Medicaid Managed Care Organizations (MCOs), who contract with the South Carolina Department of Health and Human Services (SCDHHS) for the provision of Medicaid services, request medical records from certain specific providers to comply with SCDHHS's requirements for reporting Healthcare Effectiveness Data and Information Set (HEDIS®). Thank you for cooperating with the MCOs' medical record requests and ensuring that any medical record vendors do so as well.
Tips to Avoid Noncompliance and Boost HEDIS Rates
Performance on certain HEDIS measures is dependent upon timeliness of care delivery. Sometimes, care delivered just one day late is enough to make a record noncompliant with the relevant HEDIS measures. There are tips to avoid noncompliance due to timeliness and other tips to boost specific HEDIS rates.
For all patients:
- Contact patients who are due for an annual preventive visit (physical, well-child visit, etc.) or are new to your practice. If you use Electronic Health Records (EHRs), consider using a flag to track patients due or overdue for visits or immunization. If you do not use EHRs, consider how you could create a manual tracking system.
- When possible, call patients several hours before appointments as a reminder, and include information about anything they might need to bring with them to the appointment. Ask for a commitment to make the appointment.
- Make sure your records indicate both weight and calculated body mass index (BMI) value, as height and weight alone do not count toward the related HEDIS measure. Please ensure your EHR is auto-calculating BMI if it has that ability. Note, for children younger than 20, include the BMI percentile as a value, e.g., 50th percentile, and BMI percentile plotted on an age-growth chart. BMI ranges and thresholds do not count toward HEDIS measure compliance; the measure requires a specific value (percentile).
- The HEDIS measure related to BMI is one that frequently prompts a medical record request since BMI is often not coded on claims; however, the HEDIS measure will count the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes Z68.51, Z68.52, Z68.53 and Z68.54 as compliant through claims, which decreases the number of record requests. Look for appropriate opportunities to code claims with the corresponding Z code.
- Schedule six well-child visits before child turns 15 months old. It may also help to schedule the next visit at each appointment.
- Consider making nutritional and weight management questioning and counseling routine and "document any advice given." Note nutritional behavior like appetite or meal patterns and eating/dieting habits. Note behaviors like exercise routines, participation in sports activities or bike riding.
- Consider extending your office hours for well visits into the evening, early morning or weekend for those patients unable to see you during standard business hours. Remember that extra access may also count toward patient-centered medical home recognition programs.
- Consider whether it would be appropriate to create standing orders for nurses and physician assistants in your practice to allow staff to identify opportunities to immunize.
- Consider creating a standing order for in-office lead testing for children ages 3 to 6, who haven't received previous lead screening. Note, a lead risk assessment questionnaire is not a compliant substitute for the lead screening HEDIS measure. Make sure records reflect both the date of the test and results or findings. Educate parents about the importance of testing, lead poisoning, potential sources of lead, pathways of exposure, how to avoid exposure and testing schedules. Develop a process to check medical records for lab results to follow up on previously ordered lead screenings. Sick and well-child visits may also serve as chances to encourage parents to have their child tested.
- Consider whether you could include information, such as lead testing screening, on appointment reminder cards.
- Make sure documentation of adolescent well-child visits include all of the following: medical history, physical and mental development histories, physical exam, health education and anticipatory guidance.
- Recommend immunizations to parents. It is believed that parents are more likely to agree with vaccinations when supported by their providers. Address common misconceptions about vaccinations.
- Vaccinate girls and boys for the human papillomavirus (HPV); complete the series before their thirteenth birthday. Doses not completed until after the patient turns 13 do not count toward the relevant HEDIS measure.
- Look for opportunities to turn such visits as sports physicals into well-child visits by including all necessary components of a well-child visit. Noting "cleared for sports" does not count toward the adolescent well child HEDIS measure.
For girls and women:
- Request copies of mammography results be sent to your office. Consider scheduling mammograms so that they occur before the patient's appointment with your office, so that you have the results available to review during the appointment.
- Annual urine screenings for chlamydia are compliant with the HEDIS chlamydia measure. Consider using any visit opportunity to screen for chlamydia in those patients who are sexually active. Ask your clinical staff whether chlamydia screening should be more routine. The HEDIS measure for chlamydia screenings applies to females ages 16 to 24.
- If your office does not perform chlamydia screenings or pap tests, refer members to an obstetrician or gynecologist (OB/GYN) or other appropriate provider and have copies of the results sent to you. Pap tests are not always done at OB/GYN visits, so please ask specifically whether a pap test has been done and request the result.
