______

F

Sex

Total
Absorb
-able
sulfona
-mide
Scrips

Avg
Scrips
for
Absorb
-able
sulfona
-mide
PMPY

M

______

F

Total
Tetracycline
Scrips

Avg
Scrips
for
Tetracycline
PMPY

Total
Misc.
Antibiotics
Scrips

Avg
Scrips
for
Misc.
Antibiotics
PMPY

______

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

______

_____

______

______

______

______

_____

______

______

_____

______

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

______

_____

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

M

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

F

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

Tot.

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

M

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

F

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

Tot.

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

Total
Penicillin
Scrips

Avg
Scrips
for
Penicillin
PMPY

______

_____

______

______

_____

______

______

_____

_____

______

______

_____

______

______

______

______

_____

______

______

_____

______

______

Tot.

______

M

______

F
Tot.

0-9

10-17

18-34

35-49

50-64

65-74

75-84

HEDIS 2010, Volume 2

Table ABX-1/2/3(c): All Other Antibiotic Utilization by Drug Class (continued)

Age

85+

Un.

Total

Total
Aminoglycoside
Scrips

Avg
Scrips
for
Aminoglycoside
PMPY

Total
1st Gen
Cephalosporins
Scrips

Avg
Scrips
for 1st
Gen
Cephalosporins
PMPY

______

_____

______

______

______

______

_____

______

Tot.

______

______

_____

M

______

______

Sex

Total
Absorb
-able
sulfona
-mide
Scrips

Avg
Scrips
for
Absorb
-able
sulfona
-mide
PMPY

M

______

F

Total
Lincosamide
Scrips

Avg
Scrips
for
Lincosamide
PMPY

Total
Macrolides
(not
azith.,
clar.)
Scrips

Avg
Scrips
for
Macrolides
(not
azith. ,
clar.)
PMPY

_____

______

_____

______

______

_____

______

_____

______

______

_____

______

_____

______

______

_____

Total
Tetracycline
Scrips

Avg
Scrips
for
Tetracycline
PMPY

Total
Misc.
Antibiotics
Scrips

Avg
Scrips
for
Misc.
Antibiotics
PMPY

______

______

_____

______

______

_____

______

______

_____

______

______

______

_____

______

______

_____

______

______

______

______

_____

______

______

_____

______

______

Total
Penicillin
Scrips

Avg
Scrips
for
Penicillin
PMPY

______

_____

______

______

_____

______

______

_____

F

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

Tot:

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

M

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

F

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

Tot.

______

______

_____

______

______

_____

______

_____

______

______

_____

______

______

_____

______

______

HEDIS 2010, Volume 2

Board Certification (BCR)
SUMMARY OF CHANGES TO HEDIS 2010
Clarified that physicians listed in an organization’s directory should be included.

Description
The percentage of the following physicians whose board certification is active as of December 31 of the
measurement year.
Family medicine physicians

Pediatricians

Geriatricians

Internal medicine physicians

OB/GYN physicians

Other physician specialists

Board certification refers to the various specialty certification programs of the American Board of Medical
Specialties and the American Osteopathic Association. The organization should report separately for each
product as of December 31 of the measurement year.
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Physicians

This measure applies to independent physicians or group of physicians who provide
care for members.

Organizations
must include:

Physicians who have an independent relationship with the organization. An
independent relationship exists when the organization selects and directs its
members to see a specific physician or group of physicians. An independent
relationship is not synonymous with an ―independent contract.‖ Physicians may
contract directly with the organization or indirectly (e.g., physicians contract with
an IPA).
Physicians who are listed in the organization’s directory.
Physicians who see members outside of the inpatient hospital setting or outside of
free-standing facilities.
Physicians who are hospital based and who see members as a result of their
independent relationship with the organization; for example:
Anesthesiologists with pain management practices
Hospital-based cardiologists
Hospital-based faculty (provided that they meet the criteria listed above)

Organizations
must exclude:

Physicians who practice exclusively within the inpatient hospital setting and who
provide care for members only as a result of members being directed to the
hospital; for example:
Pathologists
ED physicians
Radiologists
Chiropractors
Anesthesiologists
Podiatrists
Neonatologists

HEDIS 2010, Volume 2

Physicians who practice exclusively within free-standing facilities and who provide
care for members only as a result of members being directed to the facility; for
example:
Mammography centers
Urgent care centers
Surgicenters
Dentists who do not provide care under the organization’s medical benefits; for
example:
Endodontists
Oral surgeons
Periodontists
Dentists who provide primary dental care under a dental plan or rider.
Table BCR-A indicates how to identify physicians.

