HEDIS®: General Guidelines and Measure Descriptions

HEDIS MY2023 Highlights

New measures

  • Topical Fluoride for Children (TFC).
  • Oral Evaluation, Dental Services (OED).
  • De-prescribing of Benzodiazepines in Older Adults (DBO).
  • Emergency Department Visits for Hypoglycemia in Older Adults with Diabetes (EDH). 
  • Cervical Cancer Screening (CCS-E).
  • Social Need Screening and Intervention (SNS-E).

Retired measures

  • Breast Cancer Screening (BCS)*
  • Annual Dental Visits (ADV). 
  • Frequency of Selected Procedures (FSP).
  • Flu Vaccinations for Adults Ages 18-64 (FVA).
  • Pneumococcal Vaccinations Status for Older Adults (PNU).

*Only the Breast Cancer Screening-E (BCS-E) measure will be reported.

Overall Changes

  • Moved all optional exclusions to required exclusions.
  • Measure Specifications and Measure Codes are subject to change by NCQA until the measures and codes are frozen by NCQA on March 31, 2023.  NCQA will release an update noting any measure or code changes at that time.  

Language Diversity and Race and Ethnicity (RES) Stratification is now required for the following measures:

  • Colorectal Cancer Screening.
  • Controlling High Blood Pressure.
  • Hemoglobin A1c Control for Patients With Diabetes.
  • Prenatal and Postpartum Care.
  • Child and Adolescent Well-Care Visits. 

New RES Measures for 2023:

  • Immunization for Adolescents (including IMA-E).
  • Asthma Medication Ratio.
  • Colorectal Cancer Screening (COL-E).
  • Follow-Up After Emergency Department Visit for Substance Use.
  • Pharmacotherapy for Opioid Use Disorder.
  • Initiation and Engagement of Substance Use Disorder Treatment.
  • Well-Child Visits in the First 30 Months of Life.
  • Breast Cancer Screening.
  • Adult Immunization Status.

Report only one of the 9 categories for race:

  • White.
  • Black or African American.
  • American Indian and Alaska Native.
  • Asian.
  • Native Hawaiian and Other Pacific Islander.
  • Some Other Race.
  • Two or More Races.
  • Asked but No Answer.
  • Unknown 

Report only one of the 4 categories for ethnicity:

  • Hispanic/Latino.
  • Not Hispanic/Latino.
  • Asked but No Answer. 
  • Unknown.

Language Diversity for Members:

  • Spoken language preferred for health care. Data collection guidance. This information can be gathered through questions such as:
    • What language do you feel most comfortable speaking with your clinician or health care provider?
    • What language do you feel most comfortable speaking with your doctor or nurse? 
    • In what language do you prefer to receive your medical care? 
    • In what language do you want us to speak to you? 
    • What language do you prefer to speak when you come to the medical center?
    • What  language do you feel most comfortable speaking?
  • Preferred language for written materials. Data collection guidance. This information can be gathered through questions such as:
    • In which language would you feel most comfortable reading health care information?
    • In which language would you feel most comfortable reading medical or health care instructions?
    • What language should we write [to] you in?
    • What is your preferred written language?
    • In what language do you prefer to read health-related materials?
    • What language do you prefer for written materials?
  • Other language needs. Data collection guidance. This category captures data collected from questions that cannot be mapped to any of the categories above, such as:
    • What is the primary language spoken at home?

Best Practice and Measure Tips: How can I improve HEDIS scores?

  • Maximize use of codes: Only codes will close gaps for Administrative Measures.
  • Submit claim/encounter data for every service in an accurate and timely manner.
  • Some measures collect more than one data element. Submit codes required for all elements.
  • Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not exclude member from CCS Measure).
  • Information from the medical record must validate all required measure or exclusion components.
  • Each medical record/office note MUST contain:
    • Member Name
    • Date OF Birth (DOB) 
    • Date OF Service (DOS)
    • Note: Information on a fax cover sheet cannot be used.
  • Only completed events count toward HEDIS compliance.
  • Documentation in a medical record of a diagnosis or procedure code alone does not comply with the numerator criteria.
  • A date must be specific enough to determine a test or service was performed within the time frame specified, not merely ordered.
  • An undated event on a problem list or history sheet can be used as long as it is specific enough to determine that the event occurred during the timeframe specified in the measure.
  • Educate schedulers to review for needed screenings, tests and referrals.
  • Assist member with scheduling tests. Follow-up to ensure completes ordered screening.
  • Provide member education on disease process and rationale for tests.
  • Ask open-ended questions to determine any barriers to care or treatment.
  • Collaborate with other providers member receives services from to help ensure care is comprehensive, safe and effective.
  • Refer members to a behavioral health professional as indicated.
  • Not Acceptable: Documenting terms such as “recent,” “most recent”, “at a prior visit” or “Colonoscopy up to date”. These are not specific enough to know when an event occurred.
  • Document any upcoming scheduled screening and name of provider who will be performing.
  • Incomplete information will not close gaps.

