What Is Hedis Chart Review?

What is a Hedis chart review A HEDIS chart review is when the National Committee for Quality Assurance (NCQA) reviews a patient’s medical records to determine if the quality of care measures have been met. Medical chart reviews are also the data source used by the NCQA to determine any incentives or financial rewards for health plans.

What is chart review used for?

Clinical record review or chart review is a previously recorded data to answer clinical queries. Such a study can be used to answer specific clinical questions in a relatively easy and less resource intensive manner. But these studies may be constrained by the limited information retrievable and inadequacy of records.

What is the concept of chart review?

What is chart review? Chart reviewing varies, but primarily entails reviewing medical necessity or authorizations, and making recommendations. This can be related to length of stay, medications/treatments, procedures, physical therapy or ancillary services, amongst other things.

1. Who do you work for? You can work for the insurance company, an Independent Review Organization, or the hospital itself (helping them in the appeals process with insurance companies).
2. How do you get involved? You can sign up with a number of companies.
3. If you are very motivated, you can find the names of a lot of the Independent Review Organizations on the National Association of Independent Review Organizations ( www.nairo.org/members ), and contact them each.

Many allow you to apply online. They usually contact you and tell you what they’re expecting from you in regards to time and expertise, and you can choose to take it or not. For some companies, the more reviews you do for them, the more that you will get, while others prefer to hire you for formal full time or part time positions.

1. What kind of experience do I need? Is there training required? This varies depending on the setting.
2. Hospitals tend to want somebody with more experience.
3. Most require board certification and a license to practice medicine.
4. Some companies want people who are practicing, but not all.
5. There is a certification that you can get through the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP, www.abqaurp.org/default.aspx ), which is likely not required, but after you’ve done over 200 hours of utilization review work, could be worth looking into to make yourself more marketable for the more competitive positions.

Some companies ask you to do a formal training (you should ask for compensation for this time). How do you set your rates? Pay varies greatly. For some companies you can set your rates and for others they tell you what they offer. It’s a supply and demand thing for most, so if companies have a large number of physicians to choose from, they usually aren’t willing to pay as much.

• If it’s related to a niche group with a certain expertise, you will be able to charge more.
• Before accepting or setting the rates, you should consider the amount of time it will take you to do it, as well as the size of the chart.
• If you want a ballpark, the average seems to be between $100-150/hr.
• How much work can you expect to get? Again, varies greatly depending on their need, your subspecialty, other factors.

Some people report barely receiving any while some companies have you commit to a certain number of hours. Some companies will only hire you for a formal full time or part time position. Keep in mind that if you’re not hired for a set number of hours, they may not use you very often, and you should view that income as bonus money, rather than something you can count on (much like medical surveys/consulting ).

1. How do you know whether to approve something or not? They will send you medical records when applicable.
2. How long do you have to finish the review once it’s assigned? What does it involve? Again, it varies, but I’ve heard about 48 hours is a typical expected turnaround time.
3. The review may involve reviewing the chart, speaking to the referring clinician, and documenting your findings/recommendations.

Do you have to speak to the referring physician or practitioner? Is this uncomfortable? Most times, it seems necessary to do a peer-to-peer review with the referring clinician. It can be uncomfortable depending on the interaction! Do they provide malpractice? Most companies provide errors and omissions malpractice.

What does HEDIS measure mean?

Years Available 2001 to present Mode of Collection Abstraction of administrative claims data or data from other records. Description The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care and service.

• More than 190 million people are enrolled in health plans that report quality results using HEDIS.
• Since 2008, HEDIS has also been available for use by medical providers and practices.
• Because so many health plans use HEDIS and because the measures are so specifically defined, HEDIS can be used to make comparisons among plans.

To ensure that HEDIS stays current, the National Committee for Quality Assurance (NCQA) has established a process to evolve the measurement set each year through its Committee on Performance Measurement. Selected Content HEDIS measures address a range of health issues including: asthma medication use; persistence of beta-blocker treatment after a heart attack; controlling high blood pressure; comprehensive diabetes care; breast cancer screening; chlamydia screening; antidepressant medication management; immunization status; and advising smokers to quit.

• Population Covered Persons enrolled in health plans that report quality results using HEDIS.
• Methodology NCQA collects HEDIS survey results directly from health plans and Preferred Provider Organizations (PPOs) through the Healthcare Organization Questionnaire and collects non-survey data through the Interactive Data Submission System.

Submission formats are defined for each type of health plan (e.g., commercial, Medicare, Medicaid) and data provider group. Schedules for data submission, analysis, and health plan ratings release are available on the HEDIS website. Response Rates and Sample Size HEDIS is used by more than 90% of America’s health plans.

Is HEDIS required?

Q: Is my participation in HEDIS mandatory? A: Yes. Network participants are contractually required to provide medical record information so that we may fulfill our state and federal regulatory and accreditation obligations.

What can be found in chart review?

