Coding & Reimbursement

A heads-up on HEDIS

By Suzanne L. Corcoran

Ophthalmology practices have become accustomed to receiving requests for medical records from Medicare Advantage plans and private payers. The purpose of these audits is to confirm diagnoses that might not have been reported on the claim — in particular, for diabetic patients. Here is more information for you about what is behind these “HEDIS” audits.

Q. What is HEDIS?

A. HEDIS stands for Healthcare Effectiveness Data and Information Set. This is a set of 81 health-care performance measures that assesses how well a health plan performs in the areas of quality of care, access to care and members’ satisfaction. The National Committee for Quality Assurance (NCQA) oversees the development and implementation of the HEDIS tool.

A HEDIS score makes it possible to compare the performance of health plans on an “apples-to-apples” basis. The plans combine their HEDIS scores with CAHPS (Consumer Assessment of Healthcare Providers and Systems) scores and NCQA Accreditation standards scores to receive the NCQA’s Health Insurance Plan Rating. The NCQA ratings list includes commercial payers, Medicare and Medicaid plans.

Q. What is the Health Insurance Plan Rating, and how does it work?

A. This is a score from 1 to 5 in 0.5 increments with 5 being the highest possible rating. This system is similar to CMS’s Five-Star Quality Rating System. A score of “5” represents the top 10% of health plans in their category, ranging down to a score of “1” representing the bottom 10% of health plans.

Health plans with high scores are eligible for financial bonuses from CMS, while those with low scores could be penalized or face restrictions on marketing their plans.

A recent article from Kaiser Health News, also published in USA Today,¹ describes some of the ways health plans use these ratings to improve their operations, as well as financial performance.

Q. Who uses HEDIS?

A. HEDIS scores (and the allied Health Insurance Plan Rating) are useful to anyone in the market to purchase a health plan. Beneficiaries, employers and other interested parties get objective information about health plans from HEDIS scores. Further, the health plans use HEDIS scores as a management and marketing tool. A high score represents a significant achievement and a competitive advantage compared to other health plans, and vice versa.

Private insurance plans with Medicare and Medicaid contracts are required to collect and submit HEDIS data as a component of their contracts. Without the data, a payer will not receive a rating, which is critical to its ability to sell its insurance plans.

Q. How does eye care feature in HEDIS scores and Health Insurance Plan Ratings?

A. A HEDIS measure taken is Comprehensive Diabetes Care; it includes:

• Hemoglobin A1c testing

• Blood pressure control

• Eye exam (retinal) performed

• Medical attention for nephropathy

Q. How does the health plan know the patient received these services?

A. Claims submission data will provide some of the necessary information to the payer about a HEDIS measure: for example, a claim using CPT 83036 or 83037 for a laboratory blood test to measure HbA1c. To report a dilated eye examination of the retina, an ophthalmologist or optometrist would typically use an office visit (either 920xx or 992xx) paired with an ICD-10 code for diabetes mellitus. Additionally, the claim may contain one or more Category II CPT codes.

• CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed

• CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed

• CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed

• CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)

Payers conduct chart reviews in order to gather the necessary data to report to the NCQA. Some practices have told us that including the above Category II codes on all of their claims has reduced the number of record requests they receive, although we cannot confirm that with any official source.

Q. How do primary-care providers (PCPs) fit into this matrix, and why do they care?

A. Collection of HEDIS data is usually a condition of participation in payer panels. NCQA developed the voluntary Diabetes Recognition Program to recognize clinicians who use evidence-based measures and provide excellent care to diabetic patients.²

According to the Centers for Disease Control and Prevention, “the age-adjusted percentage of adults aged 18 years or older with diagnosed diabetes receiving a dilated eye exam in the last year was 57.0% in 1994 and 62.8% in 2010.”³

Other organizations report that fewer than 50% of diabetics receive an annual eye exam. In the Hispanic population, compliance with this HEDIS measure is even lower.⁴ This represents an unacceptable level of eye care for diabetic patients and a poor HEDIS score on this measure.

To improve this situation, and the HEDIS scores, some PCPs are using telemedicine based on fundus photographs of patients with diabetes. An inexpensive, easy-to-use nonmydriatic camera is placed in the PCP’s office with an electronic link to a reading center that is staffed by an ophthalmologist or an optometrist. The fundus photographs substitute for a face-to-face visit with an eye doctor.⁵

Medicare doesn’t usually cover these photographs, but many private payers and Medicare Advantage plans are becoming more agreeable toward accepting them. OM

REFERENCES

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.