Helpful Hints
Exclusions:
Appropriately coding for exclusionary criteria
removes member(s) from the respective
HEDIS population. Palliative/hospice coding
during the measurement year excludes
patients from most measures. Additional
measure-specic exclusions are listed under
each measure.
Electronic Clinical Data Systems
(ECDS):
NCQA is transitioning the collection of data
from a medical record review process to
claims or encounters only. To ensure your
measure compliance rates are accurate,
be sure to document and submit the
appropriate code. The measures with
the “E” listed, indicate this measure has
transitioned electronically only accepting
coding (and not medical record review) for
compliance.
Telehealth:
Telehealth is often an acceptable and
underutilized method to close many gaps
in care.
Health Education and Wellness/
Disease Management:
Refer to Disease Management for members
with asthma, diabetes, or kidney disease
for support with managing chronic health
conditions. Additionally, Health Education
and Wellness support services are available
for members. Referrals can be made
through the online provider portal or call
702-242-7546.
Adults’ Access to Preventive/
Ambulatory Health Services (AAP)
Patient Population
• Ages 20 and older who had an
ambulatory or preventive care visit
• Medicaid members annually
• Commercial members once every three
years
Action:
Reach out to members who have not been
seen to schedule an appointment
Goal: Build or maintain member/provider
relationship, and address any preventive
screenings and health concerns.
Adult Immunization Status (AIS-E)
Patient Population:
• Ages 19 and older for u and Td/Tdap
• Ages 50 and older for herpes zoster
• 66 and older for pneumococcal vaccine
Action:
Provide vaccinations and/or code any
anaphylactic reactions for the following
immunizations and document in WebIZ:
1 inuenza vaccine
1 Td/Tdap vaccine
1 (live) or 2 recombinant herpes zoster
1 adult pneumococcal vaccine
Goal: Disease protection
Antibiotic Stewardship
Avoidance of Antibiotic Treatment
for Acute Bronchitis (AAB) and/or
Appropriate Treatment for Upper
Respiratory Infection (URI)
Patient Population
• Ages 3 months and older
• Diagnosed with acute bronchitis and/or
upper respiratory infection
Action:
Avoid prescribing antibiotics for members on
or 3 days after the diagnosis.
Goal: Reduce overuse of antibiotics
Appropriate Testing for Pharyngitis
(CWP)
Patient Population
• Ages 3 and older
• Pharyngitis diagnosis
Action:
Complete a group A streptococcus (strep)
test or rapid strep test prior to prescribing
antibiotics.
Goal: Reduce overuse of antibiotics
Colorectal Cancer Screening (COL-E)
Patient Population
• Ages 45–75
• Has not completed a listed screening for
colorectal cancer
Action:
Ask and document last colorectal cancer
screening date and test type. If overdue:
place order or provide at-home testing kit.
• FOBT – annually
• FIT-DNA (i.e. Cologuard
®
): current year -
2 years prior
• Flexible sigmoidoscopy: current year - 4
years prior
• CT Colonography: current year - 4 years
prior
• Colonoscopy: current year - 9 years prior
Exclusions: History of colorectal cancer or
a total colectomy
Goal: Cancer detection
Controlling High Blood Pressure
(CBP)
Patient Population
• Ages 18–85
• Hypertension diagnosis
Action:
• Take and record BP
• Repeat BP if value is 140/90 or higher
(139/89 or less is compliant)
Goal: Ensure blood pressure (BP) is
adequately controlled (<=139/89 mmHg)
during measurement year.
Diabetes
Patient Population
• Ages 18-75
• Diabetes diagnosis
• Dispensed insulin or hypoglycemics/
antihyperglycemics
Action:
• Measure and report all of the following
labs:
— HbA1c or glucose management
indicator (GMI)
— eGFR ages 18-85
— Urine Albumin-Creatinine Ratio
(uACR) ages 18-85
— Albumin/microalbumin and a urine
creatinine test (<4 days of each other)
• Consider prescribing a statin (ages
40-75)
• Take and record BP
— Repeat the BP if either value is
140/90 or higher (139/90 or 140/89
are not compliant)
• Refer to eye care provider for retinopathy
screening
• Refer to Disease Management for help
managing HbA1c through the online
provider portal or call 702-242-7546
Goal: To measure control of diabetes.
This guide is not comprehensive; for
additional resources use your phone to scan
the QR code below.
Healthplanofnevada.com/Provider/
HEDIS-Measures
This guide is a tool to help close HEDIS gaps in care; it is a quick reference for common preventive health screenings for anyone with the ability to impact measures (i.e. clinicians, administrators and staff).
The below information describes the measure population, action(s) to close the gap and goal. It is not designed to replace clinical judgment but as a support to reinforce the importance of preventive care and
share how clinical decisions impact HEDIS.
Social Determinants of Health (SDoH) such as food insecurity, homelessness or housing instability, psychosocial circumstances, economic challenges, etc. have been identied as key factors
in impacting a patient’s health and health outcomes. Coding for these can bring attention to their prevalence and help identify needed resources.
