October 2019

HEDIS^® Measure: Well-Child Visits Within the First 15 Months of Life

At Blue Cross and Blue Shield of Illinois (BCBSIL), we are committed to offering support and resources to independently contracted providers to achieve the highest level of care possible for your patients, our members, in order to achieve the best possible health outcomes. Thank you for your dedication to ensure that your patients receive exceptional care.

The Healthcare Effectiveness Data and Information Set (HEDIS) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program^® (FEP^®) members. One of these measures focuses on well-child visits for infants and children within the first 15 months of life (W15). With the assistance of the Centers for Medicare & Medicaid Services (CMS) and the American Academy of Pediatrics, NCQA has developed this measure with a goal to promote optimal health outcomes for infants and children through regular well-child visits.

Medical record documentation must include a comprehensive visit note from the primary care physician, date of the visit, history to include physical health, physical development, mental development, a physical exam, and health education and recommendations. Documentation of these metrics is appropriate to demonstrate a well-child visit when performed by a primary care physician. Well-child exams may be performed even if the office visit is to treat illness. 

Generally, it’s recommended that infants and children receive at least six well-child visits within the first 15 months of life. The ages for well-child visits, as recommended by the American Academy of Pediatrics’ Bright Futures Periodicity Schedule, are:

• Newborn
• 1 month
• 2 months
• 6 months
• 9 months
• 12 months
• 15 months

Below is a chart for easy access for commonly used routine office visit codes. For your reference, the following are just a few of the approved codes from NCQA. For a complete list, please refer to the NCQA website at ncqa.org.

HEDIS is a registered trademark of NCQA.

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.