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.
- Children ages 6 to 12
- Newly1 filled attention-deficit hyperactivity disorder (ADHD) medication
- Prescribed in the ambulatory setting
- Members ages 18 and older
- Diagnosed with major depression
- Newly2 filled antidepressant medication
- Members ages 18 to 64
- Diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder
- Received an antipsychotic medication at any time during the year
- 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
- Members ages 6 and older
- Discharged from an acute inpatient hospital stay
- Principal diagnosis at discharge is mental illness or intentional self-harm
- Outpatient5 visit can be a telehealth visit
- Follow-up visit must be with a mental health practitioner6
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
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.