Well-Woman HEDIS Exclusions and History Of Indicators

Date: 08/02/24

Did you know that you can have members removed from Open HEDIS® Care Gaps by adding a “History Of” diagnosis to a claim? 

Well-woman exams are a key factor to a healthier and longer life. These visits target specific areas of health that have been acknowledged to make an impact on a member’s quality of life. Women ages 50 to 64 should have a mammogram every two years to screen for breast cancer. Breast cancer screenings should occur between October, two years prior, through the end of the measurement year. For example: Between October 1, 2022, and December 31, 2024. Women ages 21 to 64 should have a screening for cervical cancer. Women ages 24 to 64 should have a Pap smear every three years and women ages 30 to 64 should have a HrPV test every five years.

Collecting historical member data for applicable exclusions is key to a member’s healthcare compliancy record, especially at times when a patient has changed health plans. When this happens, the new health plan may not have a clear transfer of historical data from the patient’s previous plan. This results in the member and/or primary care provider getting notifications stating the member is due for certain screenings when they should be excluded. 

Ambetter from Arkansas Health & Wellness is asking our provider partners to help us solve for this issue by utilizing the best practices below: 

• Document all historical exclusion diagnoses in the patient’s medical record on an annual basis.
• Submit at least one claim a year with all applicable ICD-10 codes to identify the patient’s historical exclusion diagnoses. 

By adopting these best practices, you can help Ambetter get a more complete understanding of your patients’ health, making us more successful in assisting our members with any additional healthcare needs they may have and support them in living healthier, happier lives.

Coding and Documentation Requirements: 

NCQA has made changes to the quality metrics in 2024. Some metrics, such as breast cancer screening, have been retired as administrative and hybrid collection methods and reintroduced as Electronic Clinical Data Systems (ECDS) measures. 

What Does This Mean for You?

Historically, Ambetter had the ability to collect medical records throughout the year as proof that historical services had been conducted. We used this hybrid collection method to abstract data from records and close open HEDIS care gaps. As we move forward with the new ECDS measures, Ambetter will no longer be able to collect medical records on new ECDS measures, including breast cancer screening. 

We are still able to collect and abstract data for cervical cancer screening. However, starting in 2025, cervical cancer screening will also convert to an ECDS-only measure. We ask that all partnering providers reach out for coding assistance to ensure best practices are being followed when billing current services, and to ensure all active and historical diagnoses are billed once a year. 

For additional information about ECDS, please visit NCQA.org/ECDS. 

Breast Cancer Screening (BCS-ECDS): 

Measurement includes members between ages 52 and 74 who were recommended for routine breast cancer screening and also meet the criteria for participation between October 1 two years prior to the measurement period through the end of the measurement period (October 1, 2022–December 31, 2024).

Include members recommended for routine breast cancer screening with any of the following criteria:

• Administrative Gender of Female (AdministrativeGender code F) at any time in the member’s history
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) at any time in the member’s history
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement period

Exclusion Criteria:

• Members who use hospice services or elect to use a hospice benefit any time during the measurement period
• Members who die any time during the measurement period
• Members who had a bilateral mastectomy or both right and left unilateral mastectomies any time during the member’s history through the end of the measurement period. Any of the following meet the criteria for bilateral mastectomy:
  • Bilateral mastectomy 
  • Unilateral mastectomy with a bilateral modifier (CPT® modifier code 50) (same procedure)
  • o Unilateral mastectomy found in clinical data with a bilateral qualifier value (SNOMED CT modifier code 51440002) (same procedure)

Note: The “clinical” mastectomy value sets identify mastectomy; the word “clinical” refers to the data source, not to the type of mastectomy.