- Make sure records of cervical cancer screenings reflect both the date the test was performed and results or findings.
- Document any applicable surgical history of complete/total/radical abdominal or vaginal hysterectomy and make sure to include the year the surgery was performed.
- To boost the rates of cervical cancer and breast cancer screenings, consider what tools staff could use to educate patients. Examples might include handheld cards, charts, EMR flags and brochures. Patients' confusion over how the screenings apply to them is a common reason why they do not follow up on screenings.
- Schedule prenatal visits starting in the first trimester, or as early as possible, when a patient contacts you for an appointment. If possible, ask front office staff to prioritize scheduling newly pregnant patients to ensure prompt appointments in their first trimesters.
- If you use global billing/bundling, your claims may not routinely include the specific date information that counts toward the prenatal or postpartum HEDIS measures. Check to see if you have an opportunity to include specific dates of prenatal and postpartum visits on claims.
- Educate new moms on the need for a postpartum visit 21-56 days after hospital discharge, and schedule the visit. Remember that a day too early or a day too late makes the patient noncompliant with the HEDIS measure; ensure scheduling staff are aware of the importance of timely appointments. If a mother comes into the office for removal of staples after delivery, it is a prime opportunity for education and scheduling, but remember that an incision check does not count as a postpartum visit for compliance with the postpartum HEDIS measure.
For patients with pharyngitis, viral upper respiratory infection or acute bronchitis:
- For patients with pharyngitis, test for group A strep before prescribing antibiotics.
- Use educational materials that address the appropriate use of antibiotics in your waiting and treatment rooms.
- Consider referring to the illness as a "common cold," "chest cold" or "sore throat due to a cold," which are references that caregivers may be less likely to associate with the need for antibiotics. Steer the discussion to things patients can do to treat symptoms (e.g., rest, fluids, etc.). Write a prescription-like note for symptom relief such as over-the-counter (OTC) medicines (e.g., OTC cough medicine).
- Check the Centers for Disease Control and Prevention (CDC) website, cdc.gov, for helpful patient education materials, such as "prescription pad for viral infection."
- Let patients and caregivers know they can prevent infection by washing hands frequently, keeping eating utensils and drinking cups separate from other household members, washing toys in hot water and disinfectant soap, keeping away from work or school until symptoms improve, etc.
- Explain that using antibiotics when they're not needed can be harmful. Help patients understand that even though viral colds can cause mucus to be thick or change color, the change in mucus does not necessarily indicate the need for antibiotics. Help patients understand what symptoms to look for that DO indicate the need for further care.
- Consider advising patients to call back in a specified number of days (e.g., three days) if symptoms worsen, bearing in mind that antibiotics prescribed for children with upper respiratory illness after three days of onset do not count negatively toward the related HEDIS measure.
- If prescribing an antibiotic for a bacterial infection or comorbid condition in patients with uncomplicated acute bronchitis, be sure to use the diagnosis code for the bacterial infection or comorbid condition, which makes a difference to the corresponding HEDIS measures.
For patients prescribed attention deficit disorder (ADD) medications or antidepressant medications:
- Follow-up on new episodes of depression to boost the rates at which newly-diagnosed patients try medication for at least 12 consecutive weeks. Discuss when patients realistically should expect to see partial relief and an increase relief of symptoms, what to expect with side effects and what to do before stopping medications.
- Schedule follow-up visits for patients newly diagnosed with ADD or attention deficit hyperactivity disorder (ADHD) within 30 days of filling a prescription, and at least two more subsequent follow-up visits within the next nine months.
For patients with chronic obstructive pulmonary disease (COPD):
- Make sure medical records document appropriate spirometry testing for new COPD patients from one of the following sources: outpatient visits, acute inpatient encounters or transfers/readmissions. Document that spirometry testing was performed before starting pharmacotherapy treatment. Document spirometry tests on claims.
- Ask patients if they are taking their COPD prescriptions. The related HEDIS measure looks at patients discharged from the emergency room (ER) or hospital and whether they had a systemic corticosteroid within 14 days after discharge and a bronchodilator within 30 days of the event.
What are the challenges that you face as a practitioner or an office manager in meeting HEDIS needs? Are there other HEDIS compliance issues that you think SCDHHS should know about? SCDHHS is interested in learning how it can better improve the HEDIS program, which in turn improves health and reduces costs to the health system. Please call or email SCDHHS Quality Director Sharon Mancuso at (803) 898-2013 or Sharon.email@example.com to provide feedback.
Medicaid MCOs' quality departments are also a source for HEDIS questions and HEDIS specifications and compliant codes.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.