Provider Resource Guide 2024
HEDIS
®
Adult Measures
Behavioral Health (BH)
Patients with Substance use
Disorders (SUD)
To determine an SUD and the appropriate
level of treatment, the recommendation
is to utilize Screening, Brief Intervention
and Referral to Treatment (SBIRT).
When diagnosing an SUD consider
higher severity (i.e. active SUD) vs lower
severity (hazardous substance use) and
whether substance use is in early or
sustained remission. Schedule a follow-up
appointment or refer to a mental health
provider to engage patient and discuss
motivation to change.
For more information on behavioral health
services please reach out to 702-364-1484.
Follow-Up After Emergency
Department Visit for Mental Illness
(FUM)
Patient Population:
• Ages 6 years and older
• Principal diagnosis of mental illness or
intentional self-harm
Action:
• 7-day follow-up for mental illness within
7 days after the ED visit (8 days total)
• 30-day follow-up for mental illness within
30 days after the ED visit (31 days total)
Goal: Ensure proper follow-up care after a
mental health ED visit
Cardiovascular Monitoring for
People With Cardiovascular Disease
and Schizophrenia (SMC)
Patient Population
• Ages 18-64
• Cardiovascular disease
• Schizophrenia or schizoaffective disorder
Action:
Place order or complete the following lab
during the year:
• LDL-C
Goal: Metabolic monitoring
Diabetes Screening for People w/
Schizophrenia or Bipolar Disorder
Who Are Using Antipsychotic
Medications (SSD)
Patient Population
• Ages 18-64
• Schizophrenia, schizoaffective or bipolar
disorder diagnosis
• Dispensed antipsychotic medication
Action:
Place order or complete the following lab
during the year:
• Blood glucose or HbA1c
Goal: Metabolic monitoring
Women’s Measures
Cervical Cancer Screening (CCS)
Patient Population
• Women ages 21-64 who have not been
screened for cervical cancer
Action:
Schedule, perform, and document the
applicable screening and result:
• Pap smear in the measurement year or 2
years prior (ages 21-64).
• High-risk human papillomavirus (hrHPV)
testing in the measurement year or 4
years prior (ages 30-64).
• Document type of service, date
performed and result
Exclusions: Hysterectomy with no residual
cervix, male to female transgender, cervical
agenesis or acquired absence of cervix
(document total hysterectomy)
Goal: Cancer detection
Breast Cancer Screening (BCS)
Patient Population
• Women ages 50-74 who have not had a
mammogram in 2 years
Action:
Schedule or place referral for a
mammogram
Exclusion: Bilateral mastectomy
Goal: Cancer detection
Chlamydia Screening in Women
(CHL)
Patient Population
• Women ages 16-24 on birth control
• Sexually Active
Action:
Perform a chlamydia test if one hasn’t been
done within the year.
Goal: Chlamydia detection
Prenatal Care (PPC)/Prenatal
Immunization Status (PRS)/Prenatal
Depression Screening and Follow-
Up (PND)
Patient Population
• Diagnosed pregnancy
• Prenatal care visit in the 1st trimester
Action:
• Perform and document date of prenatal
visit
• Indicators of pregnancy: prenatal ow
sheet, LMP, EDD, positive pregnancy
test result, gravidity and parity, complete
obstetrical history, fetal heart tones,
measurement of fundus height, prenatal
risk assessment and counseling/
education
• Complete depression screening
(document test type and score); follow
up on positive screenings within 30 days
• Schedule inuenza & Tdap vaccinations
Goal: Ensuring early initiation of prenatal
care
Postpartum Care (PPC)/Postpartum
Depression Screening and Follow-
Up (PDS)
Patient Population
• Delivery of live birth(s)
Action:
Perform and document a postpartum visit
on or between 7–84 days (1-12 weeks) after
delivery and one of the following:
• Postpartum care (PP care, PP check,
etc.), pelvic exam, evaluation of
weight, BP, breasts and abdomen,
perineal or cesarean incision/wound
check, screening for depression,
anxiety, tobacco use, substance
use disorder or pre-existing mental
health disorders, glucose screening
for women with gestational diabetes,
infant care/breast feeding, resumption
of intercourse, family planning, sleep/
fatigue, resumption of physical activity or
attainment of healthy weight
• Complete depression screening
(document test type and score); follow
up on positive screenings within 30 days
Goal: Setting the stage for long-term health
and well-being of new mothers and their
infants
This guide is not comprehensive; for
additional resources use your phone to scan
the QR code below.
Healthplanofnevada.com/Provider/
HEDIS-Measures
Provider Resource Guide 2024
HEDIS
®
Behavioral Health & Women’s Measures
This guide is a tool to help close HEDIS gaps in care; it is a quick reference for common preventive health screenings for anyone with the ability to impact measures (i.e. clinicians, administrators and staff).
The below information describes the measure population, action(s) to close the gap and goal. It is not designed to replace clinical judgment but as a support to reinforce the importance of preventive care and
share how clinical decisions impact HEDIS.
Social Determinants of Health (SDoH) such as food insecurity, homelessness or housing instability, psychosocial circumstances, economic challenges, etc. have been identied as key factors
in impacting a patient’s health and health outcomes. Coding for these can bring attention to their prevalence and help identify needed resources.
