HEDIS Spotlight

HEDIS® (Healthcare Effectiveness Data and Information Set) is a widely used set of performance measures that ensures our members are getting the best health care possible. It is extremely important that our providers understand HEDIS® specifications and guidelines. This section highlights different HEDIS metrics in addition to providing descriptions of the measures, correct billing codes to support services rendered, and tips to direct you to corresponding resources and tools.

MEASURE: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS

MEASURE DESCRIPTION: Members 6 years of age and older who were hospitalized for treatment of selected mental health diagnoses and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 and 30 days of discharge.

CODING:

Codes to Identify Follow-up Visits (must be with a mental health practitioner)

CPT®-: 99201-99205, 99211-99215, 99217-99220, 99341- 99345, 99347-99350

UB Rev (Visit in a behavioral health setting): 0513, 0900-0905, 0907, 0911-0919

UB Rev (Visit in a non-behavioral health setting): 0510, 0515-0523, 0526-0529, 0982, 0983

TIPS:

• The literature indicates that the patient is at greater risk for hospitalization within the first 7 days post-discharge, and that the risk of patient self-harm is high within the first 3 weeks post-discharge
• Ensure that the follow-up appointment is made before the patient leaves the hospital and is scheduled within 7 days of discharge
• Assist the patient with navigation of barriers, such as using their transportation benefit to get to their follow-up appointment
• Review medications with patients to ensure they understand the purpose and appropriate frequency and method of administration
• Ensure accurate discharge dates and document not just the appointments scheduled, but appointments kept. Visits must be with a mental health practitioner.
• Follow-up visits must be supported by a claim, encounter, or note from the mental health practitioner’s medical chart

Patients with chronic mental illness who are receiving care in multiple care settings may benefit from the TCHP Case Management Program – please contact Case Management at 832-828-1430