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Adult HEDIS Measures

Click the links below to review guidance on the medical record documentation required to be submitted to close HEDIS care gaps for Adults.

  • Age 3 years and older
    Documentation required for Gap Closure

    Dated progress note or dated lab report indicating a group A streptococcus test (Group A Strep Test) in the seven-day period from three days prior to the Episode date through three days after the episode date.

    Note: Episode date is the date of service (between 07/01/21-06/30/22) for any outpatient, telephone, observation or ED visit, e-visit or virtual check-in, with a diagnosis of pharyngitis.

    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Applicable HEDIS Program Primary Care Provider
  • Age 50-74 years
    Documentation required for Gap Closure Any one of the following:
    • A mammogram report for screening performed between 10/01/20 - 12/31/22
    • A dated progress note with the date of the mammogram
    • Unilateral mammogram must have documentation of unilateral mastectomy
    • A dated progress note with documentation of exclusion (date of bilateral mastectomy or two unilateral mastectomies)
    Note: Biopsies, breast ultrasounds and MRIs do not meet compliance for this measure because these are diagnostic and are not appropriate methods for primary breast cancer screening.
    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
    Women's Health
  • Age 18-85 years
    Documentation required for Gap Closure Any one of the following:
    • A dated progress note documenting the most recent BP in the measurement year
    • A vital sign flowsheet with name, date of birth and date of service
    Notes:
    • The last BP reading for the measurement year will determine compliance. The lowest systolic and lowest diastolic BP reading on the same date is considered the representative BP.
    • BP readings performed or taken by the member with a digital device are acceptable.
    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
    Cardiology
  • Age 21-64 years
    Documentation required for Gap Closure Any one of the following:
    • Dated lab/pathology report showing cervical cytology and the result or finding
    • A dated progress note indicating date and result or finding of cervical cytology/high risk HPV
      • age 21-64 years: Cervical cytology between 2020-2022 (if this criteria is not met, compliance may be achieved by the other two methods)
      • age 30-64 years: High risk HPV testing between 2018-2022 (age 30+ at time of test)
      • age 30-64 years: Cervical cytology with /high-risk HPV co-testing between 2018-2022 (age 30+ at time of test)
    Product(s) Impacted Medicaid
    Commercial
    Applicable HEDIS Program Primary Care Provider
    Women's Health
  • Age 16-24 years
    Documentation required for Gap Closure Any one of the following:
    • Dated lab report that shows screening performed in the measurement year
    • Dated progress note indicating screening done in the measurement year (results are not required)
    Product(s) Impacted Medicaid
    Commercial
    Applicable HEDIS Program Primary Care Provider
    Women's Health
  • Age 50-75 years
    Documentation required for Gap Closure Any one of the following:
    • A dated progress note indicating the procedure type and date of service:
      • Colonoscopy: 2013-2022
      • Sigmoidoscopy: 2018-2022
      • CT Colonography (Virtual Colonography): 2018-2022
      • FIT-DNA: 2020-2022
      • FOBT: 2022
    • A result is not required if the documentation is clearly part of the member's “medical history;” if not, the result or finding must also be present
    • A dated procedure or pathology report from the appropriate timeframe
    • Lab reports imported directly into the Electronic Health Record (EHR) from the appropriate time frame
    Note:
    Digital rectal exams (DRE), FOBT performed in the office setting or performed on a sample collected via DRE are not acceptable to meet this measure.
    Product(s) Impacted Medicare
    Commercial
    FIDE-SNP
    Applicable HEDIS Program Primary Care Provider
  • Age 18-75 years
    Documentation required for Gap Closure Any one of the following:
    • A dated progress note documenting the date of collection and result of the most recent HbA1c test
    • Lab report showing “report” or “result” date and the result
    • Lab results imported into the EHR by interface with date and result of HbA1C test
    Notes
    • In-office, point-of-care testing performed during the measurement year will also meet the metric when documented in the medical record and includes date and result. Submit the most recent HbA1c performed during the measurement year; the last HbA1c of the measurement year will determine compliance. Billing with administrative claim codes is preferred.
    • HbA1c >9 is an inverted measure meaning low rates of poor control indicate better care; (e.g. A1c of 9.1% is compliant, however A1c of 9.0% is not).
    Product(s) Impacted For A1c <8
    • Medicaid
    • Commercial
    For A1c >9
    • Medicare
    • FIDE-SNP
    Applicable HEDIS Program Primary Care Provider
    Endocrinology
  • Age 18-75 years
    Documentation required for Gap Closure Any one of the following:
    • A signed and dated report/progress note in the measurement year from an eye care professional
    • A progress note from the PCP indicating the eye care professional's name, date, and result of an ophthalmoscopic exam
    • A fundoscopic photo read by an eye care professional is eligible when signed, dated, and result is present
    • A negative eye exam for retinopathy from the previous year is compliant (positive results are not acceptable for the year prior)
    Note:
    Results read by a system that provides an artificial intelligence (AI) interpretation are acceptable.
    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
    Endocrinology
    Ophthalmology
  • Age 18-85 years
    Documentation required for Gap Closure Both of the following:
    1. Documentation of at least one eGFR
    2. Documentation of at least one uACR by either of the following:
      • Both a quantitative urine albumin test and a urine creatinine test with service dates four days or less apart
      • A uACR ( Urine Albumin Creatinine Ratio)
    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
    Endocrinology
  • Age 18-75 years
    Documentation required for Gap Closure Either of the following:
    • A dated progress note documenting the most recent BP in the measurement year
    • A vital sign flowsheet with name, date of birth and date of service
    Notes:
    • The last BP reading for the measurement year will determine compliance. The lowest systolic and lowest diastolic BP reading on the same date is considered the representative BP.
    • BP readings performed or taken by member with a digital device are acceptable.
    Product(s) Impacted Medicaid
    Medicare
    Commercial
    Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
    Endocrinology
  • Age 66 years and older
    Documentation required for Gap Closure Any one of the following:
    • Dated progress note in the measurement year with evidence of pain assessment
    • Result of standardized pain assessment tool performed in the measurement year (e.g., Numeric rating scales, Pictorial Pain Scales, Brief Pain Inventory, Chronic Pain Grades, etc.)
    Note: Do not include pain assessments performed in an acute inpatient setting. Notations alone of pain management plan, pain treatment plan, screening for chest pain or documentation of chest pain does not meet criteria.
    Product(s) Impacted Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
  • Age 66 years and older
    Documentation required for Gap Closure Any one of the following:
    • A current medication list (Rx, OTC, supplements), signed and dated during the measurement year by either a prescribing practitioner or clinical pharmacist (the practitioner's signature is considered evidence the medications were reviewed)
      Notation in the medical record that patient is “not taking medication”, and the date when it was noted
    Notes:
    • A review of side effects for a single medication at time of prescription is not sufficient.
    • An outpatient visit is not required to meet criteria. Do not include medication lists or medication reviews performed in an acute inpatient setting
    Product(s) Impacted Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
  • Age 66 years and older
    Documentation required for Gap Closure Dated progress note with evidence of a complete or comprehensive functional status assessment and must include ONE of the following:
    • Notation of at least five Activities of Daily Living (ADL)
    • Notation of at least four Instrumental Activities of Daily Living (IADL)
    • Result of a standardized functional status assessment tool (e.g., Bayer, Katz, etc.)
    • A progress note stating, “All ADL's met”
    Note: An outpatient visit is not required to meet criteria.