Categories

Table BCR-A: Identifying Physicians
Product Line

Family
Medicine

Internal
Medicine









Commercial
Medicaid
Medicare

Pediatricians

OB/GYN

Geriatricians

Other
Physician
Specialists















Definitions
Family medicine
physician

A physician who provides preventive and diagnostic health care services for
individuals and families. Report general practitioners in the Family Medicine
category.

Internal
medicine
physician

A physician who provides long-term and comprehensive care and manages common
and complex illness of adolescents, adults and the elderly.

Pediatrician

A physician who provides preventive and diagnostic health care services for infants,
children and adolescents.

OB/GYN
physician

A physician who provides medical and surgical care relating to the female
reproductive system and associated disorders.

Geriatrician

A family medicine or internal medicine physician who has special knowledge of the
aging process and special skills in the diagnostic, therapeutic, preventive and
rehabilitative aspects of illness in the elderly.

Other physician
specialist

Any other physician specialist or physician subspecialist not specified above.

HEDIS 2010, Volume 2

Calculation of Board Certification
Number of
physicians in
each practice
area

Refer to Table BCR-1/2/3. For each product line, identify the number of physicians (with
active or inactive board certification) in each practice area, by type and number, with
whom the organization contracted as of December 31 of the measurement year.
Physicians are assumed to practice in the clinical area or areas in which they are listed
in the organization’s internal directory or classification system. Physicians listed under
more than one category should be counted as many times as they are listed and should
be included in each area of practice. For example, a family medicine physician who also
practices as a geriatrician should be reported in both the Family Medicine category and
the Geriatrician category.
Physicians do not have to be listed in the organization’s external provider directory to be
included in the measure. Physicians associated with an entity (e.g., vendor) should only
be counted if located in areas where the organization is licensed to operate.

Board
certification
number

Report the number of physicians in each practice area with active board certification.
For example, to be counted as a board-certified geriatrician, a physician must have a
specialty certification in geriatric medicine.
A physician with recent board certification who has not completed a residency/fellowship may be counted as board certified.
Confirmation by the appropriate certifying body that a physician is eligible for, and has
applied to, a board-certification program, may not be counted as board certification.

Board
certification
percentage

For each type of physician, calculate the percentage whose board certification is active
by dividing the board certification number by the number of physicians in each practice
area.
First, determine the number of areas of specialization and board certification status for
each physician; then determine how to count them in the denominator (i.e., number of
physicians in each practice area) and numerator (i.e., number of active board-certified
physicians) of the calculation.
A physician with only one specialty who is not board certified in that specialty counts as
1 in the denominator and 0 in the numerator.
A physician with only one specialty whose board certification is active in that specialty
counts as 1 in the denominator and 1 in the numerator.
A physician with more than one specialty counts as 1 in the denominator for each
specialty. Count in the numerator the number of specialty areas in which the physician
has active board certification.

Example

A physician listed under both hematology and medical oncology counts as 2 in the
denominator for Other Physician Specialists.
A physician whose board certification is active in both hematology and medical
oncology counts as 2 in the numerator.
A physician whose board certification is active in only one of these two areas counts
as 1 in the numerator.
A physician whose board certification is not active in either area counts as 0 in the
numerator.

HEDIS 2010, Volume 2

Note
The physician definitions for this measure are based on the American Board of Medical Specialties (ABMS)
definitions for physician specialties.
The numbers in the column Number of Physicians in Each Practice Area may not be the same as the
organization’s actual number of physicians because some physicians may practice in more than one area
and will be counted in the denominators of several percentages.

Table BCR-1/2/3: Board Certification
Type of Physician

Number of Physicians in
Each Practice Area

Active Board Certification
Number
Percentage

Family medicine
Internal medicine
Pediatricians
OB/GYN
Geriatricians
Other physician specialists

HEDIS 2010, Volume 2

Enrollment by Product Line (ENP)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The total number of members enrolled in the product line, stratified by age and sex.

