HEDIS® Tip Sheets

We’ve created tip sheets to help you satisfy Healthcare Effectiveness Data and Information Set (HEDIS) measures and code appropriately. These measures from the National Committee for Quality Assurance (NCQA) help ensure our members receive appropriate care.

The tip sheets include measurement requirements, medical record best practices and billing codes. Compliance with HEDIS measures reduces the need for you to send medical records later for review.

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

  • Members 1 to 17 years old
  • Dispensed two or more antipsychotic medications during the year
  • Medications can be the same or different, if they’re dispensed on different dates
  • The goal is to test both blood glucose with either a glucose or HbA1c test, and cholesterol with either a cholesterol or LDL-C test.

Use of Opioids from Multiple Providers (UOP)

  • Members 18 years and older
  • Dispensed an opioid for ≥ 15 days
  • Three rates are reported. Members dispensed opioids from:
    • Four or more different prescribers
    • Four or more different pharmacies
    • Combination of four or more different prescribers and four or more different pharmacies

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

  • Members ages 13 years and older
  • Emergency department visit with the principal diagnosis of alcohol and other drug (AOD) abuse or dependence
  • Follow-up visits for AOD within:
    • 7 days of the emergency department visit
    • 30 days of the emergency department visit

Follow-Up After Emergency Department Visit for Mental Illness (FUM)

  • Members ages 6 years and older
  • Emergency department visit for mental illness
  • Follow-up visits for mental illness within:
    • 7 days of the emergency department visit
    • 30 days of the emergency department visit

Follow-Up Care for Children Prescribed ADHD Medication (ADD) Tip Sheet

  • Children ages 6 to 12
  • Newly1 filled attention-deficit hyperactivity disorder (ADHD) medication
  • Prescribed in the ambulatory setting

Antidepressant Medication Management (AMM) Tip Sheet

  • Members ages 18 and older
  • Diagnosed with major depression
  • Newly2 filled antidepressant medication

Diabetes Screening for Members Taking Antipsychotics (SSD) Tip Sheet

  • Members ages 18 to 64
  • Diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder
  • Received an antipsychotic medication at any time during the year

Treatment for Alcohol and Other Drugs (IET) Tip Sheet

  • Members ages 13 and older
  • Newly4 diagnosed with alcohol or other drug (AOD) abuse or dependence
  • Treatment may occur in the inpatient, residential, outpatient,5 medication-assisted treatment (MAT) or telehealth setting

Follow Up After Hospitalization for Mental Illness (FUH) Tip Sheet

  • Members ages 6 and older
  • Discharged from an acute inpatient hospital stay
  • Principal diagnosis at discharge is mental illness or intentional self-harm
  • Outpatient follow-up visits must be with a mental health provider6 (includes telehealth visits) or in certain outpatient7 settings

1 Defined as no ADHD medication filled in past 120 days

2 Defined as no antidepressant medication filled in past 105 days

3 The Z-code should only be used when documented with a weight diagnosis (e.g. overweight, obesity) as a secondary code, do not use as a stand-alone code because it is non-reimbursable.

4 Defined as no diagnosis of AOD abuse or dependence in previous 60 days

5 Outpatient treatment includes an intensive outpatient or partial hospital program

6 Psychologist, Psychiatrist, Clinical Social Worker, Mental Health Occupational Therapist, Psychiatric/Mental Health Nurse Practitioner/Clinical Nurse Specialist, Neuropsychologist, Psychoanalyst, Professional Counselor, Marriage and Family Therapist

7 Community mental health center, electroconvulsive therapy, transitional care management services and includes intensive outpatient or partial hospital programs

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.

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