CONCLUSIONS: – A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable. Chart review is a methodology frequently used to perform retrospective research and care assessments and conduct quality improvement activities, including morbidity and mortality conferences, critical event reviews, and root cause analyses.1 This methodology facilitates epidemiological investigations, quality assessments, education, and clinical research.2 – 4 Retrospective chart reviews are used in 15% to 25% of scientific articles in emergency medical journals.5, 6 Additionally, >90% of PICUs use this approach to inform their morbidity and mortality conferences.7 Despite their widespread use and potential impact, chart reviews are time consuming, often expensive, and often yield substantial variability among reviewers, a finding not unexpected when assessing complex data and forming subjective assessments.8, 9 Chart review is seldom taught in medical school, and medical students report having limited experience with this process.10 The reliability and validity of chart review are dependent on features of the medical record as well as the subjectivity of the review elements. Chart reviews may include appraising the medical record’s physician and nursing notes, outpatient and emergency department reports, consultations, admission and discharge documentation, and diagnostics.11 Challenging features of the medical record include incomplete documentation, variation in the location of information, discrepancy in information between locations, reliance on jargon or handwriting interpretation in older records, unrecoverable information, and dependency on accurate documentation. Challenging features of chart reviews include training reviewers, creating an operational procedure for review and assessment, resolving discrepancies among multiple reviewers, and assessing validity and reliability.12 Objective review criteria with defined, measurable content are likely to have high reliability and validity, whereas subjective review criteria may have comparatively reduced agreement, validity, and reproducibility. In randomized controlled trials, subjective outcomes when compared with objective outcomes are associated with bias and overestimation of results.13, 14 Subjective variables have poor interrater reliability and agreement when compared with items that have clear criteria.15, 16 Regardless of these limitations, standardized chart reviews have high face validity and are commonly used. For example, standardized medical record review has been used to classify areas of potential harm and to detect adverse events and negligence.3, 17 – 19 Because of the limitations of previous chart review methodologies, our goal was the development of an improved and generalizable structured chart review methodology as part of a larger initiative of the Collaborative Pediatric Critical Care Research Network (CPCCRN), Informing the Research Agenda. CPCCRN’s goal was to better understand the pathophysiology associated with significant new morbidity and mortality and to identify therapeutic advances that might have prevented or ameliorated these adverse outcomes at the individual patient level. Subsequent publications in which this methodology is used are in preparation. Determining these elements is subjective in the context of complex critical illness. Our aims were (1) the development of a structured, reproducible, time-efficient, and generalizable method of chart review and (2) the assessment of this methodology for validity and reliability.

What are the advantages of chart review?

Background – Retrospective research often requires the analysis of data that were originally collected for reasons other than research ( Hess, 2004 ; Jansen et al., 2005 ). This includes physician and nursing notes, ambulatory and emergency room reports, consultations, admission and discharge documentation, laboratory and diagnostic testing reports, and other clinical or administrative data.

For over eight decades, the systematic investigation of historical records has guided various clinical research ( Butler & Quinlan, 1958 ; Wu & Ashton, 1997 ). The scientific utilization of existing health records is common in epidemiological investigations ( Haley et al., 1980 ; Jansen et al., 2005 ), quality assessment and improvement studies ( Allison et al., 2000 ; Kirkorian, 1979 ), professional education and residency training ( Holmboe, Gross, & Hawkins, 1996 ; Neidich, 1990 ; Pan, Fergusson, Schweitzer., & Hebert, 2005 ), examination of inpatient care ( Ashton, Kuykendell, Johnson, Wray, & Wu, 1995 ; Wu & Ashton, 1997 ), and in clinical research ( Hellings, 2004 ; Rajeev, Srinath, Girimaji, Seshadri, & Singh, 2004 ; Staller, Kunwar, & Simionescu, 2005 ).

Investigations using retrospective chart reviews or health record reviews have been reported to comprise 25% of all scientific articles in emergency medical journals ( Worster & Haines, 2004 ). In comparison, while a number of psychiatric studies have successfully extracted relevant data from systematic chart reviews ( Baldassano, Ghaemi, Chang, Lyman, & Lipari, 2004 ; Barzman et al., 2004 ; Bloch et al., 2005 ; Dworkin, 1987 ; Goldstein & Schwebach, 2004 ; Grant, 2005 ; Henderson et al., 2004 ; Marchand, Wirth, & Simon, 2004 ; Staller, 2004 ), its application is frequently limited and research findings questioned.

• Consequently, retrospective research is often undervalued and, hence, underutilized in psychiatry.
• The reluctance to use this research methodology may result from the lack of clear benefits of this approach; minimizing its recognized methodology maintains the limitations.
• The advantages of conducting chart reviews include: a relatively inexpensive ability to research the rich readily accessible existing data; easier access to conditions where there is a long latency between exposure and disease, allowing the study of rare occurrences; and most importantly, the generation of hypotheses that then would be tested prospectively ( Hess, 2004 ; VonKoss Krowchuk, Moore, & Richardson, 1995 ; Wu & Ashton, 1997 ; Worster & Haines, 2004 ).

However, the limitations of incomplete documentation, including missing charts, information that is unrecoverable or unrecorded, difficulty interpreting information found in the documents (e.g. jargon, acronyms, photocopies, and microfiches), problematic verification of information and difficulty establishing cause and effect, variance in the quality of information recorded by medical professionals ( Dworkin, 1987 ; Hess, 2004 ; Pan et al., 2005 ; VonKoss Krowchuk, 1995 ), have discouraged researchers from adopting this methodology.

What study design is a chart review?

A retrospective study uses existing data that have been recorded for reasons other than research. In health care these are often called ‘chart reviews’ because the data source is the medical record.

What type of research design is a chart review?

IRB Considerations for a Retrospective Chart Review The information on this web page is designed for medical students. The purpose is to help guide students through the key steps of preparing and submitting an IRB application for a retrospective chart review.

This is a quick guide and is not intended to provide guidance on formulating a research question, literature searching, data analysis, or presentation/publication of results. What is a retrospective chart review? A retrospective chart review is a type of clinical research study in which data is collected solely from the medical record or another patient database.

As a result, there is no intervention with research subjects and no interaction with research subjects. Importantly, the medical treatment or care provided to patients who are subjects in a retrospective chart review is NOT directly related to the research study.

In other words, the medical care was provided to patients regardless of whether the study was being done or not, thus the methods of a retrospective chart review are only related to identifying subjects and extracting their information from the medical record. As a result, any medical treatment, and risks/benefits thereof, have nothing to do with your study from the IRB’s perspective.

Note that a retrospective chart review is NOT a study design, rather it is a study methodology. The study design for a retrospective chart review is always observational, and can be a case series, a case control study, a cohort study, or a cross-sectional study.

A chart review can be paired with a survey or an experimental (intervention) arm of a study. This quick guide only deals with the IRB considerations for the chart review portion of the study. How do I get access to medical records? The first step in conducting a chart review is to have a research mentor who already has access to the medical record.

