by Pat Scheer, HNE Quality Operations Manager

Increasingly, the Healthcare Effectiveness Data and Information Set (HEDIS) measures are moving away from merely counting the number of tests performed, but also adding information about the result of the test.

A case in point would be reporting a blood pressure for a diabetic. The measure now requires that information about the BP levels be collected and reported regarding the percent of diabetic members whose BP is <130/80, ≥130/80, <140/90, and  ≥140/90.

Until recently, the BP level was available only through medical record review. As a major step toward collecting more information through claims submitted by providers rather than through medical record review, the National Committee for Quality Assurance (NCQA) and the American Medical Association (AMA) have developed a set of procedure codes. The Current Procedural Terminology (CPT) Category II codes are specific to the HEDIS measures, and report such things as LDL-C level, A1c level and even BP level.

Physicians are urged to add a line or two to the claims they submit in order for these items to be measured through claims data rather than having to pull the medical record, copy pertinent pages and submit the medical record information to HNE when requested. Thus, a claim that included the CPT Category II codes shown below would indicate his/her BP was the level indicated all without having the physician office having to go through the extra steps of providing the medical record documentation.

¹HEDIS is a registered trademark of the National Committee for Quality Assurance

(NCQA)