    COA Tip: Measure indicators, noted above, can take place during different visits in the measurement year to meet compliance
    Product(s) Impacted Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
    Applicable HEDIS Program Primary Care Provider
  • Age 18 years and older
    Documentation required for Gap Closure Documentation of medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, physician, physician assistant or registered nurse on the date of discharge through 30 days after discharge (31 days total)

    Documentation in the outpatient record must include evidence of the medication reconciliation and the date when it was performed; any ONE of the following meet criteria:
    • Documentation of the current medications with a notation that the provider reconciled the current and discharge medications
    • Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications)
    • Documentation of the member's current medications with a notation that the discharge medications were reviewed
    • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
    • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review; evidence that the member was seen for post-discharge hospital follow-up requires documentation that indicates the provider was aware of the member's hospitalization or discharge (documentation of “post-op/surgery follow-up” without a reference to “hospitalization,” “admission” or “inpatient stay” does not meet criteria)
    • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence that the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days)
    • Notation that no medications were prescribed or ordered upon discharge
    Note: A medication reconciliation performed without the member present meets criteria.
    Product(s) Impacted Medicare
    Applicable HEDIS Program Primary Care Provider
  • Age Not applicable
    Documentation required for Gap Closure A signed progress note indicating date of prenatal care visit (in first trimester or within 42 days of enrollment) with an appropriate provider (OB/GYN or other prenatal care provider or PCP) and evidence of ONE of the following:
    • Documentation indicating the woman is pregnant or references to the pregnancy, for example:
      • Documentation in a standardized prenatal flow sheet, or
      • Documentation of LMP, EDD, or gestational age, or
      • A positive pregnancy test result, or
      • Documentation of gravidity and parity, or
      • Documentation of complete OB history, or
      • Documentation of prenatal risk assessment and counseling/ education
    • A basic obstetric exam that includes:
      • Auscultation for fetal heart tones (FHT), or
      • Pelvic exam with obstetric observations, or
      • Measurement of fundal height (FH)
    • Evidence that a prenatal procedure was performed, such as:
      • Screening OB panel must include: hematocrit, WBC with differential, platelet count, hepatitis B antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO typing, or
      • TORCH antibody panel alone, or
      • A rubella antibody test/titer with Rh incompatibility (ABO/Rh) blood typing, or
      • Ultrasound of pregnant uterus
    Notes:
    • All visits with a PCP must include a diagnosis of pregnancy.
    • ACOG form with compliant info and provider signature log is acceptable.
    • Ultrasound and lab results must be linked to a prenatal care visit.
    Product(s) Impacted Medicaid
    Commercial
    Applicable HEDIS Program Women's Health
    Primary Care Provider
  • Age Not applicable
    Documentation required for Gap Closure Dated progress note with evidence of a postpartum visit with an OB/GYN or other pre-natal care practitioner or PCP, on or between 7 and 84 days after delivery that includes ONE of the following:
    • Evidence of a pelvic exam, or
    • Evaluation of weight, BP, breasts AND abdomen (“breastfeeding” is acceptable for the “evaluation of breasts”), or
    • Notation of “Postpartum (PP) Care, PP Care, PP check, six-week check” (a pre-printed postpartum care form is acceptable), or
    • Perineal or cesarean incision/wound check, or
    • Screening for depression, anxiety, substance use disorder, tobacco use or preexisting mental health disorder, or
    • Glucose screening for women with gestational diabetes, or
    • Documentation of any ONE of the following topics: infant care or breastfeeding, or resumption of intercourse, birth spacing or family planning, or sleep/fatigue, or resumption of physical activity, or attainment of healthy weight.
    Product(s) Impacted Medicaid
    Commercial
    Applicable HEDIS Program Women's Health
    Primary Care Provider