Calculations
Product lines

Member
months

Report the following tables for each applicable product line, stratified by age and sex.
Table ENP-1a

Total Medicaid

Table ENP-1b

Medicaid/Medicare Dual-Eligibles

Table ENP-1c

Medicaid—Disabled

Table ENP-1d

Medicaid—Other Low Income

Table ENP-2

Commercial—by Product or Combined HMO/POS

Table ENP-3

Medicare

For each product line, report all member months for the measurement year. IDSS
automatically produces member years data for the commercial and Medicare product
lines. Refer to Specific Instructions for Use of Services Tables in Guidelines for Use of
Services Measures for more information.

Medicaid Beneficiary Category Assignment
The organization assigns Medicaid members to beneficiary categories based on a state-provided list of all
payment-rate categories used by that state and the organization in their contract. The state should use the
algorithm provided below (described in Categories A–D) to assign each payment-rate category it uses to one
of the three beneficiary categories and provide this categorization of rate categories to the organization. The
organization should then report Medicaid members using the state’s categories. The state should classify
beneficiaries according to the hierarchy below, beginning with Category A.
This algorithm addresses variables most likely to influence utilization patterns.
The presence of a Medicare benefit
The presence of a disability
Whether or not there is a restricted benefits package
This last group is not reported separately because of its anticipated small numbers, but it is included in
the total count of Medicaid members

HEDIS 2010, Volume 2

Category A
Total Medicaid—
Table ENP-1a

Include all Medicaid members enrolled in the organization who receive Medicaid
benefits, including those who receive a restricted benefits package smaller in
scope than the other Medicaid members enrolled in the same organization.
A restricted benefits package meets one of the following criteria.
Pregnant women whose Medicaid eligibility is based on poverty-related
coverage and whose Medicaid benefits are restricted to services related to
pregnancy and other conditions that may complicate pregnancy, or
Other individuals whose benefits are limited (e.g., emergency services)
The organization should include individuals in either of these two groups in this
category. Total Medicaid also includes the sum of Categories B–D.
Go to Category B if a member does not meet the criteria for Category A.

Category B
Medicaid/Medicare
Eligible—
Table ENP-1b

Include all Medicaid members (including children) entitled both to the state’s full
Medicaid benefit for which the organization has contracted and to Medicare Part A
or B benefits.
Qualified Medicare Beneficiaries (QMB), other specified low-income Medicare
beneficiaries, Qualified Disabled and Working Individuals (QDWI) and Qualified
COBRA Continuation Beneficiaries whose Medicaid benefit is limited to the
payment of a premium for Medicare or commercial coverage are not included in
this category because these individuals do not receive the Medicaid benefit
package.
Go to Category C if a member does not meet the criteria for Category B.

Category C
Disabled—
Table ENP-1c

Include all Medicaid members who do not meet the criteria for Category B and who
receive Medicaid benefits wholly or in part because of physical or mental disability.
This category includes supplemental security income (SSI) beneficiaries, SSIrelated beneficiaries and other disabled, medically needy beneficiaries.
Go to Category D if a Medicaid beneficiary does not meet the criteria for Category
B and does not receive Medicaid based on a disability (Category C).

Category D
Other Low
Income—
Table ENP-1d

Include all non-disabled, non-Medicare, low-income Medicaid beneficiaries who do
not meet the criteria for Category B or Category C.

Note
NCQA recognizes that most organizations do not serve Medicaid beneficiaries in all categories. Not many
serve the few individuals with a restricted benefits package (see Category A).

HEDIS 2010, Volume 2

Table Instructions
Use Table ENP-1/2/3 to report the organization’s enrollment by product line for the most recent calendar year,
based on member months.
Medicaid
(Tables 1a-1d)

Assign Medicaid beneficiaries to Categories A–D based on the definitions provided
above.
Report by eligibility category the number of member months by age and sex, including
subtotals.
Calculate the subtotal percentages within each eligibility category by dividing the total
subtotal member months into total member months by sex (e.g., [X member months of
enrolled Medicaid disabled males, 0–19/Y member months for all Medicaid disabled
males, 0–90+ and age unknown] x 100 = Z percent of member months for Medicaid
disabled males, 0–19 years of all male Medicaid disabled member months).

Commercial
(Table 2)

Report by commercial product line the number of member months by age and sex,
including subtotals.
Calculate the subtotal percentages within the commercial product line by dividing the
total subtotal member months into total member months by sex (e.g., [X member
months of enrolled commercial product males, 0–19/Y member months for all
commercial product males, 0–90+ and age unknown] x 100 = Z percent of member
months for commercial product males, 0–19 years of age of all male commercial
product member months).