It is extremely unlikely that any health system will allow a medical student to run their own chart review, and most IRBs require a principal investigator that is a physician or faculty member. Thus, to conduct a chart review, which will require access to medical records, you will need a research mentor who has access to the medical records.

What is the IRB? The IRB is a committee of faculty, staff, and laypersons that oversees human subjects research. For the purposes of this guide, be aware that medical records are considered human subjects, as a result, retrospective chart review studies require IRB review because they are considered human subjects research.

Do chart reviews require IRB review? Yes, chart reviews must be reviewed by the IRB if they are research. Even chart reviews that you know will fall into the EXEMPT category. Chart reviews can only be determined EXEMPT by the IRB. As a result, chart review protocols must still be submitted to the IRB for this exempt determination.

• Exempt” merely means that the study is minimal risk such that it does not require ongoing oversight by the IRB.
• What category of exempt is a chart review? There are different categories of Exempt status for research studies.
• Chart reviews generally fall under Exempt Category 4(ii) or 4(iii).
• These are: 4(ii) Secondary research uses of identifiable private information or identifiable biospecimen – information recorded by investigator in manner that identity of subjects cannot readily be ascertained.4(iii) Secondary research uses of identifiable private information or identifiable biospecimen – use of identifiable information regulated under HIPAA Note that the data to be collected for a chart review is considered a “use of identifiable private information”.

Because medical records exist for clinical, and not research, purposes, the use of this data for research is considered a “secondary use”. The choice between Exempt category 4(ii) and 4(iii) depends on whether you will collect identifiers (such as MRN) as part of your study.

1. This will be described in further detail below.
2. Training All investigators listed on an IRB application must be up to date with human subjects research training per your institution’s requirements.
3. At MSU, this training can be found here: https://hrpp.msu.edu/training/index.html At other institutions, this training requirement may be different.

Online Form In most cases, the IRB will require the submission of a written protocol document which you attach to an online form. The “IRB Protocol Elements” information below is a combination of the types of information being requested by the IRB either in the written protocol or in the online form.

• At MSU, the online form is in the software “Click”.
• Https://hrpp.msu.edu/click/index.html Note that every member of the research team who is to be added to an IRB Protocol at MSU must log in to Click at least once.
• If an investigator has not ever logged into Click before, they will not show up in the system and cannot be added to the protocol.

If you or someone on your research team is unable to add a person to the online protocol in Click, tell that person to log in to Click at least once. There are different online systems used by different institutions, such as IRB Manager, SMART IRB, and other online systems.

• IRB PROTOCOL ELEMENTS Background & Significance IRB protocols should contain a background and significance section where the investigators outline for the IRB the basic background of the study along with its significance.
• Remember, the IRB committee and the IRB analysts reviewing and processing your requests are not necessarily experts in your field, so you must provide them with adequate background on your study, along with the significance of the study.

This will establish the importance of doing the study in the first place. It is within the rights of the IRB to decline approval of a study if they feel the risk of doing the study, no matter how minor, is more than the benefit of having the study results.

That’s why it’s important to clearly explain the background and significance. Objectives The objectives of your study are the main outcomes of your study as you define them. They are not broad goals, such as “to cure cancer”, or vague ideas, such as “to see if drug A works”. Instead, they are specific outcomes that you will measure.

For example, if you were doing a Covid-19 vaccine trial, your objectives would be something like, “The primary objective of this study is to determine if patients who received the experimental vaccine were diagnosed with Covid-19 at a lower rate than patients who received placebo as determined by RT-PCR testing.” You can add secondary objectives as well, such as “Secondary objectives include assessing severity of illness in the vaccinated vs.

1. Placebo group.
2. Severity is to be measured as presence of symptoms, hospitalization rate, rate of admission to ICU, and death rate.” Study Design This section can be very short.
3. An example might be: “Retrospective cohort study”.
4. That’s it.
5. Note, again, that “retrospective chart review” is not a design, it’s a method.

Therefore, “retrospective chart review” may not be enough without more info on the design (i.e. case series, case control, cohort study). Recruitment Methods For a retrospective chart review, there is no recruitment of subjects. Simply state this in the IRB application or write N/A.

Inclusion and Exclusion Criteria The IRB will ask you to describe your research subjects. Inclusion criteria refers to the characteristics of patients that make it so they may be included in your study. Here is an example: “Patients aged 18 and older who received Roux en Y gastric bypass surgery at Smith Memorial Hospital between the dates of January 1, 2019 and January 1, 2022.” Note that description includes location and dates, along with the clinical and patient characteristics that qualify the patient for inclusion.

There may be quite a few criteria in this list. Exclusion criteria are characteristics of the patients that would exclude the patient from the study EVEN IF they meet the inclusion criteria. Example: “Patients who received prior weight loss surgery” or “Patients who did not have a follow-up visit at 6- and 12- months post-surgery”.

1. Study Endpoints For a chart review, the study endpoint is simply the measurement you are using for the primary (and secondary, if necessary) outcomes in your study.
2. For example, let’s say you were doing a retrospective study in a cohort of patients with Parkinson’s disease and you were interested in seeing if their exercise level helped in slowing progression of disease.

Assume that you have a log of physical activity for these patients over a period of time. The endpoints in this study would be the measures of clinical progression of Parkinson’s in these patients. There could be multiple endpoints, as Parkinson’s has both motor and cognitive symptoms.

1. How the patients will be identified
2. Who will collect the data and from where (i.e. the EMR)
3. Whether identifiers will be collected, and which identifiers
4. Where the data will be stored (i.e. spreadsheet, database, REDCap, etc.), this includes where both the data sheet AND identifiers are stored
5. How you will protect the data (i.e. password protected, secure storage drive), including both data sheet and identifiers (if applicable)
6. Who will have access to the data
7. How data will be shared with others (such as statisticians, if applicable)

Some notes on the above items. The procedures of a chart review are mostly grabbing data from the EMR or other source of data and storing this data securely somewhere. This can occur by hand (i.e. student collects data directly from the EMR), through the use of an honest broker, with the help of the Health IT department, and so on.

