HEDIS Billing and Coding

The Healthcare Effectiveness Data and Information Set (HEDIS®) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service.

HEDIS rates are used to evaluate a health insurance company’s ability to engage its members in preventive health care practices. Physician-specific scores are used to evaluate practices’ ability to provide a wide array of care to their patients ranging from health screenings to medication management. These rates guide health plans and physicians in targeting quality improvement activities where they will have the greatest impact on member and patient health care outcomes.

WellSense uses HEDIS rates to ensure our members are offered the highest possible level of health care. To aid in documenting, coding, and billing HEDIS activities appropriately, we’ve developed a HEDIS Billing & Coding Guide for providers. Please note: This resource is not all-inclusive, and is not intended to replace professional coding standards.

Download HEDIS Billing & Coding Guide for Providers

How are the rates measured?

HEDIS rates are measured by using either administrative or hybrid data. Administrative measures are calculated based on claims or encounter data submitted to the health plan. Hybrid measures are calculated using administrative data plus a sample of medical record data. A random sample of member medical records are reviewed to abstract data for services that were rendered, but were not reported through claims or encounter data. Accurate and timely submission of administrative data reduces the necessity of medical record review.

How can I improve my HEDIS scores?

  • Submit accurate claim/encounter data for each and every service rendered
  • Ensure medical record documentation reflects all services billed
  • Bill (or report by encounter submission) for all services delivered, regardless of contract status
  • Consider including CPT II codes to reduce medical record requests
  • Continue to submit claim/encounter data on a timely basis

For more information about calculating or improving HEDIS scores, please contact us at 603-263-3079.