Medicare
(Table 3)

Report by Medicare product line the number of member months by age and sex,
including subtotals.
Calculate the subtotal percentages within the Medicare product line by dividing the total
subtotal member months into total member months by sex (e.g., [X member months of
enrolled Medicare males 0-19/Y member months for all Medicare males, 0–90+ and age
unknown] x 100 = Z percent of member months for Medicare males, 0–19 years of age
of all male Medicare member months).

HEDIS 2010, Volume 2

Table ENP-1/2/3: Member Months of Enrollment by Product Line
Age

Male

Female

Total

<1

_______________

_______________

_______________

1-4

_______________

_______________

_______________

5-9

_______________

_______________

_______________

10-14

_______________

_______________

_______________

15-17

_______________

_______________

_______________

18-19

_______________

_______________

_______________

0-19 Subtotal:

_______________

_______________

_______________

_______________%

_______________%

_______________%

20-24

_______________

_______________

_______________

25-29

_______________

_______________

_______________

30-34

_______________

_______________

_______________

35-39

_______________

_______________

_______________

40-44

_______________

_______________

_______________

20-44 Subtotal:

_______________

_______________

_______________

_______________%

_______________%

_______________%

45-49

_______________

_______________

_______________

50-54

_______________

_______________

_______________

55-59

_______________

_______________

_______________

60-64

_______________

_______________

_______________

45-64 Subtotal:

_______________

_______________

_______________

_______________%

_______________%

_______________%

65-69

_______________

_______________

_______________

70-74

_______________

_______________

_______________

75-79

_______________

_______________

_______________

80-84

_______________

_______________

_______________

85-89

_______________

_______________

_______________

>90

_______________

_______________

_______________

_______________

_______________

_______________

>65 Subtotal (%):

_______________%

_______________%

_______________%

Age unknown

_______________

_______________

_______________

_______________

_______________

_______________

0-19 Subtotal (%):

20-44 Subtotal (%):

45-64 Subtotal (%):

>65 Subtotal:

Total:

HEDIS 2010, Volume 2

Enrollment by State (EBS)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
The number of members enrolled as of December 31 of the measurement year, by state.
Product lines

Commercial, Medicaid, Medicare (report each product line separately).

Anchor Date

December 31 of the measurement year.

Calculation
Calculate enrollment by state using the address on record for members on December 31 of the measurement
year, to be determined according to the organization’s administrative processes. Report by categories (states
and territories) listed in Table EBS-1/2/3. If the member’s address is unknown or does not match, report as
―Other.‖ If a child’s address is not captured, the organization may use the address of the policyholder, parent
or caretaker.
Report on total unduplicated membership as of December 31 of the measurement year. If the organization
assigns a new member number to members who disenroll and reenroll during the measurement year, it must
develop a system to avoid double-counting members.

Table EBS-1/2/3: Member Enrollment by State
State

Number

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________

State
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas

Number

State

Number

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________

Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Fed. Sts. of Micronesia
Guam
Cmnwlth. of N. Marianas
Puerto Rico
Virgin Islands
Other
Total:

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________

HEDIS 2010, Volume 2

Race/Ethnicity Diversity of Membership (RDM)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.

Description
An unduplicated count and percentage of members enrolled any time during the measurement year, by race
and ethnicity.
Product lines

Medicaid, Medicare (report each product line separately).

Calculations
Table
instructions

Report the number and percentage of members by race/ethnicity stratified by gender
for the product population. If a member’s race or ethnicity is unknown or unavailable
from the state agency or CMS, report as ―Unknown.‖
Report on total unduplicated membership during the measurement year. If the
organization assigns a new member number to members who disenroll and reenroll
during the measurement year, it must develop a system to prevent double counting
members.

Data source

Obtain race and ethnicity data from enrollment information furnished by state
Medicaid agencies or by CMS, or supplemented through the organization’s own direct
data collection from members (e.g., surveys, health risk assessments, disease
management registries) or through other available indirect methods (e.g., surname
analysis, geocoding). When using CMS as the data source, refer to Table RDM-A for
a crosswalk of reporting categories for the RDM measure.

Race Reporting Category Definitions
White

People whose origins are in any of the original peoples of Europe, the Middle East or
North Africa; including people who indicated their race or races as ―White‖ or wrote in
entries such as Irish, German, Italian, Lebanese, Near Easterner, Arab or Polish.