• Names
• All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP code, and their equivalent geocodes, except for the initial three digits of the ZIP code if, according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all ZIP codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a ZIP code for all such geographic units containing 20,000 or fewer people is changed to 000
• All elements of dates (except year) for dates that are directly related to an individual, including birth date, admission date, discharge date, death date, and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older
• Telephone numbers
• Vehicle identifiers and serial numbers, including license plate numbers
• Fax numbers
• Device identifiers and serial numbers
• Email addresses
• Web Universal Resource Locators (URLs)
• Social security numbers
• Internet Protocol (IP) addresses
• Medical record numbers
• Biometric identifiers, including finger and voice prints
• Health plan beneficiary numbers
• Full-face photographs and any comparable images
• Account numbers
• Certificate/license numbers
• Any other unique identifying number, characteristic, or code, except as permitted by paragraph (c) of this section

Be aware that if you have a data sheet with protected health information (PHI) and identifiers, and you let someone not authorized view this sheet, you have committed a HIPAA violation. Because of this, a strategy to protect data must be part of your research protocol. There are two ways to protect confidentiality of patient data in a chart review.

1. Do not collect identifiers
2. Utilize codes to allow re-identification

If you collect data without identifiers (#1 above), this is called safe harbor de-identification. If there are no identifiers in your data set, and the covered entity (hospital, clinic, practice) has no reasonable basis to expect that individual patients can be identified from the data, then it is not subject to HIPAA privacy rules.

This type of data can be shared with statisticians. If you do collect identifiers (#2 above), you do not want to include those in the same data sheet as the health information. You would instead utilize a “correlation tool” or “key to identifiers”. In this strategy, you remove identifiers from the data, and place them in a separate file which only has identifiers.

You then give each subject a code (i.e. P1, P2, P3) which you enter into both sheets. On one sheet, you have a patient code linked to identifiers, in the other sheet you have a patient code linked to the patient’s health and demographic data. In this way, you can utilize the code to re-identify the patient.

Here is a link to an example of a basic correlation tool and data collection sheet to illustrate this concept. Sample Correlation Tool and Data Collection Sheet If you want to use codes, you need to explain why you should be allowed to do this. Here is some sample language that explains why one might want to re-identify subjects in a chart review: “The use of a correlation tool is being requested to allow re-identification of subjects.

This request is being made for two main reasons.1) In the case of data transcription errors (e.g. age of 350 years), researchers will be allowed to go back into the EMR to correct the errors.2) Upon submission of the work for publication, it is often a reviewer request to strengthen the study by the inclusion of additional data in the study.

1. With a correlation tool, investigators can go back into the EMR to collect additional data to improve the study.” Monitoring Data for the Safety of Participants This section can be completed by writing “N/A”.
2. As a chart review, you will not be interacting or intervening with subjects in any way.
3. You are doing a secondary analysis of data collected for medical care, as such your chart review study has no bearing on subject safety.

Withdrawal of Subjects Simply answer “Retrospective chart review, no possibility of subject withdrawal”. Statistical Plan In this section, you will have to describe your statistical plan, which can include a discussion or rationale for your sample size determination.

• If you need help with this section, please contact a statistician (see here for MSU CSTAT help – https://research.chm.msu.edu/students-residents/statistical-help ).
• Risks and Benefits For a chart review, there are no direct benefits to subjects and the main risk is to data confidentiality.
• In other parts of the protocol, you will state what the data confidentiality procedures are, so you don’t have to repeat them here.

Provisions to Protect the Privacy of Subjects There are no privacy risks with a retrospective chart review. Privacy = people. State something like this in your application, “This is a retrospective chart review, there are no privacy risks because there will be no interaction or intervention with subjects.” Provisions to Protect the Confidentiality of Data There are data confidentiality risks.

• Data will be stored securely (password protected, secure storage drive, use of REDCap, etc.)
• Only investigators listed on the IRB will have access to data files
• Correlation tool (or key to identifiers) will be used and stored separately from data files
• Correlation tool will be destroyed at final publication/presentation of study (if you plan to do this)

Medical Care or Compensation for Injury Answer “N/A”, the reason being you are not interacting or intervening with subjects. Cost to Subjects “N/A” for the same reason as above. Consent Process For a chart review, you will be requesting a “waiver of informed consent”.

Here is some sample language on why you would be granted a waiver: “A waiver of informed consent is requested because this is a minimal risk retrospective chart review in which no patient interaction will occur. Obtaining informed consent will require contacting each patient directly, increasing the risks to patient privacy.

Further, obtaining a signed consent form will increase the risks to data confidentiality due to creation of an additional document containing a patient identifier. Also, requiring informed consent will result in a certain number of patients who will be lost to follow up, or who might not agree to be in the study, thereby reducing the sample size and reducing the impact of this study.

• Further, a reduced sample size may require contacting additional potential participants to meet our enrollment goals, and/or expansion of the time frame for inclusion of study subjects, thereby introducing more risk to privacy and confidentiality.
• Patient rights and welfare will not be affected in any way by this study.” Vulnerable Populations Describe any vulnerable subjects that are purposely included in your study.

Here is a list of potential vulnerable subjects:

• Children
• Pregnant women
• Prisoners
• Students
• Human fetuses
• Neonates
• Individuals with physical disabilities
• Individuals with mental disabilities or cognitive impairments

Note that this is not a comprehensive list. In the IRB application, you must describe vulnerable populations if they are purposely included. Thus, if you are doing a study on pregnant women and their exposure to environmental pollutants at work, you would describe this population.