• History of bilateral mastectomy 
• Any combination of codes below that indicate a mastectomy on both the left and right side on the same date of service or on different dates of service:
  • Left mastectomy (any of the following):
    • Unilateral mastectomy with a leftside modifier (CPT modifier code LT) (same procedure)
    • Unilateral mastectomy found in clinical data with a left-side qualifier value (SNOMED CT modifier code 7771000) (same procedure)
    • Absence of the left breast  
    • Left unilateral mastectomy
  • Right mastectomy (any of the following):
    • Unilateral mastectomy with a right-side modifier (CPT modifier code RT) (same procedure)
    • Unilateral mastectomy found in clinical data with a right-side qualifier value (SNOMED CT modifier code 24028007) (same procedure) 
    • Absence of the right breast 
    • Right unilateral mastectomy
• Members who had gender-affirming chest surgery (CPT code 19318) with a diagnosis of gender dysphoria any time during the member’s history through the end of the measurement period
• Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
  • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period
  • Living long-term in an institution any time during the measurement period
• Members 66 years of age and older by the end of the measurement period, with frailty and advanced illness. Members must meet both frailty and advanced illness criteria to be excluded:
  • Frailty: At least two indications of frailty with different dates of service during the measurement period. Do not include laboratory claims (claims with POS 81).
  • Advanced Illness: Either of the following during the measurement period or the year prior to the measurement period:
    
    • Advanced illness on at least two different dates of service. Do not include laboratory claims (claims with POS 81).
    • Dispensed dementia medication
• Members receiving palliative care any time during the measurement period
• Members who had an encounter for palliative care (ICD-10-CM code Z51.5) any time during the measurement period. Do not include laboratory claims (claims with POS 81).

Historical Exclusion Codes: 

• CPT: 19180, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307
• ICD-10-CM: F64.1, F64.2, F64.8, F64.9, Z87.890, Z90.11, Z90.12, Z90.13
• ICD-10-PCS: 0HTT0ZZ, 0HTU0ZZ, 0HTV0ZZ
• ICD-9-PCS: 85.42, 85.44, 85.46, 85.48
• SNOMED: 136071000119101, 137671000119105, 137681000119108, 428529004, 429009003, 429242008

Cervical Cancer Screening (CCS) and (CCS-ECDS): 

Measurement includes members between ages 21 and 64 who were recommended for routine cervical cancer screening and were screened for cervical cancer using any of the following criteria:

• Members between ages 21 and 64 who were recommended for routine cervical cancer screening and had cervical cytology performed within the last three years
• Members between ages 30 and 64 who were recommended for routine cervical cancer screening and had cervical high-risk HPV (hrHPV) testing performed within the last five years
• Members between ages 30 and 64 who were recommended for routine cervical cancer screening and had cervical cytology/hrHPV cotesting within the last five years

Include members recommended for routine breast cancer screening with any of the following criteria:

• Administrative Gender of Female (AdministrativeGender code F) at any time in the member’s history
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) at any time in the member’s history
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement period

Exclusion Criteria:

• Hysterectomy with no residual cervix any time during the member’s history through December 31 of the measurement year
• Cervical agenesis or acquired absence of cervix any time during the member’s history through December 31 of the measurement year. Do not include laboratory claims (claims with POS code 81).
• Members who use hospice services or elect to use a hospice benefit any time during the measurement year
• Members who die any time during the measurement year
• Members receiving palliative care any time during the measurement year
• Members who had an encounter for palliative care (ICD-10-CM code Z51.5) any time during the measurement year. Do not include laboratory claims (claims with POS code 81).
• Members with Sex Assigned at Birth (LOINC code 76689-9) of Male (LOINC code LA2-8) at any time in their medical history

Historical Exclusion Codes: 

• ICD-10-CM: Q51.5, Z90.710, Z90.712
• ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ
• ICD-9-CM: 752.43, V88.01, V88.03, 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8
• SNOMED: 37687000, 248911005, 428078001, 429290001, 429763009, 473171009, 723171001, 10738891000119107

For measurement-specific information on the above measures, please see the links below: 

• For coding information and tip sheets regarding HEDIS care gap closure, visit our Provider Resources page. 
• For condition education, visit our Member Resources page.