What is HEDIS?

• Patient demographics (full name, date of birth, etc.)
• Provider name, signature and credential
• Date of service (DOS)
• Encounter with multiple pages, patient demographic and provider information should be on every page.

Two measures specifications and examples:

Adult BMI Assessment (ABA)

This measure looks at the percentage of members ages 18 to 74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year (2016) or the year before the measurement year (2015).

For memberse age 21 and older, documentation in the medical record must include:

• Date of the Body Mass Index (BMI)
• Weight
• BMI Value

For members 18 to 20, documentation of BMI percentile is required:

• BMI documented as a percentage
• BMI percentile plotted on an age-growth chart

Notation of only height and weight does not meed criteria.

Weight assessment and counseling for nutrition and physical activity for children/adolescents (WCC)

This measure looks at the percentage of members ages three to 17 who had an outpatient visit with PCP and had evidence of BMI percentile that was documented, had documentation of counseling for nutrition and documentation of counseling for physical activity during the measurement year.

Guidelines for the three components for this measure should be documented at least once during the measurement year (2016):

• Height and weight in the measurement year
• BMI percentile (ages 3-15) or BMI value (Ages 16-17)
• Counseling for nutrition
• Counseling for physical activity

Quick tip: Moda members coming in for sports or school checkups? Turn these into complete child checkups. This benefits the member, and unclogs your schedules from overlapping visits.

Want to learn more? Explore our site for quality improvement tools and tips. We are here to help and if you have any comments about ways we can improve or are interested in learning more about the HEDIS process and results from our review, we would love to hear from you. Email us at [email protected] with your comments or questions.

• 24-hour access to accommodate scheduling
• Administrative efficiency
• Education and guidance
• Real-time approval for most cases
• Online reporting capabilities
• Increase to quality of care

Get started today!

To begin requesting prior authorizations through the Magellan Rx self-service portal, visit ih.magellanrx.com/ and select "New Access request-Provider" on the right side of the home page. Find out which medications require prior authorization through Magellan Rx at modahealth.com/medical/injectables. 

• Coding rules require that manifestation diagnosis codes, external causes of morbidity/injury codes and certain other diagnosis codes with specific sequencing instructions must always be reported as secondary to another diagnosis code.
• CMS also identifies specific diagnosis codes that are unacceptable as a principle diagnosis on facility claims. This CMS list will be applied to commercial claims for 2017 dates of service.

Any claim billed with primary diagnosis code that does not meet these requirements will deny with explanation code 992 (Primary diagnosis is invalid for this setting. Please resubmit with valid primary diagnosis).

To see Moda's Diagnosis Code Requirement reimbursement policies RPM053 and RPM054, visit

modahealth.com/medical/policies_reimburse.shtml. 

• One face-to-face visit with the prescribing provider within 30 days of medication initiation (even after a 'medication vacation' over summer months).
• Two additional visits with the prescribing provider over the next nine months, one of which can be a telephone visit.

A Moda Health advocate regularly reaches out to eligible patients and providers to facilitate appointment scheduling and answer any questions about the guidelines. If you have questions about Moda's care programs or if you would like to speak to an advocate, contact our care team at 855-718-1769.

NCQA's guidelines for follow-up care for children prescribed ADHD medication can be found here.

• Significant reduction in the primary composite outcome of death from CV causes, nonfatal myocardial infarction (MI; excluding silent MI), and nonfatal stroke vs. placebo (10.5% vs. 12.1%).
• Results driven by death from CV causes (nonfatal MI and stroke not statistically significant)
• Numerically higher incidence of nonfatal stroke with Jardiance than placebo (3.2% vs. 2.6%)
• Significant decrease in rates of death from CV causes (3.7% vs. 5.9%), death from any cause (5.7% vs. 8.3%) and hospitalization from heart failure (2.7% vs. 4.1%) with Jardiance vs. placebo, respectively.

• Strengthened warnings about acute kidney injury risk for Invokana and Farxiga:
• 101 post-marketing cases were reported from March 2013 to October 2015
• ~50% occurred within one month of initiating treatment, and most improved upon discontinuation
• FDA recommendations:
• Consider predisposing factors to acute kidney injury prior to prescribing
• Evaluate renal function prior to initiation as well as occasionally during therapy
• Educate patients on signs and symptoms of acute kidney injury
• If acute kidney injury occurs, discontinue the medication and treat kidney impairment promptly

Clinical pharmacist interpretation: While the CV outcomes data is promising, further evidence is needed to make a strong recommendation for SGLT2 inhibitors over other second-line diabetes treatment options. The new kidney warnings make individualizing therapy based on patient-specific factors even more critical.

References:

1. Zinman B, Wanner, C, Lachin J, et al. "Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes." N Engl J Med. 2015; 373: 2117-28.

2. FDA Strengthens Kidney Warnings for Diabetes Medicines Canagliflozin (Invokana, Invokamet) and Dapagliflozin (Farxiga, Xigduo XR)." FDA Drug Safety Communication. U.S. Food and Drug Administration, 14 June 2016. Web. 27 July 2016.