However, if your study was on adults 18-65 years old who have asthma, you may have pregnant women as part of your study, but you do not have to describe them as a vulnerable population because you are not purposely including them in your study. Vulnerable populations are described here because they are vulnerable to coercion or undue influence, and you are being asked to explain any additional safeguards to protect them.

In the case of a chart review, if you have vulnerable populations, there are generally no additional safeguards in place. This is because you are not interacting with subjects or intervening in any way. As such, simply state that no additional safeguards are in place beyond the data protection procedures already described.

1. Sharing Results with Subjects For a chart review, state that results will not be shared with subjects.
2. References Include a list of references in your protocol.
3. Attachments Attach all documents requested by the IRB.
4. This may include a blank version of your data collection sheet or a blank version of your correlation tool (if applicable).

Since you are requesting a waiver of informed consent, you will not have to attach an informed consent form. Likewise, you will not have to attach any recruitment materials or messages to participants because you will not be interacting with subjects in any way.

• After Submissin to the IRB At MSU, only the PI can submit the IRB application.
• If you are not the PI of the study, and you are ready to submit your IRB application, please notify your PI to do so.
• Once submitted, check the IRB page in Click regularly for comments.
• If you would like your application to be reviewed and approved quickly, respond to all questions in a timely manner.

Responding to an IRB question in Click also requires the PI to submit that comment. If you are not the PI, and you want to respond to an IRB question, let your PI know they have to submit response or comment. Good luck! *Content developed by Mark D. Trottier, PhD

What is the main goal of HEDIS?

Healthcare Effectiveness Data and Information Set (HEDIS) CMS contracts with NCQA to collect Healthcare Effectiveness Data and Information Set (HEDIS ® ) measures from Medicare Special Need Plans (SNPs). The HEDIS measurement set is sponsored, supported and maintained by NCQA.

1. Measures relate to many significant public health issues such as cancer, heart disease, behavioral health and diabetes.
2. SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement and provide a set of measurement standards that allow comparison with other plans.

HEDIS data help identify performance gaps and establish realistic targets for improvement. SNPs have reported the following measures since HEDIS Measurement Year (MY) 2016:

Colorectal Cancer Screening Care for Older Adults Use of Spirometry Testing in the Assessment and Diagnosis of COPD Pharmacotherapy Management of COPD Exacerbation Controlling High Blood Pressure Persistence of Beta-Blocker Treatment After a Heart Attack Osteoporosis Management in Women Who Had a Fracture Antidepressant Medication Management Follow-Up After Hospitalization for Mental Illness Potentially Harmful Drug-Disease Interactions in Older Adults Use of High-Risk Medications in Older Adults Transitions of Care (Reporting began in HEDIS MY 2020) Plan All-Cause Readmissions

Please see the link below for the most recent SNP HEDIS Performance Report. : Healthcare Effectiveness Data and Information Set (HEDIS)

What is an example of Hedis data?

Examples of data tracked by HEDIS includes asthma medication use, beta blocker treatment after a heart attack, high blood pressure controls, diabetes care and breast cancer screening, just to name a few.

What are HEDIS codes?

What is HEDIS Coding | HEDIS Coding Services | Medical Coding The Healthcare Effectiveness Data and Information Set (HEDIS) is set of norms employed by most of the healthcare plans in the US for measuring performance in relation to service and care. HEDIS was created by the NCQA (National Committee for Quality Assurance) and is vital for locating gaps in the performance and making the required changes to improve customer satisfaction.

• What is HEDIS? HEDIS is a combination of 75 measures spanning 8 care domains.
• Accurate for all the procedures within these measures is essential for organizations looking for NCQA accreditation, healthcare practices thinking of improving HEDIS rates, and MAOs (Medicare Advantage Organizations).
• Details of HEDIS Coding HEDIS coding is carried as follows: Reimbursement claims are coded with ICD-9 (Diagnosis Codes) and CPT (Procedure Codes).

These are the codes that offer the encounter and claim information needed for payment and measurement of the quality of the care goals for the NCQA accreditation. The right ICD-9 and CPT codes approved by the NCQDA must be attributed for indicating that good care was provided.

The HEDIS quality care goals need to be indicated through the claims data. Bills must be prepared only with CPT-4 or ICD-9 codes. Only properly paid bills must be used in the HEDIS report. Improper bills would bring about miscalculation. The HEDIS report must be submitted only on confirmation of the accuracy of the information in that report.

This will bring down the chances of obtaining revisions for the calculation of HEDIS scores. A professional can help with HEDIS coding services to help insurers meet the quality goals set by NCQA and enable healthcare practices to maximize their HEDIS reimbursement.

Who collects the data for HEDIS?

NCQA collects HEDIS data from health plans, health care organizations and government agencies. Data are used to improve HEDIS measures and the health care system. Visitors to this page often check HEDIS FAQs, QRS FAQs, or ask a question through MyNCQA,

Who runs HEDIS?

NCQA, which administers HEDIS ®, collects audited results from health plans for their respective populations.

What is chart review in CMS?

This is an indicator value that is set to ‘Y’ when MAOs report diagnoses obtained from medical record reviews (i.e., chart reviews) that were not initially reported on encounter data records when the MAO submitted the encounter. Otherwise, the value is set to null.

Chart review records may be submitted for any service type (including services that are not eligible for risk adjustment), and there are no limitations on the number of chart review records in totality or per encounter. Additional details regarding the meaning and use of chart review records can be found in the Medicare Encounter Data User Guide.

Source: Medicare Advantage Organizations (MAOs)

Can chart review be prospective?

A Prospective Chart Review evaluates patient data that does not yet exist in the subject’s medical record at the time the project is submitted for initial REB review.

What are the parts of a patient chart?

What is a patient medical chart? – A patient medical chart, commonly referred to as just a patient chart, is a complete and total record of a patient’s clinical data and medical history. Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results, patient demographics, diagnoses, progress notes and reports.

What are disadvantages of charts?

