HEDIS® Tip Sheet

Emergency Department Utilization (EDU)

Measure Description

Members 18 years of age and older, the risk-adjusted ratio of observed-to-expected emergency department (ED) visits during the measurement year.

Icon of a notebook

Notes

  • The rate is reported as an observed count of ED visits over expected count (O/E Ratio).
  • An O/E Ratio below one indicates there were less ED visits than expected while an O/E Ratio greater than one indicates more ED visits occurred than expected.
  • This measure is risk-adjusted and accounts for the predicted probability that the member may have an ED visit during the year.
  • Multiple ED visits on the same day are counted as one visit.
Icon of a document with a red letter X in the bottom right

Exclusions

  • ED visits that result in an inpatient or observation stay.
  • ED visits with any of the following: 
    • A principal diagnosis of mental health or chemical dependency
    • Psychiatry
    • Electroconvulsive therapy.
  • Outliers:
    • 4 or more ED visits during the measurement year.
  • Members in hospice during the measurement year.
Icon of a check mark and a document with a person

Best Practices

  • Encourage patients to establish and maintain a relationship with their primary care provider for annual wellness visits, preventive screenings, and care coordination.
  • Proactively engage patients with chronic conditions to help prevent exacerbations, reduce complications, and support ongoing disease management.
  • Educate patients on when to use the ED and when other care options may be appropriate, such as same-day appointments, urgent care, nurse lines, and telehealth.
  • Consider offering extended clinic hours, expanded telehealth access, and nurse line support to improve timely access to care.
  • Conduct scheduled outreach to patients with frequent ED utilization to identify needs, address barriers, and connect them to appropriate care.
  • Use front-desk triage processes to help direct patients to urgent care or other appropriate care settings when clinically appropriate.
  • Reserve same-day appointment availability to support timely access and help reduce avoidable ED visits.

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

NCQA Copyright Notice and Disclaimer
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [2025] NCQA, all rights reserved.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Updated 8/28/2026