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HEDIS Quick Reference Guide
®
► Adult & Well Women Measures
Diabetes Management
Pregnancy Management - Prenatal Care
Members age 18 and over must have diabetic specific care.
Pregnant members must receive their 1st prenatal visit in the 1st trimester
or within 42 days of enrollment into Peach State Health Plan.
To Improve Hedis® Scores
Ensure the following are obtained:
• Annual HbA1c or more frequently as needed (the goal is <9.0%)
- Indicate results of HbA1c:
3044F< 7.0%
3045F between 7.0 – 9.0%
3046F >9.0
- Peach State reimburses for HbA1c testing performed in the provider’s
office (83036 and 83037)
• Annual Medical Attention for Nephropathy
• Retinal Eye Exam (dilated)
• Controlled Blood Pressure (<140/90)
Contact Peach State Provider Services at 1-866-874-0633 for assistance
locating a specialist.
Adult Visits
Obtain a BMI at every visit (sick and/or well)
To Improve Hedis® Scores
• BMI – add diagnosis code V85.0 – V85.5 to your claim.
•D
iscuss, document and offer smoking cessation strategies and efforts
at every adult visit (sick and/or well).
• Offer adults annual flu shots during the months of September
through May.
Controlling High Blood Pressure
Members age 18 – 85 years old with a diagnosis of Hypertension must
have adequately controlled blood pressure.
HEDIS® defines “adequately controlled” as less than 140 systolic and
less than 90 diastolic (<140/90).
To Improve Hedis® Scores
• S chedule follow up appointments and/or BP checks if BP is not
“controlled” as evidenced by a BP <140/90.
HEDIS® rules state the last documented BP of the year is the only one
that counts.
Breast Cancer Screening
Women age 50 – 74 years old should have a mammogram
To Improve Hedis® Scores
• E nsure that an order or prescription is given at well women exams for
women 50 – 74 years old.
• Document unilateral or bilateral mastectomy and date in chart.
Source HEDIS® 2014 Volume 2 Technical Specifications. The above guidelines are
HEDIS® measures and should not take the place of clinical practice guidelines.
HEDIS® is a registered trademark of the National Committee for Quality Assurance
(NCQA). Reimbursement for these services will be in accordance with the terms
and conditions of your agreement.
© Peach State Health Plan. All rights reserved.
To Improve Hedis® Scores
Ensure the following are obtained:
Prenatal Care –
• Encourage member to attend all scheduled prenatal visits
• Ensure antepartum flow sheet is completed at each visit
• Note: Appointments for only ultrasounds are not classified as prenatal
care visits
Pregnancy Management - Postpartum Care
Members must receive their postpartum visit 21 - 56 days after delivery.
To Improve Hedis® Scores
Ensure the following are obtained:
Postpartum Care –
• Postpartum visit must be 21 – 56 days after delivery and include one of
the following:
- Pelvic exam or,
- Evaluation of weight, BP, breast, and abdomen, or
-Notation of “breast feeding”
- Notation of postpartum care
- Postpartum care, “PP care”, “PP check”, “6 week check”
- A preprinted form
Peach State Health Plan offers member education and incentives for
completion of prenatal visits through the Start Smart for Your Baby
Program.® For more information contact Peach State’s Case Management
Department at 1-800-504-8573.
Chlamydia Screening
Sexually active females age 16 - 24 years old should be tested for
Chlamydia each year.
To Improve Hedis® Scores
• HEDIS specifications indicate females are “sexual active” and need
Chlamydia screenings based on a history of specific diagnoses and
prescriptions.
Cervical Cancer Screening
Women age 21 – 64 with cytology testing should have a cervical cancer
screening every 3 years.
Women age 30 – 64 with cytology and HPV testing should have cervical
cancer screening every 5 years.
To Improve Hedis® Scores
• Document hysterectomy, type (partial, total) and date performed in
chart.