Improve Medication Adherence:

  • Is treatment appropriate? Should therapy continue? Follow-up to assess how the medication is working.

  • Use prescription benefit at the pharmacy. Only prescription fills processed with a member’s health plan ID card can be used to measure a member’s adherence.

Talk with members about:

  • Why they are on a medication, the importance of taking medication as prescribed and timely refills. Confirm instructions.
  • Any barriers? Are there concerns related to health benefits, side effects or cost? Any problems getting medications from pharmacy?
  • Develop a medication routine with each patient if they are on multiple medications that require them to be taken at different times.
  • Encourage members to utilize pillboxes or organizers.
  • Advise members to set up reminders or alarms for when medications are due.
  • Adjust the timing, frequency, amount and or dosage when possible to simplify the regimen.

Required Enrollment

  • To ensure there is enough time for member to receive services, each measure has criteria for:
    • Continuous enrollment:  Specifies the minimum amount of time that a member must be enrolled with an organization before becoming eligible for a measure
    • A gap is the time when a member is not covered by the organization.  An allowable gap can occur any time during continuous enrollment.
    • Anchor date:  If a measure requires a member to be enrolled and to have a benefit on a specific date, the allowable gap must not include that date; the member must also have the benefit on that date.

Measure Exclusions

An exclusion will remove a member from the measure denominator based on information captured in claims, encounter, pharmacy, and/or enrollment data. 

  • Required exclusions: Must be applied as part of identifying the denominator.
  • Exclusions for hospice, palliative care, advanced illness, frailty and long-term nursing home residence exclusions are specified in HEDIS measures where the services being captured may not be of benefit for this population or may not be in line with patients’ goals of care.
  • The below exclusions are calculated by the software based on administrative data.  Supplemental or medical record data may not be used for these exclusions. 
    • FRAILTY: Members ages 81 and older as of Dec. 31 of the measurement year who had a diagnosis of frailty in the measurement year (See Frailty Diagnosis Value Set).
    • FRAILITY AND ADVANCED ILLNESS: Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness. Members must meet BOTH of the following frailty and advanced illness criteria to be excluded: 
      • Frailty: At least two indications with different dates of service during the measurement year. 
      • Advanced illness is indicated by one of the following: 
        • Two or more outpatient, observation, emergency (ER) or non-acute inpatient encounters or discharges on separate dates of service with a diagnosis of advanced illness.
        • One or more acute inpatient encounter(s) with a diagnosis of advanced illness.
        • One or more acute inpatient discharge(s) with a diagnosis of advanced illness on the discharge claim.
        • NOTE: Advanced illness diagnosis must occur in the measurement year or year prior.
        • Dispensed a dementia medication: Donepezil, Galantamine, Rivastigmine, Memantine or Donepezil-memantine.
    • Long Term Care: Medicare members ages 66 and older as of Dec. 31 of the measurement year who are either: 
      • Enrolled in an Institutional Special Needs Plan (I-SNP).
      • Living long term in an institution.

Measure Codes

The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure.

Measure Codes listed for each measure are not all inclusive and subject to change based on the current NCQA Specifications for each measure. Below are common value sets for quick reference:

  • Telephone Visits: Eligible measures will reference the Telephone Visits Value Set and or the Online Assessments Value Set. 
    • Telephone Visits Value Set: CPT  98966-98968, 99441-99443.
    • E-visit or virtual check-in (Online Assessments Value Set):
      • CPT: 98970-98972, 99421- 99423, 99444, 99457, 99458
      • NOTE: Effective January 1, 2020, CPT code 98969 was deleted from the AMA CPT Code list. 
      • HCPCS: G0071, G2010, G2012, G2061-G2063, G2250- G2252
    • Telephone Visits Modifiers Value Set: GT, 95: 
      • GT: Via interactive audio and video telecommunication system.
      • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.
    • Telehealth Place of Service (POS) (Telehealth POS Value Set): 02, 10: 
      • 02: Telehealth Provided Other than in Patient’s Home
      • 10: Telehealth Provided in Patient’s Home
  • Outpatient Visit (Outpatient Value Set): 
    • CPT: 99202-99205, 99211-99215, 99241-99245, 99341- 99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483
      • NOTE: Effective January 1, 2020, CPT code 99201 was deleted from the AMA CPT Code list. However, CPT code 99201 will be used for claim data reporting prior to code deletion. 
    • HCPCS: G0402, G0438, G0439, G0463, T1015**.
    • UBREV: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0982, 0983
    • Outpatient Place of Service (POS): 
05Indian Health Service Free-standing Facility
07Tribal 638 Free-standing Facility
09Prison/Correctional Facility
13Assisted Living Facility
14Group Home
15Mobile Unit
16Temporary Lodging
17Walk-in Retail Health Clinic
18Place of Employment-Worksite
19Off Campus-Outpatient Hospital
20Urgent Care Facility
22On Campus-Outpatient Hospital
33Custodial Care Facility
49Independent Clinic
50Federally Qualified Health Center
71Public Health Clinic
72Rural Health Clinic


  • Ambulatory Outpatient Visit Value Set: 
    • CPT: 92002, 92004, 92012, 92014, 99202-99205, 99211-99215, 99241-99245, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99461, 99483
      • NOTE: Effective January 1, 2020, CPT code 99201 was deleted from the AMA CPT Code list. However, CPT code 99201 will be used for claim data reporting prior to code deletion. 
    • HCPCS: G0463, T1015**.
      • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
    • UBREV: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0524, 0525, 0526, 0527, 0528, 0529, 0982, 0983
  • Hospice Encounter Value Set: 
    • HCPCS: G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043,  T2044, T2045, T2046 
    • UBREV: 0115, 0125, 0135, 0145, 0155, 0235, 0650, 0651, 0652, 0655, 0656, 0657, 0658, 0659
  • Hospice Intervention: 
    • CPT:  99377-99378 
    • HCPCS: G0182
  • Palliative Care Encounter: 
    • G9054 Oncology
    • M1017 Patient admitted to palliative care services
    • Z51.5 Encounter for palliative care
      • Direct Reference Code for the following measure: ACP, BPD, CBP, CCS, COL, COU, CRE, DAE, DDE, EED, HBD, HDO, KED, LBP, OMW, OSW, SPC, SPC, SPD
  • Frailty Encounter: 
    • CPT: 99504, 99509
    • HCPCS: G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031.
    • Frailty Diagnosis Value Set: 
      • [L89.xxx] Pressure ulcer
      • [M62.50] Muscle wasting and atrophy, not elsewhere classified, unspecified site
      • [M62.81] Muscle weakness (generalized)
      • [M62.84] Sarcopenia
      • [W01.0XXA] Fall
      • [W19.XXXA] Unspecified fall, initial encounter
      • [W19.XXXD] Unspecified fall, subsequent encounter
      • [W19.XXXS] Unspecified fall, sequela
      • [Y92.199] Unspecified place in other specified residential institution as the place of occurrence of the external cause
      • [Z59.3] Problems related to living in residential institution
      • [Z73.6] Limitation of activities due to disability
      • [Z74.01] Bed confinement status
      • [Z74.09] Other reduced mobility
      • [Z74.1] Need for assistance with personal care
      • [Z74.2] Need for assistance at home and no other household member able to render care
      • [Z74.3] Need for continuous supervision
      • [Z74.8] Other problems related to care provider dependency
      • [Z74.9] Problem related to care provider dependency, unspecified
      • [Z91.81] History of falling
      • [Z99.11] Dependence on respirator [ventilator] status
      • [Z99.3] Dependence on wheelchair
      • [Z99.81] Dependence on supplemental oxygen
      • [Z99.89] Dependence on other enabling machines and devices
      • Additional codes apply
  • Advanced Illness: 
    • ICD-10-CM: A81.00, A81.01, A81.09, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.63 C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C91.00, C91.02, C92.00, C92.02, C93.00, C93.02, C93.90, C93.92, C93.Z0, C93.Z2, C94.30, C94.32, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F04, F10.27, F10.96, F10.97, G10, G12.21, G20, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G35, I09.81, I11.0, I12.0, I13.0, I13.11, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J68.4, J84.10, J84.112, J84.17, J84.170, J84.178, J96.10, J96.11, J96.12, J96.20, J96.21, J96.22, J96.90, J96.91, J96.92, J98.2, J98.3, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K74.0, K74.00, K74.01, K74.02, K74.1, K74.2, K74.4, K74.5, K74.60, K74.69, N18.5, N18.6.

