Decoding the HEDIS MY 2025 Technical Specifications

After holding a public comment period earlier this year, the National Committee for Quality Assurance (NCQA) has finalized changes for HEDIS^® Measurement Year (MY) 2025 and published its MY 2025 technical specifications for health plans. These updates come as NCQA continues to advance the electronic clinical data systems (ECDS) reporting standard, with the goal of transitioning to fully digital measurement by 2030, and seeks to advance health equity through race and ethnicity measure stratification.

Here, we offer a summary of new HEDIS measures, retirements, and other changes, along with recommendations to help your organization prepare.

Measure retirements for MY 2025

The Antidepressant Medication Management (AMM) measure has been fully retired, reflecting NCQA's shift towards other aspects of mental health. Administrative and hybrid reporting for measures Cervical Cancer Screening (CCS), Childhood Immunization Status (CIS), and Immunizations for Adolescents (IMA) will now only be reportable via ECDS. Changes also include the retirement of the Pain Assessment numerator in the Care for Older Adults (COA) measure, leaving only Medication Review and Functional Status Assessment.

In addition, NCQA has removed all ICD-9 codes from measure value sets, especially those with longer look-back periods. The Eye Exam for Patients with Diabetes (EED) measure has transitioned to an administrative-only measure, eliminating its hybrid reporting component. These updates mark a significant reduction in hybrid reporting, with only eight hybrid measures remaining for 2025.

New measures for MY 2025

Blood pressure control

Three new measures have been introduced for Measurement Year 2025. The first is Blood Pressure Control for Patients with Hypertension (BPC-E). This measure aims to eventually replace the hybrid measure Controlling High Blood Pressure (CBP) with an ECDS version. BPC-E reports on the percentage of members aged 18–85 with hypertension whose most recent blood pressure was less than 140/90 during the measurement period. The BPC-E measure has expanded diagnosis criteria compared to CBP, adding members with one outpatient or telehealth hypertension diagnosis and a dispensed antihypertensive medication in the prior year or the first six months of the measurement year.

Another notable difference from CBP is the change to the logic for selecting a representative blood pressure if more than one is available on the latest date of service. Instead of CBP’s logic to use the lowest systolic and lowest diastolic readings from that day, BPC-E requires that the latest blood pressure reading taken on that day be used.

This small shift in words represents a significant change in HEDIS, as it becomes the first measure now to mandate a time component in the logic. To help gain clarity for our health plan customers, Cotiviti has been in communication with NCQA over this change to the specification. In keeping with this shift, NCQA has indicated that the measure should prioritize EMR records that contain a time component over other data sources that don’t have a time associated on the latest date of service.

Mammograms

Two new mammography-focused measures have been added to expand upon the current Breast Cancer Screening (BCS) measure. The first, Documented Assessment After Mammogram (DBM-E), evaluates the percentage of mammogram episodes documented with a BI-RADS assessment within 14 days for members aged 40 to 74. Notably, this measure includes events for members aged 40–49, whereas BCS has not finalized the proposed change to add 40-49 year old members.

The second measure, Follow-Up After Abnormal Mammogram Assessment (FMA-E), assesses the percentage of episodes with inconclusive or high-risk BI-RADS assessments that receive appropriate follow-up within 90 days for members aged 40–74. Their introduction marks a significant focus on improving screening and follow-up care for breast cancer.

Both measures are event-based and do not have any requirements pertaining to deduplication of nearby events. As such, a member could have multiple mammograms counted in the eligible population on the same date of service. Cotiviti recommends taking a close look at the way that your plan sends mammogram data for the BCS-E measure today to evaluate if there is consistency between sources for the information (such as the provider or the date that the mammogram occurred). This will help prevent inflation of your DBM-E eligible population due to source inconsistencies.

In addition, both measures make use of a new code system called RadLex Radiology Lexicon. Cotiviti recommends reviewing data available in your EMR sources to see if RadLex ID codes are available in them to map to your HEDIS data repository.

Changes to existing HEDIS measures for MY 2025

Several existing HEDIS measures have undergone changes for 2025, including but not limited to:

• Race and Ethnicity Stratification (RES): Direct and indirect source stratifications have been removed for measures in the RES program, reducing reportable RES data elements by 58%. This change aims to provide insights into racial or ethnic disparities in care while simplifying reporting. In addition, NCQA also made updates to the source categories for MY 2025 for reporting the Race/Ethnicity Diversity of Membership (RDM) measure. Cotiviti recommends reviewing the changes to the RES general guidelines as well as the RDM measure source types to begin evaluating if your race and ethnicity data source mappings need some updates for 2025. Note specifically that NCQA has repurposed the “Unknown” source category for a new use case for MY 2025, so sources previously mapped to “Unknown” will now need to be mapped to “No Data” for MY 2025.
• Gender inclusivity: The Chlamydia Screening (CHL) measure has been updated as NCQA seeks to foster more inclusive care for transgender patients. NCQA will use the same eligibility criteria as for the breast cancer and cervical cancer screening measures. NCQA has also removed the gender stratifications from Risk measures for MY 2025, though the risk weight models will still have gender incorporated.

• Adult Immunization Status (AIS-E): This measure had changes across all its numerators, including age stratification updates, updates to eligible zoster vaccines, and a new numerator for hepatitis B vaccination compliance. Cotiviti recommends that when health plans look at their data sources for hepatitis B compliance, ensure that numeric result values are provided alongside codes from the Hepatitis B Tests with a Threshold of 10 value set so the events can be used for compliance.

• Mental health: NCQA finalized many of its previously proposed changes to Follow-Up After Emergency Department Visit for Mental Illness (FUM) and Follow-Up After Hospitalization for Mental Illness (FUH), including allowing intentional self-harm diagnoses to be in any position rather than just the principal position. Several new diagnoses are also now included in the eligibility criteria, including phobia, anxiety, and additional intentional self-harm diagnoses. In addition, members in residential treatment facilities will no longer be excluded from the measures and will now count as compliant. Several additional new numerator options were added to both measures, and many existing numerator options were simplified to be more inclusive of mental health diagnoses in any position on the claim.

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