Important HEDIS® and Quality Measures

Fall 2018

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to assess performance on key measures of care and service. Neighborhood also uses HEDIS results to see where we need to focus our improvement efforts and to educate medical providers regarding steps they can take to improve HEDIS rates as well as the health of our members.

Child and Adolescent Access to Primary Care Practitioner (CAP)

These measures assess children and young adults 12 months-19 years of age who had a visit with a Primary Care Practitioner (PCP). The measure reports on four separate percentages:

  • Children 12-24 months who had a visit with a PCP during the measurement year.
  • Children 25 months-6 years who had a visit with a PCP during the measure year.
  • Children 7-11 years who had a visit with a PCP during the measure year or the year prior to the measurement year.
  • Adolescents 12-19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.

Access to primary care is important for the health and well-being of children and adolescents. High-quality primary care services have been found to significantly reduce children’s non-urgent ER visits.1 A consistent source of primary care can fill the need for screening, appropriate treatment and preventive services for children and adolescents.


  1. Bloom, B., R.A. Cohen, G Freeman. 2012. “Summary health statistics for U.S. children: National Health Interview Survey, 2011.” National Center for Health Statistics. Vital Health Statistics 10(254).


Lead Screening in Children (LSC):

This measure assesses the percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. Patients with a blood lead level greater than or equal to five mcg/dL. must be rescreened within 90 days of the elevated blood lead level.

According to the U.S. Department of Housing and Urban Development, exposure to lead can cause damage to the brain and other vital organs, as well as intellectual and behavioral deficits. Children who are exposed to lead often have no obvious symptoms and therefore, lead poisoning often goes unrecognized.

Screening for lead is an easy way to detect an abnormal blood lead level in children. According to the Centers for Disease Control, there is no safe blood lead level.2 If not found early, exposure to lead and high blood lead levels can lead to irrevocable effects on a child’s physical and mental health.

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Developmental Screening in the First Three Years of Life

The American Academy of Pediatrics (AAP) recommends developmental screening for early identification of developmental delays. It is important to screen children for development and autism based on the following recommended schedule:

  • Developmental Screening should be performed at 9 months, 18 months and 30 months.
  • Autism Screening should be performed at 18 months and 24 months.

Neighborhood’s clinical medical policy for Pediatric Development and Autism Screening states that up to 5 screenings without authorization are covered before age three.  The same CPT code (96110) is used to bill for both general developmental screening and for autism screening. Use the “U1” modifier when billing to differentiate the autism screening. You can bill separately, one instance with the modifier and one without, if both screens were performed during the same visit.

If these screenings are automated as part of your practice’s EMR, you will still need to bill CPT code 96110 to indicate that the screening was completed. Additionally, this code is not on the capitation listing. It is a covered service and will pay out as fee for service over and above the capitation payment.

For more information, please refer to the clinical medical policy located in the Providers section of Neighborhood’s website.

Please keep these measures in mind at every visit with your patients.