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HEDIS®: General Guidelines and Measure Descriptions

Best Practice and Measure Tips

How can I improve HEDIS scores?

Best practice to increase closure of gaps and provide details for member exclusions is to:

  • Maximize use of codes: Only codes will close gaps for Administrative Measures.
  • Submit claim/encounter data for every service in an accurate and timely manner.
  • Some measures collect more than one data element. Submit codes required for all elements.
  • Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not exclude member from CCS Measure).
  • Educate schedulers to review for needed screenings, tests and referrals.
  • Assist member with scheduling tests. Follow-up to ensure completes ordered screening.
  • Provide member education on disease process and rationale for tests.
  • Ask open ended questions to determine any barriers to care or treatment.
  • Collaborate with other providers member receives services from to help ensure care is comprehensive, safe and effective.
  • Refer members to a behavioral health professional as indicated.
  • Improve Medication Adherence:
    • Is treatment appropriate? Should therapy continue? Follow-up to assess how the medication is working.
    • Use prescription benefit at the pharmacy. Only prescription fills processed with a member’s health plan ID card can be used to measure a member’s adherence.
  • Talk with members about:
    • Why they’re on a medication, the importance of taking medication as prescribed and timely refills. Confirm instructions.
    • Any barriers? Are there concerns related to health benefits, side effects or cost? Any problems getting medications from pharmacy?
    • Develop a medication routine with each patient if they are on multiple medications that require them to be taken at different times.
    • Encourage members to utilize pill boxes or organizers.
    • Advise members to set up reminders or alarms for when medications are due.
    • Adjust the timing, frequency, amount and or dosage when possible to simplify the regimen.

Measure Exclusions

Exclusions: Exclusions are either Optional or Required. An exclusion will remove member from the measure denominator based on a diagnosis and/or procedure captured in their claim, encounter and or pharmacy data. If applicable, the exclusion is applied after claims data is processed within the certified HEDIS® software while the Annual HEDIS measure denominators are created.

  • Optional exclusions: Some measures allow using an exclusion based on measure compliance. If the member is not compliant, the optional exclusion can be used. Death is an optional exclusion for all measures.
  • Required exclusions: Must be applied as written as part of identifying the denominator.
  • Exclusions for hospice, palliative care, advanced illness, frailty and long-term nursing home residence exclusions are specified in HEDIS measures where the services being captured may not be of benefit for this population or may not be in line with patients’ goals of care.
  • Required Exclusions: HOSPICE/PALLIATIVE CARE: Members who use services or elect to use a benefit, regardless of when the services began in the measurement year. Supplemental data can be used for the hospice exclusion.
  • The below exclusions are calculated by the software based on administrative data. Supplemental or medical record data may not be used for these exclusions.
    • FRAILTY: Members ages 81 and older as of Dec. 31 of the measurement year who had a diagnosis of frailty in the measurement year (See Fraility Diagnosis Value Set).
    • FRAILITY AND ADVANCED ILLNESS: Members ages 66–80 as of Dec. 31 of the measurement year who had a diagnosis of frailty and advanced illness.*
  • NOTE: Advanced illness diagnosis in the measurement year or year prior.
  • Advanced illness is indicated by one of the following:
    • Two or more outpatient, observation, emergency (ER) or non-acute inpatient encounters or discharges on separate dates of service with a diagnosis of advanced illness.
    • One or more acute inpatient encounter(s) with a diagnosis of advanced illness.
    • One or more acute inpatient discharge(s) with a diagnosis of advanced illness on the discharge claim.
    • Dispensed a dementia medication: Donepezil, galantamine, rivastigmine or memantine.
    • Long Term Care: Medicare members ages 66 and older as of Dec. 31 of the measurement year who are either:
      • Enrolled in an Institutional Special Needs Plan (I-SNP).
      • Living long term in an institution.

Measure Codes

The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure.

Measure Codes listed for each measure are not all inclusive and subject to change based on the current NCQA Specifications for each measure. Below are common value sets for quick reference:

