Adult HEDIS Measures

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 07/01/22-06/30/23) for any outpatient, telephone, observation or ED visit, e-visit or virtual check-in, with a diagnosis of pharyngitis.

• A mammogram report for screening performed between 10/01/21 - 12/31/23
• 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)

• A dated progress note documenting the most recent BP
• A vital sign flowsheet with name, date of birth and date of service

• 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.

• 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 2021-2023 (if this criteria is not met, compliance may be achieved by either of the two bullets noted below)
  • age 30-64 years: High risk HPV testing between 2019-2023 (age 30+ at time of test)
  • age 30-64 years: Cervical cytology with /high-risk HPV co-testing between 2019-2023 (age 30+ at time of test)

• Dated lab report that shows screening performed
• Dated progress note indicating screening done (results are not required)

• A dated progress note indicating the procedure type and date of service:
  • Colonoscopy: 2014-2023
  • Sigmoidoscopy: 2019-2023
  • CT Colonography (Virtual Colonography): 2019-2023
  • FIT-DNA: 2021-2023
  • FOBT: 2023
• 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

• 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

• 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).

• Medicaid
• Commercial

• Braven
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

• 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)

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)

• A dated progress note documenting the most recent BP
• A vital sign flowsheet with name, date of birth and date of service

• 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.

• Dated progress note with evidence of pain assessment (negative or positive findings)
• Result of standardized pain assessment tool (e.g., Numeric rating scales, Pictorial Pain Scales, Brief Pain Inventory, Chronic Pain Grades, etc.)

• A current medication list (Rx, OTC, supplements), signed and dated 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

• 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

• 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”

• 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

• Documentation indicating the member 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

• 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.

• 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 members 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.