Category: HEDIS Measures

Posted in HEDIS Measures, Updates

HEDIS® Measures: W30 and WCV (well child visits)

Posted on by KR2Medical Billing

Well-child visits in the first 30 months of life (W30):
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:

  1. Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
  2. Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.

Child and adolescent well-care visits:
Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

In order to complete these measures AAP developed a comprehensive schedule.

In order for Providers to comply with AAP, the providers should follow AAP recommendations: eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure.  Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures. 

For Empire BCBS NY Child Well Care visit coverage:

BCBS Empire NY offers complete coverage for well-child visits regardless of when visit is received:

Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.

Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Colorectal Cancer Screening (COL)

Posted on by KR2Medical Billing

This HEDIS® measure evaluates the percentage of patients age 50 to 75 who had appropriate screening for colorectal cancer.

In order for PCPs to get credit for this Measure they need to document the following:

Document (date and result) one or more of these screenings:

  • Colonoscopy during measurement year or nine years prior
  • Fecal occult blood test (FOBT) during measurement year
  • CT colonography during measurement year or four years prior
  • Fecal immunochemical test (FIT)-DNA test during measurement year or two years prior
  • Flexible sigmoidoscopy during measurement year or four years prior

There following are exclusions for this measure:

  • Diagnosis of colorectal cancer
  • Total colectomy
  • Members who receive palliative 

Quest Test available:

There is an option for your patient to get a FIT kits through Quest Diagnostics.®* This option is only available for PARTICIPATING providers.

Quest will ship InSure® ONE™ FIT kits directly to your practice. There are 2 ways to order:

  • Online, use the Quest Quanum® Lab Services Manager. Create an account at https://bit.ly/3qLxNPh.
  • Via phone, call 1-866-MY-QUEST and state supplies for assistance.

Quest will ship the kits to your practice at no cost, based on usage and test completion.

Posted in HEDIS Measures, Training, Updates

New and Retired Medicaid HEDIS measures (NCQA 2020/2021)

Posted on by KR2Medical Billing

Source: Empire BCBS NY

New HEDIS Medicaid Measures:

  1. Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year

2. Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:

  • Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
  • Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
  • Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
  • Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event

Retired Medicaid measures:

  • Comprehensive Diabetes Care (CDC) retired sub-measures —
    • Medical Attention for Nephropathy (retired for Commercial and Medicaid)
    • HbA1c control (< 7.0%) for a selected population
  • Adult BMI Assessment (ABA)
  • Medication Management for People With Asthma (MMA)
  • Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)