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QUALITY AND STARS

NCQA confirms HEDIS® updates for Measurement Year (MY) 2024

With the August publication of the HEDIS Measurement Year 2024 Volume 2: Technical Specifications for Health Plans, the National Committee for Quality Assurance (NCQA) has now confirmed several proposed updates for the Measurement Year (MY) 2024 season following a public comment period earlier this year. Here, we break down these changes for health plans across three key themes.

Cross-cutting consolidation and simplification

As NCQA continues its focus on electronic clinical data acquisition, several measures are being moved from administrative/hybrid reporting to the electronic clinical data systems (ECDS)-only standard, including:

  • Follow-Up Care for Children Prescribed ADHD Medication (ADD)
  • Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
  • Colorectal Cancer Screening (COL)

Notably, Eye Exam for Patients With Diabetes (EED) will remain a hybrid measure for MY 2024.

Meanwhile, no new measures will be added for MY 2024 and four measures are being retired altogether:

  • Ambulatory Care (AMB)
  • Inpatient Utilization—General Hospital/Acute Care (IPU)
  • Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS)
  • Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

In addition, several General Guidelines have now been removed and repurposed elsewhere:

  • The Hospice and Deceased General Guidelines have moved to each applicable measure’s ”Required exclusions” specification
  • Restricting use of lab claims and CPT Category II codes with modifiers is now defined in measures directly for individual applicable value sets

Several value sets have been consolidated or removed:

  • The Observation Value Set has been retired from all measures using it
  • Conditions using multiple value sets have been combined into single, larger value sets
  • All value sets containing only one code have been removed and replaced with direct reference codes

Notably, NCQA also confirmed that for MY 2025, ICD-9 diagnosis and procedure codes will be removed from value sets.

Finally, for several measures, logic that previously required diagnoses in conjunction with visit setting codes has been simplified to require only diagnosis codes:

  • Advanced illness exclusion:
    • Simplified to two diagnoses on different dates of service or dispensed dementia medication
    • Now a required exclusion along with I-SNP, LTI, and frailty
  • Diabetes measure event/diagnosis criteria:
    • Claim/encounter data: Simplified to only require two diagnoses of diabetes on different dates of service during the MY or prior year (PY)
    • Pharmacy data: Added a requirement to also have a diagnosis of diabetes in the MY or PY, removing the Diabetes Exclusions Value Set exclusion as well
  • Osteoporosis Management In Women Who Had a Fracture (OMW) negative diagnosis history:
    • Simplified to fracture diagnosis 60 days prior to episode date
  • Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) required exclusions:
    • Simplified identifying members for whom first-line antipsychotic medications may be clinically appropriate; only requires applicable diagnoses on two different dates of service in the MY

Expansion of inclusivity and diversity initiatives

As NCQA seeks to advance gender-inclusive measurement for transgender health plan members, it is expanding the criteria for the Breast Cancer Screening (BCS-E) and Cervical Cancer Screening (CCS, CCS-E) measures.

These measures now identify members recommend for routine cancer screening using the following criteria:

  • Administrative gender of Female (AdministrativeGender F) at any time in the member’s history
  • Sex Assigned at Birth (LOINC 76689-9) of Female (LOINC LA3-6) at any time in the member’s history
  • Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse Female-typical) in the MY

New exclusions to these measures include:

  • BCS-E: Gender affirming chest surgery with a diagnosis of gender dysphoria in the member’s history
  • CCS, CCS-E: Sex Assigned at Birth (LOINC 76689-9) of Male (LOINC LA2-8) in the member’s history

In addition, to advance health equity, NCQA is adding nine additional measures for Race and Ethnicity Stratification (RES) reporting to the existing set of 13 measures, including:

  •  Follow-Up After Emergency Department Visit for Mental Illness (FUM)
  • Follow-Up After Hospitalization for Mental Illness (FUH)
  • Postpartum Depression Screening and Follow-Up (PDS-E)
  • Prenatal Depression Screening and Follow-Up (PND-E)
  • Childhood Immunization Status – Combination 10 (CIS-E)
  • Cervical Cancer Screening (CCS-E)
  • Prenatal Immunization Status (PRS-E)
  • Kidney Health Evaluation for Patients With Diabetes (KED)
  • Eye Exam for Patients With Diabetes (EED)

Introduction of further consistency and specificity

We continue to see efforts from NCQA to ensure cross-measure consistency in verbiage and measure structure. There are also multiple instances where NCQA has added more detailed, specific requirements to the specification than in prior years. These additional changes include:

  • Shifting to more consistent use of “days” instead of “months” or “years” within measure language (e.g., replacing “The MY and the 2 years prior to the MY” with “the MY and the 730 days prior to the MY”)
  • Splitting value sets that were a combination of ICD diagnoses with other code systems; “do not include laboratory claims” requirement has been added next to all ICD diagnosis-only value sets
  • Aligning the age stratifications for the Kidney Health Evaluation for Patients With Diabetes (KED) measure with the National Kidney Foundation, adjusting the 65-74 and 75-85 age groups to now be 65-75 and 76-85
  • Introducing a new audit term, “secondary source validation” (SSV), in the Supplemental Data General Guideline (GG) regarding how to audit NCQA Data Aggregator Validation (DAV) data that has had post-processing performed
  • Defining requirements to deduplicate multiple delivery claims; adding “if a member has more than one delivery in a 180-day period, include only the first eligible delivery.” The new requirement impacts the following measures:
    • Prenatal Immunization Status (PRS-E)
    • Postpartum Depression Screening and Follow-Up (PDS-E)
    • Prenatal Depression Screening and Follow-Up (PND-E)
    • Prenatal and Postpartum Care (PPC)
  • Renaming the HbA1c Control for Patients With Diabetes (HBD) measure to the Glycemic Status Assessment for Patients With Diabetes (GSD) measure, introducing a new glucose management indicator (LOINC 97506-0) option for compliance

As these changes demonstrate, keeping up with the complexities of evolving HEDIS reporting requirements can be difficult without the right support in place. Learn why Cotiviti’s Quality Intelligence was a top performer in the 2023 Best in KLAS® ratings, empowering health plans to:

  • Drill down to member-level claim detail for optimal insight and analysis
  • Customize views to display the most meaningful data and facilitate smooth workflows
  • Set goals and benchmarks to monitor progress in real time
  • Gain visibility and insight at every level to find your best improvement opportunities through our transparent data model

Read the fact sheet

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

WRITTEN BY

Samantha Davis
Samantha is the HEDIS program manager supporting Cotiviti’s Quality Intelligence solution. She has over 10 years of experience working in HEDIS and is primarily responsible for bridging her knowledge of HEDIS requirements to inform product roadmap, operations, and client collaboration, guiding the organization through the annual HEDIS update cycle.

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