  • Telephone visits: Eligible measures will reference the Telephone Visits Value Set and or the Online Assessments Value Set.
    • Telephone Visits Value Set: CPT 98966-98968, 99441-99443.
  • Telephone Visits Modifiers: GT, 95:
    • GT: Via interactive audio and video telecommunication system.
    • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.
  • Telehealth Place of Service (POS) 02:
    • E-visit or virtual check-in (Online Assessments Value Set): 98969-98972, 99421-99444, 99457, G0071, G2010, G2012, G2061-G2063
  • Outpatient visit (Outpatient Value Set): CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99350, 99381-99385, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 G0402, G0438, G0439, G0463, T1015**.
  • Ambulatory outpatient visit: 92002, 92004, 92012, 92014, 99201-99205, 99211-99215, 99241-99245, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337, 99341-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99461, 99483, G0463, T1015**.
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
  • Urgent care center visit: S9083, S9088.
  • Hospice Intervention: 99377-00378.
    • HCPCS: G0182.
  • Palliative Care Encounter:
    • G9054 Oncology.
    • M1017 Patient admitted to palliative care services.
    • Z51.5 Encounter for palliative care.
  • Frailty Encounter:
    • CPT: 99504, 99509.
    • HCPCS: G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031.
    • Fraility Diagnosis Value Set:
      • [] Pressure ulcer
      • [M62.50] Muscle wasting and atrophy, not elsewhere classified, unspecified site
      • [M62.81] Muscle weakness (generalized)
      • [M62.84] Sarcopenia
      • [W01.0XXA] Fall
      • [W19.XXXA] Unspecified fall, initial encounter
      • [W19.XXXD] Unspecified fall, subsequent encounter
      • [W19.XXXS] Unspecified fall, sequela
      • [Y92.199] Unspecified place in other specified residential institution as the place of occurrence of the external cause
      • [Z59.3] Problems related to living in residential institution
      • [Z73.6] Limitation of activities due to disability
      • [Z74.01] Bed confinement status
      • [Z74.09] Other reduced mobility
      • [Z74.1] Need for assistance with personal care
      • [Z74.2] Need for assistance at home and no other household member able to render care
      • [Z74.3] Need for continuous supervision
      • [Z74.8] Other problems related to care provider dependency
      • [Z74.9] Problem related to care provider dependency, unspecified
      • [Z91.81] History of falling
      • [Z99.11] Dependence on respirator [ventilator] status
      • [Z99.3] Dependence on wheelchair
      • [Z99.81] Dependence on supplemental oxygen
      • [Z99.89] Dependence on other enabling machines and devices
  • Advanced Illness:
    • ICD-10: A81.00, A81.01,, A81.09,, C25.0,, C25.1,, C25.2,, C25.3,, C25.4,, C25.7,, C25.8,, C25.9,, C71.0,, C71.1,, C71.2,, C71.3,, C71.4,, C71.5,, C71.6, C71.7, C71.8, C71.9, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C91.00, C91.02, C92.00, C92.02, C93.00, C93.02, C93.90, C93.92, C93.Z0, C93.Z2, C94.30, C94.32, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F04, F10.27, F10.96, F10.97, G10, G12.21, G20, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, I09.81, I11.0, I12.0, I13.0, I13.11, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J68.4, J84.10, J84.112, J84.17, J96.10, J96.11, J96.12, J96.20, J96.21, J96.22, J96.90, J96.91, J96.92, J98.2, J98.3, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K74.0, K74.1, K74.2, K74.4, K74.5, K74.60, K74.69, N18.5, N18.6.

Data Reporting Terminology

  • Denominator: Number of members who qualify for measure criteria, based on NCQA technical specifications.
  • Numerator: The number of members who meet compliance criteria based on NCQA technical specifications for appropriate care, treatment or service.
  • Administrative Measures: Use the total eligible population for the denominator. Medical, pharmacy and encounter claims count toward the numerator. For some measures, supplemental data counts toward the numerator. Medical record review is not allowed for these measures.
  • Hybrid Measures: For the Annual HEDIS Audit Season, the denominator is a random sample of 411 members. This is created from a health plan’s total eligible population by the software following NCQA requirements. The numerator includes medical and pharmacy claims, encounters, medical record review data and supplemental data.
  • Supplemental Data: Standardized file process to collect data from sites to close gaps. • Synchronous telehealth requires real-time interactive audio and video telecommunications.
  • Telehealth is billed using standard CPT and HCPCS codes for professional services in conjunction with a telehealth modifier and/or a telehealth POS code.
  • CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present).
  • Asynchronous telehealth, sometimes referred to as an e-visit or virtual check-in, is not “real-time” but still requires two-way interaction between the member and provider.
    • Asynchronous telehealth can occur using a patient portal, secure text messaging or email.


  • Elements which require the last result in the Measurement Year may impact member compliance throughout the year. (Example: A1c in March 6.0 = compliant. June A1c test no result reported. System will default to >9 until the result is received.)
  • Member ages for each measure are based on different criteria. This may impact the age range to include additional ages. (Example: 18 years of age by December 31 of the measurement year- Consider when member turns 18 and include service performed during the measurement year when member was 17.) The files must have Auditor approval.