Product Lines: EHP, Priority Partners, and USFHP.

Measurement Period: January 1–December 31.

Description:
The percentage of persons 5-64 years of age with an urgent care visit, acute inpatient discharge, observation stay discharge or ED visit with a diagnosis of asthma that had a corresponding outpatient follow-up visit with a diagnosis of asthma within 30 days.

Stratifications:
Age as of the episode date.

• 5–11 years.
• 12–17 years.
• 18–50 years.
• 51–64 years.

COPD diagnosis.

• Persons diagnosed with COPD (COPD Value Set) any time during the person’s history through the last day of the measurement period.
• Persons who did not meet criteria for the stratification above (i.e., did not have a diagnosis of COPD any time during the person’s history through the last day of the measurement period).

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS.

Initial Population:

• Measure Item Count: Episode.
• Age: 5–64 years of age as of the episode date.
• Benefits: Medical.
• Continuous Enrollment: Episode date through 30 days after episode date (31 total days).
• Allowable gap: None.

Definition:
Direct transfer: A direct transfer occurs when the discharge date from an initial stay is followed by an admission to a subsequent stay within one calendar day or less. Direct transfers can occur between different facilities and between acute inpatient and observation settings.

Asthma episode: An encounter between January 1 and December 1 with a diagnosis of asthma.

• For urgent care visits that result in an ED visit, the ED visit is the episode.
• For urgent care or ED visits that result in a nonacute inpatient stay, the urgent care or ED visit is the episode.
• For acute inpatient or observation stays that result in a nonacute inpatient stay, the acute inpatient or observation stay discharge is the episode.

Asthma episode date: The date of service for the asthma episode.

• For acute inpatient or observation stay discharges, the episode date is the date of discharge.
• For direct transfers, the episode date is the discharge date from the last transfer admission.
• For ED or urgent care visits, the episode date is the date of service.

Denominator:
Acute visits for asthma on or between January 1 and December 1 of the measurement period. Limit to One Episode per 31-Day Period.

• Urgent care visits (POS 20) with asthma diagnosis
• ED visits with asthma diagnosis
• Acute inpatient or observation discharges with asthma diagnosis

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerator:
30-day follow-up.

An outpatient visit, telephone visit, e-visit or virtual check-in (Outpatient and Telehealth Value Set) with a diagnosis of asthma (Asthma Value Set) within 30 days after the asthma episode. Do not include visits that occur on the same day as the asthma episode. Services provided in an urgent care setting (POS code 20) are not included.

Best Practice and Measure Tips

• New Measure for HEDIS MY 2026.
• Ensure Accurate Asthma Diagnosis Coding:
  • Use specific ICD-10 codes for asthma (e.g., J45.40–J45.998) to ensure episodes are correctly captured.
  • Avoid using unspecified or general respiratory codes that may not count toward the measure.
• Document All Encounter Types Clearly:
  • Clearly indicate urgent care, ED, inpatient, and observation stays in documentation and claims.
• Coordinate Post-Discharge Follow-Up:
  • Schedule follow-up visits within 30 days of an asthma-related Urgent Care, ED, Observation stay or hospitalization.
  • Use follow-ups to assess symptom control, medication adherence, and environmental triggers.
• Educate Patients on Asthma Action Plans:
  • Provide individualized asthma action plans and review them during visits.
  • Educate patients on early symptom recognition and when to seek care to prevent exacerbations.
• Optimize Controller Medication Use:
  • Ensure patients with persistent asthma are prescribed and adherent to controller medications (e.g., inhaled corticosteroids).
  • Reassess medication regimens regularly and adjust based on control levels.
• Reduce Avoidable ED Visits:
  • Encourage patients to use primary care or urgent care for non-emergent symptoms.
  • Offer same-day appointments or telehealth options to manage worsening symptoms early
• Track and Review Episodes:
  • Monitor patients with frequent exacerbations and implement care management strategies.
  • Use EHR alerts or registries to flag patients with recent asthma-related acute care visits.

