HEDIS® Tips: Focus on Diabetes, Behavioral Health


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 providers to comply with SCDHHS' 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.

This alert emphasizes two conditions addressed in HEDIS® measures: diabetes and behavioral health. The following are tips to boost certain HEDIS® rates.

Tips to Avoid Noncompliance by a Focus on Special Conditions

For all patients:

  • HEDIS® measures members with either type of diabetes who had a hemoglobin A1c (HbA1c) test and a nephropathy screening/monitoring test during the year. Order the test/screening each year, and make sure they are documented in the chart. Failure to document monitoring for nephropathy, and incomplete or missing information from a specialist who may be monitoring nephropathy, will cause the patient not to be counted as compliant with the measure.
  • Review diabetes services needed at each office visit, for example, eye exam, nephropathy testing, etc. Refer patients annually to an optometrist or an ophthalmologist for an eye exam. Communicate the importance of this exam, and if possible, help coordinate scheduling.
  • Dilated or retinal eye exam, remote imaging and fundus photography can count as an eye exam if the results are assessed by an optometrist or ophthalmologist. Results must be documented.
  • Arrange for labs to be done before patient appointments. Give lab slips for next appointment after each visit.
  • If point-of-care HbA1c tests are completed in the office, include billing codes on the claim for the service performed. Also, ensure HbA1c result and date are documented in the chart.
  • When labs indicate “poor control” (HbA1c greater than 9%), adjusting therapies and repeating the labs later in the calendar year might result in an improved HbA1c, thereby improving performance on the related diabetes HEDIS® measures.
  • Make a note in the record of steroid-induced diabetes and/or gestational diabetes, if applicable.


For patients with behavioral health concerns:

  • For children newly diagnosed with attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD), schedule the first follow-up visit while the patient is still in the office to occur within 30 days of prescription fill. Then schedule at least two more subsequent follow-up visits to occur within the next nine months. Explain to the child’s caregiver that all these visits are necessary for multiple reasons, including making sure the dosage stays correct as the child grows and managing side effects.
  • Follow-up on new episodes of depression to assure the patient remains on medication for at least 12 weeks. Discuss when patients realistically should expect to see partial relief and greater relief of symptoms, potential side effects and what to do before stopping medications.
  • For patients who have been hospitalized for mental health disorders, HEDIS® measures whether the patient had follow-up treatment from a mental health practitioner within seven days of discharge. Outpatient visits that occur on the same day as discharge do not count toward the measure of follow-up treatment.  If the seven-day window is missed, the next best goal in terms of HEDIS measure compliance is to get treatment within 30 days. When possible, work with the hospital discharge planner to set up post-discharge appointments for patients with mental health disorders.  
  • For patients who have visited the emergency room with a principal diagnosis of mental illness or alcohol/other drug abuse without being admitted inpatient, HEDIS® measures whether the patient received follow-up treatment from a mental health care practitioner within seven days of discharge. If the seven-day window is missed, the next best goal in terms of HEDIS® measure compliance is to get treatment within 30 days.
  • Certain HEDIS rates measure screenings related to patients with behavioral health concerns. When managing care for patients with schizophrenia or bipolar disorder on antipsychotic medications, one tip is to schedule and follow up on a diabetes screening test at least once in the same year.
  • Patients with diabetes and schizophrenia are also measured on their rates of receiving an LDL-C screening. Consider arranging lab appointments when the member is in the office rather than relying on the member to follow through with lab appointments. Please note both the dates of the tests and results in medical records. Ensuring labs are done when the patients are in the office will help with success. Follow up with patients frequently to check for adherence to medication recommendations.   
  • Some HEDIS® measures are related to opioid use. For patients who are prescribed/use opioids, check the prescription registry to ensure you are aware of other instances in which your patients have been prescribed opioids by other providers.

Provider Feedback

What are the challenges that you face as a practitioner or an office manager in meeting HEDIS needs? Are there other HEDIS 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 contact the SCDHHS Quality Division at Quality@scdhhs.gov to provide feedback.

For other 2019 HEDIS Tips alerts, please see HEDIS and HEDIS Record Requests from January 2019 and HEDIS Tips from April 2019.  Medicaid MCOs are also a source for HEDIS information and specifications, including coding that is compliant with HEDIS specifications.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
*For more information about what counts for the HEDIS measure please refer to NCQA’s technical specifications/Managed Care Organization’s quality department.

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