CMS HEDIS 5 Star Measure Ratings TIPS

CMS created the 5 star rating system to help consumers and patients and their families compare different organizations for their short or long term medical use. Now CMS assigns ratings to different Health plans based on several criteria. Starting in 2015 Health plan will be graded heavily and incentivized or scrutinized by the 5 star ratings that are assigned to them by CMS. A lot of 5 star measures are NOT being captured by the Health Plans for various reasons. Even though it is known that most patients do have yearly blood tests during their annual wellness visits or for any specific reasons. Laboratories submit data directly to Health Plan for reimbursements and data collection purposes. Here are some recommendations made by the various health plans to make sure that data is captured and lab reporting errors and other issues are eliminated.
  1. Please make sure the patient complete name, Health Plan ID number and the actual Health Plan name is legible on the lab slip.
  2. For all your Diabetic patients make sure to obtain a yearly HgA1c and LDL-C test. Also measure urine micro albumin for renal assessment or document that patient is on an ARB, or ACE inhibitor. Our goal is to bring those values to under control for better treatment and to satisfy the measures.
  3. Please make sure that each Diabetic patient receives an eye exam by either an ophthalmologist or optometrist yearly.
  4. Remember that colon cancer screening should be performed for all patients between ages of 50 to 75. The criteria are colonoscopy q10 years or sigmoidoscopy q5 years. More patient prefer Fecal occult blood test (FOBT) every year using Guaiac test or Immunochemical test (FIT). Make sure the correct CPT and ICD 9 codes are identified. FOBT and FIT have different codes.
  5. Biannual mammograms are recommended for all female patients between ages 40 to 75.
  6. Care for older adults are newly added. They include, Medication reconciliation vs review, Pain assessment, advance care planning and functional assessment that needs to be addressed at least once a year.
  7. Please make sure that the patient BMI is captured at least once a year and the code V85.xx is reported.


 Please familiarize yourself with the CPT and ICD9 codes that pertain to the above measures. You can obtain more information about 5 star measures by referring to HEDIS 2014 or 2015 guidelines in the NCQA website. The link is provided here.