These strategies not only improve HEDIS performance but also enhance patient outcomes and reduce unnecessary hospital utilization.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.
• Persons with a diagnosis of cystic fibrosis at any time in the person’s history through the last day of the measurement period. Laboratory claims (POS 81) with a diagnosis of cystic fibrosis will not be included in the exclusion.
• ED or urgent care visits followed by admission to acute inpatient or observation care within 31 days.
• Multiple episodes within a 31-day period: Only the first ED/urgent care visit or last inpatient/observation discharge episode is counted for the measure, all other episodes will be excluded.
• Direct transfers with a discharge after December 1 will be excluded.

Numerator Exclusions:

• Follow-up visits on the same day as the asthma episode.
• Follow-up provided in an urgent care setting (POS 20).

Exclusion Codes

Cystic Fibrosis

• ICD10PCS: E84.0, E84.11, E84.19, E84.8, E84.9
• SNOMED CT US Edition: 81423003, 86092005, 86555001, 190905008, 190909002, 235978006, 720401009, 762269004, 762270003, 762271004, 1296527009, 1296528004
  Measure Codes

Asthma

ICD10PCS: J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998

•  SNOMED CT US Edition: 11641008, 12428000, 18041002, 19849005, 34015007, 41553006, 55570000, 56968009, 57607007, 59786004, 63088003, 92807009, 93432008, 195949008, 195967001, 195977004, 225057002, 233678006, 233679003, 233683003, 233687002, 233688007, 233691007, 266361008, 281239006, 370218001, 370219009, 370220003, 370221004, 389145006, 404804003, 404806001, 404808000, 405944004, 407674008, 409663006, 418395004, 423889005, 424643009, 425969006, 426656000, 426979002, 427295004, 427603009, 427679007, 442025000, 445427006, 703953004, 703954005, 707444001, 707445000, 707446004, 707447008, 707511009, 707512002, 707513007, 707979007, 707980005, 707981009, 708090002, 708093000, 708094006, 708095007, 708096008, 733858005, 734904007, 734905008, 735588005, 735589002, 762521001, 782513000, 782520007, 786836003, 829976001, 1290026000, 401000119107, 901000119100, 1741000119102, 1751000119100, 5281000124103, 72301000119103, 99031000119107, 124991000119109, 125001000119103, 125011000119100, 125021000119107, 2360001000004109, 10674711000119105, 10674791000119101, 10674991000119104, 10675391000119101, 10675431000119106, 10675471000119109, 10675551000119104, 10675711000119106, 10675751000119107, 10675871000119106, 10675911000119109, 10675991000119100, 10676231000119102, 10676271000119104, 10676391000119108, 10676431000119103, 10676511000119109, 10676671000119102, 10692681000119108, 10692721000119102, 10692761000119107, 10742121000119104, 16055311000119107, 16584951000119101

COPD

• ICD10PCS: J44.0, J44.1, J44.81, J44.89, J44.9
• SNOMED CT US Edition:13645005, 135836000, 185086009, 195951007, 196001008, 285381006, 313296004, 313297008, 313299006, 1751000119100, 106001000119101, 293241000119100

Outpatient and Telehealth

• CPT: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99421, 99422, 99423, 99429, 99441, 99442, 99443, 99455, 99456, 99457, 99458, 99483
• HCPCS: G0071, G0402, G0438, G0439, G0463, G2010, G2012, G2250, G2251, G2252, T1015*
  • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC).
• SNOMED CT US Edition: 50357006, 77406008, 84251009, 86013001, 90526000, 185317003, 185463005, 185464004, 185465003, 209099002, 281036007, 314849005, 386472008, 386473003, 401267002, 439740005, 866149003, 3391000175108, 444971000124105, 456201000124103
• UBREV 0510, 0511, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0982, 0983