HEDIS^® Tip Sheet

Compliance for 7-Day and 30-Day Follow-Up

Any of the following services done with a mental health provider or having a diagnosis of substance use or drug overdose (unintentional) may count as a follow-up visit:  

• An outpatient visit.
• An intensive outpatient visit or partial hospitalization.
• A non-residential substance abuse treatment facility visit.
• A community mental health center visit.
• An observation visit.
• A peer support service visit.
• An opioid treatment service that bills monthly or weekly with a diagnosis of SUD, substance use, or drug overdose.
• A telehealth visit.
• A telephone visit.
• An e-visit, or virtual check-in.
• A substance use or substance use disorder service.
• A behavioral health screening or assessment for SUD or mental health disorders.
• A pharmacotherapy dispensing event or medication treatment event.

Notes

• The 30-day follow-up rate is part of the BlueAlliance and BlueAlliance Care+ program.
• Members included in the measure are those who had an ED visit with a principal diagnosis of substance use disorder.
• A member can be included in the measure more than once as the denominator is based on ED visits.
• If the member has more than one qualifying ED visit within a 31-day period, include only the first eligible visit.
• A follow-up may include follow-up visits and pharmacotherapy events with any diagnosis of SUD, substance use, or drug overdose (unintentional).
• May include visits and pharmacotherapy events that occur on the date of the ED visit.

Exclusions

• ED visits that result in an inpatient stay.
• ED visits followed by an admission to an acute or nonacute setting on the date of the ED visit or within 30 days of the ED visit regardless of the primary reason for the admission.
• ED visits followed by residential treatment on the date of the ED visit or within 30 days after. Residential treatment includes:
  • Residential Behavioral Health Treatment Center
  • Psychiatric Residential Treatment Center
  • Residential Substance Abuse Treatment Facility
  • Residential Program Detoxification Center
• Members in hospice during the measurement year.
• Members who died during the measurement year.

Best Practices

• Encourage use of telehealth appointments with a mental health provider for follow-up visits.
• Schedule follow up visits as soon as possible and educate patients, utilizing teach-back methods, on the importance of keeping follow-up appointments. 
• Include caregivers, if applicable, in discharge education and follow-up instructions. 
• Utilize EMR flags and reporting to identify patients in need of follow-up visits, cancel their appointment, or no-show appointments. Follow up with these patients in a timely manner to assist with appointment booking within seven days of ED visit. 
• Consider referrals to case managers or social workers to help with care coordination.
• Consistently use the same diagnosis for AOD abuse or dependence for subsequent follow-up visits (only a mental illness diagnosis code will fulfill this measure).