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Effectiveness Measures HEDIS® and NQF

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Effectiveness Measures HEDIS® and NQF Effectiveness Measures HEDIS® and NQF 2020 EFFECTIVENESS TOOL FOR CDPHP® PROVIDERS Table of Contents Section One - Overview ......................................................................................................................................................3 What is HEDIS? ........................................................................................................................................................................ 3 What is the NQF? ..................................................................................................................................................................... 4 What is Risk Adjustment? ..........................................................................................................................................................5 What is the Provider’s Role in 2020? ......................................................................................................................................... 6 List of CDPHP Contacts and Resources to Help With Effectiveness for 2020 ..................................................................................7 HEDIS Spring Chart Review 2020 Timeline ................................................................................................................................ 8 What’s New with Enhanced Primary Care (EPC) Effectiveness Metrics for 2020? .......................................................................... 9 Section Two - Effectiveness Measures ....................................................................................................................10 HEDIS and NQF 2020 Groupings and Measure Listing (cont.) ....................................................................................................12 ECDS Measures .................................................................................................................................................................... 172 Appendix ................................................................................................................................................................................174 EPC - Internal Medicine Effectiveness Metrics for 2020 ........................................................................................................... 175 EPC - Pediatric Effectiveness Metrics for 2020 ........................................................................................................................ 176 EPC - Family Medicine Effectiveness Metrics for 2020 ............................................................................................................. 177 CG CAHPS Questions for EPC Practices ................................................................................................................................... 178 Gap List Reconciliation Tip Sheet ........................................................................................................................................... 179 Surveys ................................................................................................................................................................................ 181 What is HEDIS? HEDIS stands for Healthcare Effectiveness Data and Information Set f HEDIS is a set of STANDARDIZED quality measures. This standardization helps the public compare the performance of organizations across the nation. f The NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) coordinates and administers the program. » CDPHP volunteers to participate in the program. » HEDIS measures are not created by CDPHP. f HEDIS 2020 (2019 DOS) specifications include 96 measures across six domains of care. f HEDIS measures focus on prevention, screening, conditions across all body systems, access to care, satisfaction with care, as well as utilization of specific procedures and care settings. f NCQA has expanded the size and scope of HEDIS to include measures for physicians, ACOs and other organizations Per the October 2020 communication from NCQA, “HEDIS measures and specifications are not clinical guidelines, and do not establish a standard of medical care, and have not been tested for all potential applications.” Types of HEDIS Measures Administrative Method An organization must identify a measure's denominator and numerator, using transaction data or other administrative databases. The denominator comprises all eligible members (see eligible population). The organization reports a rate based on all members who meet the denominator criteria and who are found through administrative data to have received a particular service. ECDS Electronic clinical data system. A structured, electronic version of a patient's comprehensive medical experiences, maintained over time, that may include some or all key administrative clinical data relevant to care (e.g., demographics, progress notes, problems, medications, vital signs, past medical history, social history, immunizations, laboratory data, radiology reports). Hybrid measures A measure that requires the organization to identify the numerator using both administrative and medical record data. The denominator consists of a systematic sample of members drawn from the measure's eligible population. Section One - Overview 3 What is the NQF? NQF stands for the National Quality Forum f The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care. f NQF measures and standards serve as a critically important foundation for initiatives to enhance health care value, make patient care safer, and achieve better outcomes. f Specifics of each NQF measure are included in Section Two. Source: NCQA HEDIS 2020 Volume 2; Technical Specifications for Health Plans HEDIS measures and specifications are not a substitute for clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. 4 What is Risk Adjustment? Risk Adjustment is a payment model that is linked to diagnosis coding As health care moves away from fee-for-service reimbursement, there is increased focus on accuracy and specificity in diagnosis coding and medical documentation. In a risk-adjusted payment model, the more severe or complex a diagnosis, the higher the risk value assigned to it. A risk adjustment value is assigned to each diagnosis code that falls into the payment model. Hospital and physician claims are the main sources of data that drive the risk adjustment model. However, it is important that all providers of care review their diagnosis coding practices to ensure they are painting an accurate clinical picture of the patient. Likewise, it is critical that the documentation in the medical record support the coding. Again this year, you will find coding tips throughout this reference tool for specific measures and conditions. To get you started, here are three easy steps you can take to ensure your diagnosis coding is accurate: 1. Do not code from a Problem List. Make sure that all problems listed as active problems are appropriate and haven’t been brought forward (copy and pasted) in error. 2. Do not default to coding using only generic or unspecified codes. It is not incorrect to use an unspecified code but it is important to code to the level of specificity known for that encounter. 3. Do not use “rule out” diagnosis codes. If a definitive diagnosis has not been established, code the signs or symptoms that brought the patient to the office today. Source: NCQA HEDIS 2020 Volume 2; Technical Specifications for Health Plans HEDIS measures and specifications are not a substitute for clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. 5 What is the Provider’s Role in 2020? f HEDIS and NQF data collection is a year-round process – claims data is the primary source. f Complete and accurate coding of all claim submissions from the provider’s office is the priority and will ensure the integrity of CDPHP data. » Claim submissions should also be timely to avoid delays in monthly updates to tracking reports. f HEDIS codes are published each October in the Value Set Directory (VSD), which is part of the final specifications published by NCQA. » Every HEDIS measure is linked to specific coding criteria. » Only HEDIS codes in the Value Set Directory count toward numerator compliance for specific HEDIS measures. f NCQA allows plans to collect additional hybrid HEDIS data through a process called Medical Record Review (MRR), which is conducted each spring. » CDPHP nurses go onsite to offices to search for information that may exist in the chart but was either never submitted via code on a claim, or was submitted but with a non-HEDIS code. » Partnering with CDPHP to allow remote access to your electronic medical record (EMR) system during this time will reduce the administrative burden for your staff and expedite the review process. • Contact us at [email protected] to coordinate. f Practices are encouraged to review their gap lists and submit documentation for members who meet measure criteria for permanent exclusion from a measure when applicable. Source: NCQA HEDIS 2020 Volume 2; Technical Specifications for Health Plans HEDIS measures and specifications are not a substitute for clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. 6 List of CDPHP Contacts and Resources to Help With Effectiveness for
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