Disadvantages of graphs and charts – However, graphs and charts also have some disadvantages that you need to be aware of. One of the main disadvantages is that they can be misleading, confusing, or inaccurate if they are not designed, labeled, or interpreted correctly.

They can also create bias or distortion, as you can manipulate the data or the visual elements to emphasize or hide certain aspects. Graphs and charts can also distract or overwhelm your readers, if you use too many, too complex, or too colorful ones. They can also reduce your flexibility and creativity, as you have to follow certain conventions and standards for different types and formats.

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Why should you review the patient’s chart?

Patient medical charts display a patient’s key medical information so practitioners can make more accurate diagnoses and develop treatment plans with better outcomes.The information found in patient charts includes demographics, medications, family history and lifestyle.All medical professionals involved in a patient’s care can access the patient’s chart, though the chart technically belongs to the patient. This article is for medical professionals looking to understand all the ins and outs of patient charts.

In a way, patient charts are the crux of the medical industry. They substantially increase the likelihood of positive patient outcomes and give medical professionals the general patient profiles they need to develop meaningful treatment plans. Virtually every reputable medical practitioner uses them to guide their clinical decision-making.

What is the purpose of chart audits?

Eight Steps to a Chart Audit for Quality For many family physicians, the idea of a chart audit conjures up images of federal investigators or insurance company representatives descending on their offices to look for evidence of wrongdoing. For the most part, however, a chart audit is not so scary.

• A chart audit is simply a tool physicians can use to check their own performance, determine how they’re doing and identify areas where they might improve.
• The purpose of this article is to describe some scenarios in which a chart audit might be helpful and to offer step-by-step instructions for doing one.

Chart audits can serve many purposes, from compliance to research to administrative to clinical. You can conduct a chart audit on virtually any aspect of care that is ordinarily documented in the medical record. Practices frustrated with clinical processes that don’t work well can use chart audits to document that something is wrong, find the defect in the process and fix it.

Perhaps the most beneficial use for a chart audit is to measure quality of care so that you can improve it. Chart audits are often used as part of a quality improvement initiative. For example, a practice might review charts to see how often a particular vaccine is offered, given or declined. If the audit determines that the vaccine is not being offered or given as recommended, then there is room for improvement.

The same practice could review the panels of individual physicians within the group to see if they differ in performance on this measure and to give focus to their improvement efforts (for, see below). A chart audit is one of numerous data sources available for quality improvement efforts.

• Others include patient surveys, discharge summary reviews, billing/claims data and employee feedback.
• Below we describe eight steps to a formal chart audit.
• Although the process is not necessarily linear, we will discuss each step in the order it might typically occur, using the example of a breast cancer screening audit to illustrate each step.

Because the audit will involve reviewing confidential data, it is important to check your institutional guidelines regarding patient confidentiality before you get too far into the planning process. Step 1: Select a topic. The focus of your audit must be clear, neither too narrow nor too broad, and measurable using data available in the medical record.

• If possible, choose an area that interests you.
• You will find that you are more able to recognize nuances in your study when you have personal interest in the topic.
• Of course, your topic should also be of interest to the practice, perhaps a problem or aspect of care that the providers have identified as needing improvement.

The Joint Commission recommends studying issues that are high frequency, high risk or both. You should also consider early in the process how important external comparison is to your purpose. If it is quite important, then choose a topic that has an existing, well-defined measure and available benchmark data – even one you might not choose otherwise – because this will be more practical than developing your own standard for comparison.

Chart auditing is an iterative process – don’t be discouraged if you change directions several times before settling on a topic. Example : Your practice wants to measure how well it’s doing on meeting recommendations for preventive care. Since the insurance carriers in the area are focusing heavily on women’s health, the group decides to focus its chart review on screening for breast cancer (mammography).

Step 2: Identify measures. Once you’re set on a topic, you need to define exactly what you will measure. Criteria must be outlined precisely, with specific guidelines as to what should be counted as a “yes” (criteria met) and what should be counted as a “no” (not met).

• For example, if you decided to review the rate at which foot exams were performed on patients with diabetes in the last year, you would need to decide what qualifies as an adequate foot exam.
• Is it monofilament testing for sensation? Visual inspection? Palpation of pulses? Many would say all three are necessary for a complete foot exam.

If only two of the three are documented, how will you count that? It may be worthwhile to do a literature review to help you define your measures or consult measures used by insurers or accrediting bodies; adopting measures that have been used successfully in the past will make your work easier.

Time since last mammogram. This provides the most specific information but would require more analysis. Mammogram completed within last year. This measure attempts to assess compliance with clinical guidelines. The U.S. Preventive Services Task Force recommends screening mammography every one to two years for women age 40 and older. However, the Healthcare Effectiveness Data and Information Set (HEDIS) measures, which most health plans use for National Committee for Quality Assurance (NCQA) accreditation purposes, require at least one mammogram completed within the past 24 months. Mammogram ordered within last year. Do you want to measure only whether the study was done, or whether it was recommended or ordered by the provider? Should providers be held accountable when patients decline to have the test?

After considerable discussion, the group decides to measure whether a mammogram was completed or recommended within the last 24 months. Step 3: Identify the patient population, To determine which records to review, you need to define the population you want to assess.

1. Characteristics to consider may include age, gender, disease status and treatment status.
2. In many cases, the focus of the audit and even the measure itself will help to define the population.
3. You’ll also need to develop specific inclusion or exclusion criteria.
4. Example : In keeping with the HEDIS breast cancer screening measure that your group decided to follow, your patient population will be women age 40 to 69.

Because you’ll be looking for evidence of a mammogram in the past 24 months, the lower age limit for the sample will be 42. Only those patients with at least three visits in the last two years and one in the last 13 months will be included. You decide to exclude women who have had bilateral mastectomies or are terminally ill.