Black or African
American

People whose origins are in any of the Black racial groups of Africa; including people
who indicated their race or races as ―Black, African Am., or Negro,‖ or wrote in entries
such as African American, Afro-American, Nigerian or Haitian.

American Indian
and Alaska
Native

People whose origins are in any of the original peoples of North and South America
(including Central America), and who maintain tribal affiliation or community
attachment; including people who indicated their race or races by marking this
category or writing in their principal or enrolled tribe, such as Rosebud, Sioux,
Chippewa or Navajo.

Asian

People who are Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese and
―Other Asian,‖ which may include people who are Burmese, Hmong, Pakistani, Thai
or from two or more Asian subgroups.

HEDIS 2010, Volume 2

Native Hawaiian
and Other Pacific
Islander

People whose origins are in any of the original peoples of Hawaii, Guam, Samoa
or other Pacific Islands; including Carolinian, Fijian, Kosraean, Melanesian,
Micronesian, Northern Mariana Islander, Palauan, Papua New Guinean, Ponapean
(Pohnpelan), Polynesian, Solomon Islander, Tahitian, Tarawa Islander, Tokelauan,
Tongan, Trukese (Chuukese) and Yapese.

Some Other
Race

People whose race information has been collected but does not fit into any of the
other seven race categories. This category includes people who may be Mulatto,
Creole and Mestizo or another race not specified in the Census race categories.

Two or More
Races

People with any combination of races, including ―Some Other Race.‖

Ethnicity
reporting
category:
Hispanic or
Latino

People of Spanish, Mexican, Puerto Rican or Cuban origins.
Note: NCQA encourages collecting and reporting race and Hispanic ethnicity based
on categories adapted from the official U.S. census forms established by the U.S.
Department of Commerce, Bureau of the Census and defined by the Office of
Management and Budget (OMB). Because CMS and state agencies may have
varying classification schemes for race and ethnicity, refer to Table RDM-A for
HEDIS reporting.

Table RDM-A: CMS/HEDIS Crosswalk for Reporting Categories
CMS Category

HEDIS Race

HEDIS Ethnicity

0 = Unknown

Unknown

Unknown

1 = White not Hispanic

White

Not Hispanic

2 = Black not Hispanic

Black

Not Hispanic

3 = Other

Some Other Race

Unknown

4 = Asian

Asian

Unknown

5 = Hispanic

Unknown

Hispanic

6 = North American Native

American Indian/AN

Unknown

Table RDM-1/3: Race/Ethnicity Diversity of Membership
Data Source: __________________
Values include NR, CMS, Health plan direct, Surname analysis/geo-coding, Multiple sources, Other
Total unduplicated membership during the measurement year:
Number of members: _________________
The total unduplicated count of members in the organization is the denominator for calculating the percentages. Each cell represents the
proportion of members of a specific race/ethnicity combination of the total unduplicated count of members in the organization.
Percentage of members with known race information (sum all the race categories, except Unknown Race, and divide by the number
of total unduplicated members during the measurement year): _________________
Percentage of members with known ethnicity information (sum all the ethnicity categories, except Unknown Ethnicity, and divide by
the number of total unduplicated members during the measurement year): _________________

HEDIS 2010, Volume 2

Table RDM-1/3: Race/Ethnicity Diversity of Membership (continued)
Hispanic or Latino
Race
White

Sex

Number

Percentage

Number

Percentage

Number

Percentage

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

______

_______

_______

_______

_______

_______

_______

______

______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

______

_______

_______

_______

_______

_______

_______

______

______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

______

_______

_______

_______

_______

_______

_______

______

______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

______

_______

_______

_______

_______

_______

_______

______

______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

_______

_______

_______

_______

_______

_______

_______

______

_______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

_______

_______

_______

_______

_______

_______

_______

______

_______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

_______

_______

_______

_______

_______

_______

_______

______

_______

Male

_______

_______

_______

_______

_______

_______

______

______

Female

_______

_______

_______

_______

_______

_______

______

_______

_______

_______

_______

_______

_______

_______

______

_______

Male

_______

_______

_______

_______

_______

_______

______

_______

Female

_______

_______

_______

_______

_______

_______

______

_______

_______

_______

_______

_______

_______

_______

______

100%

Total:
Asian

Total:
Native Hawaiian
and Other
Pacific Islander

Total:
Some other
race

Total:
Two or more
races

Total:
Unknown

Total:
Total

Total

Percentage

Total:
American-Indian
and Alaska
Native

Unknown Ethnicity

Number

Total:
Black or AfricanAmerican

Not Hispanic or
Latino

Total:

HEDIS 2010, Volume 2

Language Diversity of Membership (LDM)
SUMMARY OF CHANGES TO HEDIS 2010
No changes to this measure.
Description
An unduplicated count and percentage of Medicaid and Medicare members enrolled at any time during the
measurement year by demand for language interpreter services and spoken language.
Product lines

Medicaid, Medicare (report each product line separately).

