During my years in managing HEDIS, I came across many data related issues that prevented valid procedures and diagnosis to be credited towards HEDIS measures. Below are common examples that usually require very little efforts and returns real percentage point in rates improvement.

 

 

Specialty Mapping

 

HEDIS specification requires specific provider type for administration of the procedure/diagnosis in order to consider the service as a numerator compliant "Hit". There are cases where eligible member (denominator member) had valid required procedure during the appropriate timeframe, however, rendering provider specialty which was FP was not mapped as Primary Care Provider and therefore the event was not credited. Typically, there are tens of sub specialties that can and should be mapped to few provider types mainly OB, PCP. The mapping list should be maintained and version controlled on a regular basis. It is crucial to make sure that every appropriate new sub-specialty will be mapped to the appropriate HEDIS provider type.

 

Mapping invalid/homegrown codes

 

Valid procedures/diagnoses at times are billed under non standards coding. The reason usually related to state or plan specific billing requirements. Nevertheless, these services can and should be used for HEDIS reporting. The challenge in many cases is identifying HEDIS invalid codes which are originated from standards corrupted/truncated vs. valid homegrown. Most HEDIS systems would not be able to identify those and would simply flag as invalid.  In order to maximize number of events existing in claims data, process, of homegrown codes identification and mapping to appropriate standard codes, should be applied as part of data conversion.

 

Identify coding misplacement (HCPCS, CPT, ICD, NDC, etc....)

 

A common issue that occurs during data conversion process is placement one type of code under different data element on the file layout. The reason usually goes back to the source data system (claims system) which hosts two types of procedure codes (HCPCS and CPT let's say) under the same "proce" column in claims table. Invalid code in these cases would simply be valid HCPCS that was placed under CPT column. Again, valid event which should be credited toward specific HEDIS measure will not be counted.

 

Supplemental databases

 

Growing trend in the past few years is pulling clinical data from external sources which does not reside in the claims system. Those external sources can be providers who either miscoded or did not bothered to submit claims at all due to capitation arrangement which is monthly flat fee not dependent on claim submission. Other sources would be third party vendors such as dental, vision and behavioral health or state bodies such as Kids registry, Lead registry, city encounters, family planning and such. In most case, these external data do not have member key identifier and need to be match via other methods such as first/last name, date of birth and address. Other challenge in some cases would be mapping their internal codes (or service description) to standards in order to allow recognition per HEDIS specs.

 

 

For additional information/questions, please do not hesitate to contact me at info@hedis-consultant.com