For more information contact Peach State Provider Services at
1-866-874-0633.
www.pshp.com
HEDIS Quick Reference Guide
®
► Pediatric Measures
Childhood Obesity
Well Child Visit
ALL Children age 3 -17 years old must have documentation of BMI
Percentile, Nutritional Counseling and Physical Activity Counseling
in the Medical Record.
Eight (8) visits should occur by 15 months (HEDIS requires at least 6 visits)
Children over 3 years of age must receive a well-child visit every year.
To Improve Hedis® Scores
• Take advantage of sick visits and sports physicals to perform a
well-child visit
• BMI Percentile
- Add informational diagnosis code V85.5X to claim see below:
- Less than 5th percentile for age: V85.51
- 5th to less than 85th percentile for age: V85.52
- 85th to less than 95th percentile for age: V85.53
- Greater than or equal to 95th percentile for age: V85.54
• Nutritional Counseling
- add informational diagnosis code V65.3 to claim
• Physical Activity Counseling
- add informational diagnosis code V65.41 to claim
BMI percentile must be documented and dated (can be plotted on
growth chart). BMI, Nutritional/Counseling and Physical/Activity
can be completed at well and/or sick visit.
To Improve Hedis® Scores
• Document BMI percentile, date and plot on growth chart
• Document type of anticipatory guidance (nutritional and physical
counseling)
• Refer members to a dentist at 6 months or after eruption of 1st tooth
• Ensure shots are up to date for adolescents and children turning
2 years old
• Developmental Screenings should be done at ages 9, 18 and 30 months
Peach State reimburses for use of standardized screening tool for
developmental screening (96110)
Contact Peach State Provider Services at 1-866-874-0633 if you would
like to schedule a Peach State Day to increase well visits compliance.
Childhood Immunization and Lead Screening
Children must be fully immunized and have one lead screening
on or before the 2nd birthday.
Note: If the child is 2 years and 1 day old, service(s) will not count
towards HEDIS scores
Adolescent Immunizations
To Improve Hedis® Scores
Note: If the child is 13 years and 1 day old, service(s) will not count
towards HEDIS scores.
• Check compliance with immunizations and lead at 18 month well-visit
- (not 2 yrs. old)
Adolescents NEED 1 meningococcal, 1 TD/Tdap and females 3 HPV
“before” 13th birthday.
To Improve Hedis® Scores
• Check compliance with immunizations and lead at 18 month well-visit
- (not 2 yrs. old)
• Check status of immunizations at 11 year old well visit
- (not 12 year old)
• Schedule a visit to “catch up” on immunizations and lead screenings
• Schedule a visit to “catch up” on immunizations and lead screenings
• If using a Certified Lead Analyzer, submit CPT Code 83655
• Encourage and explain benefits of HPV immunization to female members
• Encourage and offer flu shots during the months of September through
May
Enter immunizations in GRITS registry as required
www.grits.state.ga.us
Enter immunizations in GRITS registry as required
www.grits.state.ga.us and lead screenings https://sendss.state.ga.us
Overdue immunizations can be administered at sick visits
(as medically appropriate).
Overdue immunizations and lead testing can be administered at
sick visits (as medically appropriate).
Developmental Screening Tool
Developmental Screenings must be done at ages:
9 months, 18 months, 30 months
To Improve Hedis® Scores
• Peach State Health Plan reimburses for standardized developmental
tool, submit CPT Code (96110)
• Autism screening is expected at 18 and 24 months
Source HEDIS® 2014 Volume 2 Technical Specifications. The above guidelines are
HEDIS® measures and should not take the place of clinical practice guidelines.
HEDIS® is a registered trademark of the National Committee for Quality Assurance
(NCQA). Reimbursement for these services will be in accordance with the terms
and conditions of your agreement.
© Peach State Health Plan. All rights reserved.
For a list of standardized reimbursable developmental screening tools
refer to the Department of Community Health (DCH) website
https://www.mmis.georgia.gov/portal
Early Periodic Screening Diagnostic Treatment (EPSDT) Manual
www.pshp.com