Calculations
Table
instructions

Report the number and percentage of members by demand for language interpreter
services and spoken language stratified by gender for each product population. If a
member’s interpreter service needs or spoken language is unknown or unavailable
from the state agency or CMS, report as ―Unknown.‖
Report total unduplicated membership during the measurement year. If the
organization assigns a new member number to members who disenroll and reenroll
during the measurement year, it must develop a system to prevent double-counting
members.

Data source

Obtain interpretation service needs and language spoken from enrollment information
furnished by state Medicaid agencies or supplemented through data that the
organization collected from its members (e.g., surveys, health risk assessments,
disease management registries) or through indirect methods (e.g., surname analysis,
geo-coding).

Need/Want
Interpreter

Identify individuals who need or want interpreter services; enter this information in
Table LDM-1/3. This information should be reported by gender for the organization
population.
Data collection guidance for organizations and agencies. This information can be
gathered through a two-part question to beneficiaries/members:
(Does the Medicaid or Medicare beneficiary) Do you need or want an interpreter to
communicate with a doctor or health care practitioner?
No
Yes
Unknown (if data are unavailable)

Spoken
Language

Indicate the language spoken by the member at home most of the time; enter this
information in Table LDM-1/3. This information should be reported by gender for the
organization population.
Data collection guidance for organizations and agencies. This information may be
gathered through the second part of a two-part question:
What language (does the beneficiary) do you speak most of the time at home?

HEDIS 2010, Volume 2

Note
The U.S. Census asks Does this person speak a language other than English at home?

Table LDM-1/3: Language Diversity of Membership
Data source: __________________
Values include NR, CMS, Health plan direct, Surname analysis/geo-coding, Multiple sources, Other
Total unduplicated membership during the measurement year:
Number of members _________________
The total unduplicated count of members in the organization is the denominator for calculating the percentages. Each cell represents the
proportion of members with identified demand for interpreter services and indicated spoken language of the total unduplicated count of
members in the organization.

Demand for Language Interpretation Services
Need/Want an Interpreter

Yes

Number

Percentage

Male

Sex

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

Total:
Need/Want an Interpreter

No

Total:
Need/Want an Interpreter

Unknown

Total:
Total: (This should sum to 100%)

Total:
Percentage of members with known interpretation needs:
(Sum the Yes/No categories and divide by the number of total unduplicated
members during the measurement year )
English

Total:
Spanish (or Spanish Creole)

Total:
Other Indo-European Languages (e.g., French or French Creole, Italian,
Portuguese or Portuguese Creole, German, Yiddish, Scandinavian
languages, Greek, Russian, Polish, Serbo-Croatian, Armenian, Persian,
Gujarathi, Hindi, Urdu)

Male

____________

____________

Female

____________

____________

____________

____________

Asian and Pacific Island Languages (e.g., Chinese, Japanese, Korean,
Mon-Khmer, Cambodian, Miao, Hmong, Thai, Laotian, Vietnamese,
Tagalog and Other Pacific Island languages)

Male

____________

____________

Female

____________

____________

____________

____________

Total:

Total:

HEDIS 2010, Volume 2

Table LDM-1/3: Language Diversity of Membership (continued)
Spoken Language at Home
Other Languages (e.g., Navajo, Other Native North American languages,
Hungarian, Arabic, Hebrew, African languages)

Sex

Number

Percentage

Male

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

Male

____________

____________

Female

____________

____________

____________

____________

____________

____________

Total:
Unknown

Total:
Total: (this should sum to 100%)

Total:
Percentage of members with known spoken language:
(Sum all the language categories, except unknown and divide by the number of total
unduplicated members during the measurement year)

Note
CMS does not provide language information on its Medicare beneficiaries. Medicare organizations should
obtain language data through alternate sources, including surveys and case management and enrollment
registries.

HEDIS 2010, Volume 2

HEDIS 2010, Volume 2