HEDIS Terminology

  • Anchor dates: A measure may require a member to be enrolled and to have a benefit on a specific date.
  • Continuous enrollment: Specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. It ensures that the organization has enough time to render services. The continuous enrollment period and allowable gaps in coverage are specific to each measure.
  • Denominator – Number of members who qualify for measure criteria, based on NCQA technical specifications.
  • Element – Measurable way a HEDIS measure is broken down and defined. Also referred to as a sub-measure.
  • Eligible Population: all members who satisfy all specified criteria, including age, continuous enrollment, benefit, event and the anchor date enrollment requirement for the measure.
  • HEDIS Measure – Term for how each domain of care is further broken down. Specifications outline measure definition and details, which outline the specifications required to evaluate the recommended standards of quality for the element(s) in the measure. (Example: COL, BCS measures). NCQA defines how data can be collected for a measure:
    • Administrative Measures: The total eligible population is used for the denominator. Only data considered “administrative” is allowed. Medical, pharmacy, supplemental data, and / or encounter claims count toward the numerator. Medical record review is not allowed for these measures during the Annual Project.
    • Hybrid Measures: Data is collected during the Annual Project through medical record reviews, but can also be collected Prospectively. Most allow administrative data to be included. For the Annual HEDIS Audit Season, the denominator is a random sample of 411 members. This is created from a health plan’s total eligible population by the software following NCQA requirements. The numerator includes data from medical and pharmacy claims, encounters, medical record review data and supplemental data.
  • HEDIS Project – Timeframe during the year when data is collected. There are two Projects:
    • Annual Project – Also referred to as Retrospective. This is required by NCQA as part of Accreditation. For HYBRID Measures, the member population is based on a sample of members from each LOB. Administrative Measures look at the total member population. The Audit timeframe is January to May for data collection.
    • Prospective Project – Involves data collection for all LOB, for all members for the next Annual Project. The QI HEDIS Team data collection timeframe is June to January. However, throughout the year Johns Hopkins Health Plans prepares for the Annual Project in various ways to optimize audit results. Review of NCQA Specifications, and updates to training and educational materials are also performed during this time.
  • Line of Business (LOB) – Identifies the reporting population: Commercial (EHP, USFHP), Medicaid (Priority Partners) Medicare (Advantage MD)
  • Measurement Year (MY) – Refers to the year prior to the Reporting Year. NCQA Specifications reference in measure requirements and anchor dates.
  • Numerator: The number of members who meet compliance criteria based on NCQA technical specifications for appropriate care, treatment or service.
  • Prior Year (PY) – Year prior to measurement year.
  • Primary Source Validation (PSV) – Steps in the data validation process required by NCQA.
  • Reporting Year – Calendar year after the end of the MY during which the Annual HEDIS Audit occurs. (e.g., For MY2022, the Report Year is 2023).
  • Supplemental Data (Non-Standard) – Data collected prospectively which are not in a standard file layout. Medical record reviews are an example.
  • Supplemental Data (Standard): Standardized file process to collect data from sites to close gaps.
  • Sub-measure – A measure can be broken down into more specific data elements of care.
  • Telehealth: Telehealth is billed using standard CPT and HCPCS codes for professional services in conjunction with a telehealth modifier and/or a telehealth POS code.
    • Synchronous telehealth requires real-time interactive audio and video telecommunications.
      • Telehealth is billed using standard CPT and HCPCS codes for professional services in conjunction with a telehealth modifier and/or a telehealth POS code.
      • CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present).
  • Asynchronous telehealth sometimes referred to as an e-visit or virtual check-in, is not “real-time” but still requires two-way interaction between the member and provider.
    • Asynchronous telehealth can occur using a patient portal, secure text messaging or email.


  • Elements which require the last result in the Measurement Year may impact member compliance throughout the year. (Example: A1c in March 6.0 = compliant. June A1c test no result reported. System will default to >9 until the result is received.)
  • Member ages for each measure are based on different criteria. This may impact the age range to include additional ages. (Example: 18 years of age by December 31 of the measurement year- Consider when member turns 18 and include service performed during the measurement year when member was 17.) 

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