HEDIS Coding provided by BillingParadise:

Understanding HEDIS Better

Coordinated Care strives to provide quality healthcare to our membership as measured through HEDIS quality metrics. We created the HEDIS Quick Reference Guide to help you increase your practice’s HEDIS rates and to use to address care opportunities for your patients. Please always follow the State and/or CMS billing guidance and ensure the HEDIS codes are covered prior to submission.

What is HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) to objectively measure, report, and compare quality across health plans. NCQA develops HEDIS® measures through a committee represented by purchasers, consumers, health plans, health care providers, and policy makers.

How are the scores uses?

As state and federal governments move toward a quality-driven healthcare industry, HEDIS rates are becoming more important for both health plans and individual providers. State purchasers of healthcare use aggregated HEDIS rates to evaluate health insurance companies’ efforts to improve preventive health outreach for members.

Physician-specifc scores are also used to measure your practice’s preventive care efforts. Your practice’s HEDIS score determines your rates for physician incentive programs that pay you an increased premium, for example Pay For Performance or Quality Bonus Funds.

How are rates Calculated?

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the need for medical record review. If services are not billed or not billed accurately, they are not included in the calculation.

How can doctors improve HEDIS scores?

Submit claim/encounter data for each and every service rendered.

Make sure that chart documentation reflects all services billed.

Bill (or report by encounter submission) for all delivered services,regardless of contract status.

Ensure that all claim/encounter data is submitted in an accurate and timely manner

Ensure that all claim/encounter data is submitted in an accurate and timely manner

Consider including CPT II codes to provide additional details and reduce medical record requests


P4P is an activity-based reimbursement, with a bonus payment based on achieving defined and measurable goals related to access, continuity of care, patient satisfaction and clinical outcomes. 

What are the HEDIS measure categories?

HEDIS has more than 90 measure categories of which 6 of them are important and are mainly observed.

Effectiveness of Care.

Access/Availability of Care.

Experience of Care.

Utilization and Risk Adjusted Utilization.

Health Plan Descriptive Information.

Measures Reported Using Electronic Clinical Data Systems

Obgynparadise provides HEDIS audits and coding for various hospitals and health systems. Surgical groups looking to streamline their charts using HEDIS coding audits are in the right place. Our coders have been providing HEDIS coding and auditing services for the past 5 years and hospitals and clinical groups have benefited more and were able to learn about how effectively they can treat patients and get reimbursed for the progress of the patients as well.

Get a brief consultation with our coding team and get educated on how your hospital/clinical group can effectively administer treatment, compliance and financial progress.