1. Step 4: Determine sample size,
2. A manual audit of all charts meeting your inclusion criteria will not be feasible in most situations.
3. That’s where sampling comes in.
4. For an informal, or “quick and dirty,” audit designed to give you a sense of whether a more sophisticated audit is warranted, you may find it useful to sample a minimum of 20 charts.

For better results, a common rule of thumb is to try for 10 percent of the eligible charts. Or you may choose to use a convenience sample: the patients from a single day or all the charts on a single shelf in the records room. If you want to track a measure over time, or if you want your results to be statistically valid, your sample size is critical.

If the sample is too small, the random variability will be too large, and the results will be limited in their applicability. Calculating a statistically valid sample size for a chart review follows steps adapted from statistical techniques used for descriptive studies. The process uses a nomogram, or table, to identify the desired number: 1.

Estimate the expected proportion within the population that will have the measure of interest, If you have a benchmark from literature or prior studies, use it. Otherwise, consult with colleagues or experts in the field to determine an estimate. The tables generally require this proportion to be 50 percent or less.

• If more than 50 percent of the population is expected to have the characteristic, then base your sample size calculation on the proportion without the characteristic.2.
• Specify the width of the confidence interval you wish to use,
• All empirical estimates based on a sample have a certain degree of uncertainty associated with them.

It is necessary, therefore, to specify the desired width of the confidence interval (W). This gives a range of values that you can be confident contains the true value. In most cases, an appropriate width is 0.20 (that is, plus or minus 10 percent).3. Set the confidence level,

This is a measure of the precision or level of uncertainty. Typically 95 percent is used, meaning that we are 95 percent certain that the interval includes the true value. This is arbitrary, however, and other levels of confidence can be used. The table shown below is for a 95-percent confidence level.

The narrower the width of the confidence interval and the higher the confidence level, the larger the sample size.4. Use the nomogram (below) to estimate sample size, According to HEDIS 2007 Audit Means, Percentiles and Ratios, the NCQA’s annual report of health plan performance data, 68.9 percent of women age 40 to 69 had a mammogram during 2006.

1. This makes the expected proportion of those without screening 31.1 percent.
2. We choose a width of the confidence interval of 0.20 (plus or minus 10 percent) and a confidence level of 95 percent.
3. This means that we want to be 95 percent confident that the result falls between 58.9 percent and 78.9 percent.

Using the nomogram to determine the sample size, we read down the left column of figures for the expected proportion without the characteristic (0.30 is the closest value to 31.1 percent) and then across to the chosen width of the confidence interval (0.20).

When we follow the column down, we find the required sample size (81). If the number required is too large to be completed, we can recalculate with a lower confidence level or wider interval; this will produce a smaller sample size. Step 5: Create audit tools. To complete your chart audit, you will need instruments on which to record your findings.

How they are structured and the details they include will affect the analysis you can do and the eventual usability of your findings. Data should be collected in a format that keeps all individual records separate but allows for easy compiling. Many chart audits involve the calculation of a rate, percentage, mean or other statistical measurement.

1. An electronic spreadsheet format can be customized to do these calculations for you.
2. For those more comfortable with paper-based systems, a preprinted form that lists the specific items to check in each chart serves well as an audit tool.
3. One form is completed for each chart, and the forms can then be sorted and counted as desired.

A separate form can be used to tabulate results. Creating clear, simple audit tools will make it possible for nonclinical staff to perform many audits effectively. Once you’ve developed the forms, if someone other than you will be doing the actual chart reviews, go over a few examples together to be sure the reviewer understands the criteria exactly as you intend.

Step 6: Collect data, Select the date or dates on which you will collect data. Be sure to coordinate the specifics (date, time and number of charts to be pulled) with the medical records staff. Review each chart to determine if the patient meets the selection criteria. The reviewer should complete one audit tool (paper form or row in the electronic spreadsheet) for each patient that meets the criteria.

To protect patient confidentiality, patient names should not be included on the review forms. Example : You instruct your office staff to pull the charts of roughly 100 adult female patients. Once you’ve identified 81 that meet the selection criteria, your nursing supervisor fills out the audit tool for each one, reserving questionable cases for physician review.

1. Step 7: Summarize results,
2. Summarizing the data is a little more complex than just counting up all the data sheets.
3. You must consider how the data will be used and make sure the information is presented in a way that will make it meaningful.
4. Inconsistencies here can produce data that can’t be interpreted.

Example : Your breast cancer screening audit results show that 57 percent of your sample received mammograms (). Step 8: Analyze and apply results, Once you have compiled your data and calculated the results, you can compare them to local or national benchmarks.

There may be multiple benchmarks, depending on your topic and the performance measure you calculated. You should take into account the differences between your population and those you’re comparing it with, as appropriate. If the measure is truly important to the group, you may wish to set a performance goal based on what the group feels is appropriate and reasonable and make it the focus of a quality improvement initiative.

Example : At 57 percent, your group’s breast screening rate is less than the national benchmark of 68.9 percent. This benchmark is the mean for commercial HMO patients, according to the HEDIS 2007 Audit Means, Percentiles and Ratios, the NCQA’s annual report of health plan performance data (view it at ).

Of the 35 patient charts that had no documentation of a mammogram, only 10 records showed that the physician had discussed the need for a mammogram with the patient. The challenge is now to drill down to figure out whether the issue was discussed but not documented in those other charts or whether it was simply overlooked.

Telephone contact with the 25 identified patients might help you begin to clarify this so that an appropriate intervention can be designed. Chart audits can be useful tools in improvement and safety efforts. It is essential to define precisely what you want to measure and the criteria by which you will measure it.

If you’re floundering, you probably haven’t defined this well enough.) Sample sizes can be chosen informally or determined in a statistically valid fashion. Summarize your data in a way that makes sense for the problem you’re addressing. Make sure to act on problems you find, and remeasure later to see that your changes made a difference.

You and your patients will be glad you did.

What is a chart review in coding?

