Posted in Training, Updates

HEDIS Measure: Well-child visits in first 30 months.

Bringing young children to see the primary care physician, for a well-care visit is extremely important.

These visits track:

Prevention: wellness visits ensure children receive scheduled immunizations that prevent illness. It is also a great opportunity to discuss nutrition and safety in the home.

Growth and development. Evaluating children for growth and development enables parents to see how much their children have grown since the last visit. It is also an opportunity to share the children’s development, to discuss milestones, social behaviors, and learning.

Raising concerns. Offering parents an opportunity to share concerns at the start of the visit will help in your evaluation of the patient. They may want to talk about development, sleep and eating habits and behaviors.

Team approach. Regular visits create strong, trustworthy relationships among physician, parent, and child. The American Academy of Pediatrics (AAP) supports well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental, and social health of a child.

Description of the measure:

Describes the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months.

The rates are reported as follows:

Well-child visits in the first 15 months: Six or more well-child visits with children who turned age 15 months during the measurement year.

Well-child visits for ages 15 to 30 months: Two or more well-child visits with children who turned age 30 months during the measurement year.

In order to receive credit for this measure the following DX should be used:

  • ICD-10:110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z02.5, Z76.1, Z76.2

The following CPT codes should be used:

  • CPT: 99381-99382, 99391-99392, 99461

The following HCPCS should be used:

  • HCPCS: G0438-G0439, S0302

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Posted in HEDIS Measures, Training, Updates

Proper coding for Comprehensive Diabetes Care HEDIS Measure: retinal eye exams (DRE)

Definition:  Comprehensive Diabetes Care HEDIS® Measure Retinal Eye Exam (DRE) is a percentage of patients between ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

What is new?

The compliance of this measure is good for 2 years. You are allowed to bill the proper codes for the current measurement year, or prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years.

New definition:

Low risk for retinopathy (no evidence of retinopathy in the prior year). The codes can be used to indicate that retinopathy was not present the previous year.

Proper Codes:


Please make sure to document the following measurements in the patient’s medical records:  HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test and the estimated glomerular filtration rate test.


DRE exams are an important component of in evaluating the overall health of diabetic patients. Providers should also strive to meet the Comprehensive Diabetes Care HEDIS measure with the following:

  • Hemoglobin A1c (HbA1c) testing
  • HbA1c poor control (>9.0%)
  • HbA1c control (<8.0%)
  • Retinal Eye exam performed
  • Blood Pressure control (<140/90 mm Hg)

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Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Use of Imaging Studies for Low Back Pain

HEDIS Measures get updated every year. In this post we will discuss the proper coding and billing for HEDIS Measure: Use of Imaging Studies for Lower Back Pain; and list the changes for the upcoming 2022 year. This measure applies to all types of insurances: Medicare, Commercial, and Medicaid.


One out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.  Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.

What causes back pain?

HEDIS Measure: Use of Imaging Studies for Low Back Pain Definition-
Members 18-50 years of age with a new primary diagnosis of low back pain in an outpatient or ED visit who did not have an x-ray, CT or MRI within 28 days of the primary diagnosis. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur)

Proper Medical Coding:

CPT codes for imaging Studies-

List of Proper DX codes:

Measure Exclusions:

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Proper Exclusions Coding:

Improve the score for this HEDIS Measure:

-Avoid ordering diagnostic studies within 30 days of a diagnosis of new-onset back pain in the absence of red flags (e.g., cancer, recent trauma, neurologic impairment,
or IV drug abuse).
• Provide patient education on comfort measures, e.g., pain relief, stretching exercises, and activity level.
• Use correct exclusion codes if applicable (e.g., cancer).
• Look for other reason for visits for low back pain (e.g., depression, anxiety, narcotic dependency, psychosocial stressors, etc.).
• Document and code/bill all comorbidities (e.g. MVA, fall, trauma, etc.

HEDIS Measure: Use of Imaging Studies for Low Back Pain 2022 Changes:

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