NCQA releases proposed HEDIS MY 2025 updates

Acute Hospitalization Following Outpatient Surgery (HFO)

For Medicare Advantage beneficiaries, this risk-adjusted utilization measure would capture the percentage of select outpatient procedures that were followed by an unplanned acute hospitalization for any diagnosis within 15 days, and the predicted probability of an acute hospitalization. This would include four rates:

• Colonoscopy
• General surgery
• Orthopedic procedures
• Urology procedures

Blood Pressure Control for Patients With Hypertension (BPC-E)

This would measure the percentage of members for all product lines from 18–85 years old who had a diagnosis of hypertension and whose most recent blood pressure was at the following levels during the measurement period:

• <140/90 mm Hg
• <130/80 mm Hg

BPC-E would be an electronic clinical data systems (ECDS) measure intended to eventually replace the hybrid Controlling High Blood Pressure (CBP) measure. The draft measure expands on the CBP denominator by adding members who have a diagnosis of hypertension and at least one dispensed anti-hypertensive medication, and includes race and ethnicity stratifications (RES).

Documented BI-RADS Assessment after Mammogram (DBM-E)

This would measure the percentage of mammograms for members 40–74 years old from all product lines that have a documented breast imaging reporting and data system (BI-RADS) assessment within 14 days of the procedure. DBM-E would be an ECDS measure.

Follow-Up After Abnormal Breast Cancer Screening (BCF-E)

This would measure the percentage of inconclusive or high-risk BI-RADS assessments that received appropriate follow-up care within 90 days for members 40–74 years old from all product lines. BCF-E would be an ECDS measure.

Cervical Cancer Screening Follow-Up (CCF-E)

This would measure the percentage of commercial and Medicaid members from 21–64 years old with possible or confirmed higher-risk cervical cancer screening results who receive follow-up care within 90 days. CCF-E would be an ECDS measure.

Acute Hospital Utilization (AHU)

This measure would be added to HEDIS reporting for Medicaid plans for members 18–64 years old.   Medicaid members with six or more inpatient or observation stay discharges during the measurement year would be excluded as outliers.

Adult Immunization Status (AIS-E)

To improve vaccination rates, an indicator would be added to this measure to assess hepatitis B vaccination rates for members 19–59 years old. This numerator would be made compliant by the presence of either the childhood or adult Hepatitis B vaccine series, evidence of anaphylaxis due to the Hepatitis B vaccine, or a positive result for Hepatitis B prevaccination blood testing.

In addition, updates to lower the oldest age stratification from 66+ to 65+ years old are proposed for the influenza, Td/Tdap, zoster, and pneumococcal immunizations. The herpes zoster live vaccine would also be removed from the zoster immunization indicator as it is no longer available in the United States.

Follow-Up After Emergency Department Visit for Mental Illness (FUM) and Follow-Up After Hospitalization for Mental Illness (FUH)

For both measures, additional diagnoses would be added to the denominator including:

• Phobia
• Anxiety
• Intentional self-harm X-chapter codes
• Suicidal ideation

Any diagnosis position would be allowed for intentional self-harm diagnoses, while the principal position requirement would be maintained for other mental health diagnoses.

In the FUH measure’s numerators, to acknowledge the shortage of mental health providers, follow-up care performed by any care provider rather than solely by a mental health provider would be allowed if accompanied by a mental heath diagnosis..

For both measures’ numerators, the mental health diagnosis would be allowed in any diagnosis position on the follow-up claim, rather than just in the principal position, and psychiatric residential treatment, as well as peer support services and occupational therapy for a mental health diagnosis, would be included as options for follow-up care.

Potentially Harmful Drug-Disease Interactions in Older Adults (DDE)

Medications would be updated to align with recommendations in the updated AGS Beers Criteria, adding anticholinergics to the History of Falls Rate. The Total Rate would be retired based on feedback suggesting that it is not clinically meaningful.

Use of High-Risk Medications in Older Adults (DAE)

Medications will be added, removed, and regrouped to align with recommendations in the updated AGS Beers Criteria.

Breast Cancer Screening (BCS-E)

Members 40–49 years old will be added to the measure and performance will be stratified by ages 40–49 and 50–74 for all product lines.

Well-Child Visits in the First 30 Months of Life (W30) and Child and Adolescent Well-Care Visits (WCV)

Telehealth visits will be removed from consideration for measure compliance.

Childhood Immunization Status (CIS), Immunizations for Adolescents (IMA), and Cervical Cancer Screening (CCS)

In a recent update to the public comment materials that were originally posted, NCQA has now confirmed that CIS, IMA, and CCS will transition to ECDS-only reporting for MY 2025, retiring administrative and hybrid reporting for these measures.