Chart Reviews – Chart reviews are in-depth audits that assess the provider’s understanding and compliance with proper documentation and coding, thus validating submitted information to ensure proper payment. Reviews are accomplished after extensive data analysis, and encompass as much historical information as necessary to assure a complete understanding of the patient’s health status.

Documented risk-adjusted diagnoses that were improperly coded using non-risk-adjusted codes. In these cases, we will prepare encounters for submission to the Plan. Reported risk adjusted diagnoses that are not substantiated by the provider’s documentation and which must be removed from the patient’s diagnostic profile. This step requires provider feedback to impart an understanding of the correct documentation required in the future. Conditions evident in the patient’s medical chart, which have not been previously recognized, documented or reported as risk adjusted conditions by the provider.

Because chart reviews provide an accurate picture on the day the record is audited, our approach is to create an educated medical practice that is fully conversant in the activities that bring MRA success so they can all “do it right the first time.” : Risk Adjusted Reimbursement: Chart Reviews | Coleman

What are the benefits of chart audit?

Annual Chart Audits Can Greatly Benefit HBPC Providers and Practices | Home Centered Care Institute About this Article: Regular chart audits can significantly help home-based primary care (HBPC) practices improve their coding accuracy and the quality of their documentation, while also identifying lost revenue due to under-coding or missed billing.

In this interview, HCCI’s Brianna Plencner discusses how chart audits can also uncover potential compliance issues and ensure documentation and coding practices are current and appropriate. Article: In addition to its offerings in home-based primary care (HBPC), the offers, including chart audits, which are a valuable tool that HBPC practices can use to evaluate provider performance and improve coding and documentation.

“A formal audit provides confidential, qualified feedback on a provider’s documentation and coding practices,” explains Brianna Plencner, HCCI’s Manager of Practice Improvement. A Certified Professional Medical Coder and Certified Professional Medical Auditor, Plencner also holds a diploma in Medical Insurance Billing and Coding.

Before joining HCCI, she also served as practice manager for, which was founded by Dr. Thomas Cornwell, CEO of HCCI. HCCInsights recently asked Plencner to share her perspective on the benefits of conducting a chart audit. HCCInsights: Why would an HBPC practice consider using an outside agency to perform a formal chart audit? Plencner: First, there are many reasons to conduct routine chart audits.

Medical practices can use the audit process to educate providers and staff and foster a culture of continuous quality improvement. Expert reviews of patient charts also promote more accurate and complete documentation and maximize the likelihood the practice will receive appropriate reimbursement for the services provided.

Because the home-based patient population is complex, the practice’s coding must fully represent the severity of each patient’s illnesses and all the services rendered. At the same time, the audit process can minimize compliance risks by identifying and correcting billing errors. In terms of why an outside agency would be used, external auditors inherently provide an objective point of view.

Their audit decisions are not influenced by an intimate knowledge of the practice and are solely based on the data examined. HCCInsights: How does the chart audit process work? What should a practice anticipate? Plencner: Following the execution of a Business Associate Agreement (BAA)*, a nationally certified medical auditor will first work with you to remotely access your practice’s medical record, review a sampling of patient charts, and evaluate the quality of provider documentation and coding accuracy.

1. Then, after a preliminary conversation with our main contact and/or the leadership at your practice, our experts will conduct a virtual meeting with your providers and practice staff to walk through the charts reviewed and discuss the findings and recommendations.
2. Practices also have the option of requesting that a consultant travel to their location to provide onsite coaching in coding and documentation.

As needed, the consultant can also develop customized documentation tools and training plans and assist with incorporating these into the practice’s procedures. Again, the goal of all these activities is to enhance your documentation and increase your reimbursement.

*Editor’s Note: A Business Associate Agreement (BAA) is a legal document signed between a healthcare provider and contractor/vendor. A provider enters into a BAA with a contractor/vendor who might, in the course of the proposed work engagement, (e.g., HCCI) receive access to Protected Health Information (PHI).

HCCInsights: What types of things do the auditors review? Plencner: It’s a pretty extensive list. Everything from Evaluation and Management (E/M) coding, to ensure the correct level of service is selected and the documentation supports medical necessity, to whether the necessary information is recorded, and timely signatures have been obtained.

• The auditor will also check whether all services provided were billed out.
• These are just a few examples of what’s typically reviewed.
• HCCInsights: Based on your personal experience, what are the most common issues discovered during a formal HBPC chart audit? Plencner: Among the top issues we typically discover are: (1) failure to document a complete history of present illness (HPI); (2) failure to document all services being provided, such as reviewing patient records and history, talking to other providers, ordering tests, etc., which is important for determining the correct level of Medical Decision Making (MDM); and (3) under-coding** the correct level of service, which – believe it or not – is actually more common in HBPC practices than over-coding.

**Editor’s Note: Under-coding” is reporting a lower level of service than the documentation supports. HCCInsights: It seems like there are changes to billing and coding nearly every day – how do auditors keep up? Plencner: Nationally certified medical auditors are required to complete a variety of continuing education requirements every year to maintain their accreditation.

As experts in their field, HCCI auditors actively participate in coding and documentation “boot camps,” webinars and other credential-specific programs. HCCInsights: Are chart audits required or optional? Plencner: At a minimum, internal chart audits are a required component of a practice compliance plan.

The industry standard is an annual audit of 10 charts per provider to determine coding accuracy and compliance. Practices without an internal billing staff, or practices desiring an unbiased third-party review, would find a lot of value from doing an external chart audit.

HCCInsights: Does HCCI offer other types of consulting services? Plencner: Yes, HCCI can conduct practice assessments to evaluate operational standards, clinical functions, policies and procedures, and opportunities for improvement. All our consulting services are customized to the practice’s specific needs and concerns.

We also can offer practices customized education, such as exclusive webinars and onsite, interactive training for the entire team. HCCInsights: How would a practice learn more about initiating a chart audit through HCCI? Plencner: Call us at 630-283-9222 or email,