HEDIS Measure Specifications

HEDIS Measure Required Documentation Provider Specialty Exclusions
Childhood Immunizations

Complete immunizations on or before child's 2nd birthday: Combo 3

  • 4 doses - Dtap/DT
  • 4 doses - PCV
  • 3 doses - IPV
  • 3 doses - Hep B
  • 3 doses - Hib
  • 1 dose - MMR
  • 1 dose - VZV

Document the first Hep B vaccine given a the hospital or at birth when applicable, or if unavailable name of hospital where child was born.

No provider requirements specified Exclusion: Document all seropositive and illness history of chicken pox, measles, mumps and rubella. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978
Well Child Visits: Members age 3 - 6 years One Well Child Visit with a PCPC during the measurement year.
All three components of a Well Child Visit must be included:
  • Health and Developmental History (physical and mental)
  • Physical Examination
  • Health Education/Anticipatory Guidance
PCP  
Controlling High Blood Pressure: Members age 18 - 85 years Documentation of the most recent blood pressure (BP) reading during the measurement year after the diagnosis of hypertension was made.
Documentation of diagnosis with hypertension (HTN) prior to June 30th of measurement year and evidence of adequately controlled BP (<140/90) during the measurement year.
No provider requirements specified  
Diabetic Care - HbA1c Test: Members age 18-75 years with a diagnosis of diabetes A copy of HbA1c test result from the measurement year or a note from the
medical record indicating the date when the HbA1c test was performed and the test results.
No provider requirements specified Exclusions: Members that are not diabetic per current PCP documentation OR members with a diagnosis of polycystic ovaries, gestational diabetes, or steroid induced diabetes. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978
Cervical CancerScreening: Women ages 21-64 years

The lab result or a note from the medical record indicating the date when the cervical cytology was performed and the result or finding.Women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

  • Women ages 21-64 who had cervical cytology performed every 3 years
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing every 5 years

The following does not qualify:

  • Lab results that indicate inadequate sample of no cervical cells
  • Referral to OB/GYN alone
  • Biopsies are considered diagnostic
No provider requirements specified Exclusions :Documentation of Total Hysterectomy. Partial Hysterectomy can only be used if absence of cervix is documented. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Members age 3-17 years Documentation of an outpatient visit with evidence of the following during the measurement year:
  • BMI Percentile documentation*
  • Counseling for nutrition
  • Counseling for physical activity
No provider requirements specified

Exclusions: Members with a diagnosis of pregnancy during the measurement year or year prior. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978
Adolescent Immunizations: Members who turn 13 years of age during measurement year One dose of meningococcal vaccine and one Tdap/Td. Documentation from the medical record indicating the name of the specific antigen and the date of the immunization or a certificate of immunization prepared by an authorized health care provider or agency, including the specific dates and types of immunizations administered. No provider requirements specified Exclusion: Anaphylactic reaction to the vaccine or its components. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978
Diabetic Care - Eye Exam: Members age 18-75 years with a diagnosis of diabetes An eye screening for diabetic retinal disease.. This includes diabetics who had one of the following:
  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
  • A negative retinal or dilated exam (negative for retinopathy) by an eye care professional (optometrist or ophthalmologist) in the year prior to the measurement year
Optometrist or Ophthalmologist  
Diabetic Care - Medical Attention to Nephropathy: Members age 18-75 years with a diagnosis of diabetes A nephropathy screening test or evidence of nephropathy. This includes diabetics who had one of the following during the measurement year:
  • A nephropathy screening test
  • Evidence of treatment for nephropathy or ACE/ARB therapy
  • Evidence of stage 4 chronic kidney disease (CKD Stage 4 Value Set).
  • Evidence of ESRD (ESRD Value Set).
  • Evidence of kidney transplant (Kidney Transplant Value Set).
  • A visit with a nephrologist, as identified by the organization’s specialty provider codes.
  • A positive urine macroalbumin test
  • A urine macroalbumin test (Urine Macroalbumin Tests Value Set) where laboratory data indicates a positive result.
  • At least one ACE inhibitor or ARB dispensing event (Table CDC-L)
No provider requirements specified  
Children and Adolescents Access to Primary Care: Members 12 months–19 years of age

Claim/encounter submission for PCP visit during the measurement year.

PCP  
Annual Monitoring for Patients on Persistent MedicationsMembers 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent in the measurement year.
  • Annual monitoring for members on ACE Inhibitors or ARBs must receive at least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year
  • Annual monitoring for members on Digoxin must receive at least one serum potassium, one serum creatinine and at least one serum digoxin therapeutic monitoring test in the measurement year.
  • Annual monitoring for members on Diuretics must receive at least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.
No provider requirements specified Exclusions: Members who had an inpatient (acute or non-acute) claim/encounter during the measurement year