HEDIS® Tip Sheet

Emergency Department Utilization (EDU)

Line of business: BlueAlliance (Commercial) 

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.

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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.
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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.
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Best Practices

  • Encourage patients to engage with their PCP for annual wellness visits, screenings, and care coordination.
  • Engage with patients who are diagnosed with chronic conditions to help prevent and minimize exacerbations and complications.
  • Educate patients about appropriate ED use and other options available such as same-day appointments, urgent care, nurse lines, and telehealth.
  • Consider extended clinic and telehealth hours and addition of a nurse line.
  • Offer/coordinate support services for patients diagnosed with chronic conditions or experiencing exacerbations.
  • Consider a scheduled outreach with patients who frequent the ED.
  • Triage patients at the registration desk and direct to urgent care if appropriate.
  • Keep same-day appointments available.  

Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

Questions  

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

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Updated 1/22/2025