HEDIS Spotlight

HEDIS® (Healthcare Effectiveness Data and Information Set) is a widely used set of performance measures that ensures our members are getting the best health care possible. It is extremely important that our providers understand HEDIS® specifications and guidelines. This section highlights different HEDIS metrics in addition to providing descriptions of the measures, correct billing codes to support services rendered, and tips to direct you to corresponding resources and tools.   MEASURE: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS MEASURE DESCRIPTION: Members 6 years of age and older who were hospitalized for treatment of selected mental health diagnoses and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 and 30 days of discharge.   CODING: Codes to Identify Follow-up Visits (must be with a mental health practitioner) CPT®-: 99201-99205, 99211-99215, 99217-99220, 99341- 99345, 99347-99350 UB Rev (Visit in a behavioral health setting): 0513, 0900-0905, 0907, 0911-0919 UB Rev (Visit in a non-behavioral health setting): 0510, 0515-0523, 0526-0529, 0982, 0983   TIPS:

• The literature indicates that the patient is at greater risk for hospitalization within the first 7 days post-discharge, and that the risk of patient self-harm is high within the first 3 weeks post-discharge
• Ensure that the follow-up appointment is made before the patient leaves the hospital and is scheduled within 7 days of discharge
• Assist the patient with navigation of barriers, such as using their transportation benefit to get to their follow-up appointment
• Review medications with patients to ensure they understand the purpose and appropriate frequency and method of administration
• Ensure accurate discharge dates and document not just the appointments scheduled, but appointments kept. Visits must be with a mental health practitioner.
• Follow-up visits must be supported by a claim, encounter, or note from the mental health practitioner’s medical chart
• Patients with chronic mental illness who are receiving care in multiple care settings may benefit from the TCHP Case Management Program – please contact Case Management at 832-828-1430

MEASURE: Metabolic monitoring for children and adolescents on antipsychotics   MEASURE DESCRIPTION: Children age 1 – 17 years that had two or more antipsychotic prescription dispensing events of the same or different medications and had metabolic testing (Glucose or HbA1C and LDL –C or other cholesterol test).   CODING: Codes to identify Metabolic Testing Glucose test CPT: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951 HbA1C test CPT: 83036, 83037, 3044F-3046F LDL –C test CPT: 80061, 83700, 83701, 83704, 83721, 3048F-3050F Cholesterol tests other than LDL, CPT: 82465, 83718, 84478   TIPS: Stress importance to parent/caregiver of the need to have these tests performed Schedule follow-up appointments before patient leaves your office Have staff outreach no-show patients to reschedule   MEASURE: Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications   MEASURE DESCRIPTION: Patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test.   CODING: Glucose test CPT: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951 HbA1C test CPT: 83036, 83037, 3044F-3046F   TIPS:

• Screen your patients with these diagnoses that are taking antipsychotic medications yearly for diabetes
• Explain to the patient the importance of completing lab work ordered