Humana's Your Practice

Tips for Improving HEDIS Results

Humana utilizes the Health Plan Employer Data and Information Set (HEDIS®) to assess its performance in meeting clinical care guidelines and satisfying members’ needs. Measures cover a variety of clinical and preventive indicators including immunizations, cancer screenings, prenatal care, asthma, diabetes, hypertension and heart disease monitoring.

Humana, in collaboration with its network physicians, collects HEDIS information annually on individual member care through claims and encounter data and medical record documentation. Physicians can help facilitate that the care provided in their offices is acknowledged in the HEDIS assessment by:
• Providing the appropriate care within the designated time frames
• Accurately coding all claims and encounters
• Thoroughly documenting all care in the patient’s medical record

In addition, HEDIS measures look for documentation of specific information relating to certain common diagnoses and treatment protocols. Here are some tips for physicians in specific patient care areas that will help meet HEDIS assessment measures.

Comprehensive diabetic care

Patients diagnosed with Type 1 or Type 2 diabetes mellitus should have the following procedures completed as recommended in the American Diabetes Association clinical practice guidelines:
• Lipid profile done in measurement year or prior year (most recent LDL-C should be 100 or less)
• HbA1c (result should be 9.0 or less)
• Dilated eye exam
• Microabuminuria test or documented treatment for nephropathy
• The last BP reading*
• Foot exam (must specify “foot” in documentation)*

*Note: The last two items are not reported as HEDIS measures, but are audited by Humana to review other elements of diabetic management.

Cholesterol management after acute cardiac events

Lipid profile should be performed between 60 and 365 days after hospital discharge following an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA). The results must be documented in the medical record; the low-density lipoprotein cholesterol (LDL-C) result should be less than 100 milligrams.

Beta blocker treatment after AMI

The medical record should contain documentation that a prescription for a beta blocker was given within seven days of hospital discharge after an acute myocardial infarction (if not contraindicated); or it should contain documentation of an active prescription for a beta blocker prior to hospital admission. The patient should continue therapy for at least 180 days.

Controlling hypertension

The medical record should contain documentation confirming a diagnosis of hypertension and documentation of the last blood pressure reading. Adequate control is defined as a systolic blood pressure less than or equal to 140 and a diastolic blood pressure less than or equal to 90.

Cervical cancer screening

Medical records of all female patients above age 21 should include the results of a Pap smear done during the measurement year or the two prior years.

Breast cancer screening

Medical records of female patients above age 52 should include the results of a mammogram done during the measurement year or the prior year.

Colorectal cancer screening

For patients 50 and over, documentation of one of the following screening tests should be included in the medical record:
• Colonoscopy during the measurement year or prior nine years
• Flexible sigmoidoscopy during the measurement year or prior four years
• Barium enema during measurement year or prior four years
• Fecal occult blood test (three cards submitted by patient with results documented in the medical record) during the measurement year

Childhood immunizations

The medical records for all pediatric patients should contain all the documentation listed below. To achieve a “pass” score on this HEDIS measure, all vaccinations must be given on or before a child’s second birthday.
• Four DTP or DTAP vaccinations and the dates of administration
• Three IPV/OPV, one MMR, three H flu type B, three hepatitis B, one varicella zoster (VZV), and a pneumococcal vaccine or documentation of the disease or a seropositive result; documentation must include the specific date each antigen was given
• Mention of chicken pox in history is not sufficient; the record should include documentation of the child’s age when infected and/or the date of infection

Note: New pediatric patients must transfer prior immunization records to the current physician’s office to satisfy immunization documentation requirements.

Adolescent immunizations

The medical record should contain the documentation listed below as appropriate for the patient’s age. To achieve a “pass” score on this HEDIS measure, all vaccinations must be given on or before a child’s 13th birthday.
• One MMR on or between fourth and 13th birthdays OR two MMRs between first and fourth birthdays
• Three doses of hepatitis B or a completed two-dose hepatitis B regimen
• One varicella zoster (VZV) or documentation of the disease or a seropositive result; documentation must include the specific date each antigen was given
• Mention of chicken pox in history is not sufficient; the record should include documentation of the child’s age when infected and/or the date of infection

For more information about HEDIS performance measures, visit www.ncqa.org/Programs/HEDIS/.