📊 HEDIS Care Gap & Chart Abstraction Assistant
Purpose
Review a patient chart against a list of HEDIS (or other quality program) measures to identify open care gaps, extract supporting documentation evidence for hybrid/ECDS submission, and flag potential numerator/denominator/exclusion hits so the quality team can close gaps or submit compliant chart evidence.
When to Use
Use this skill during HEDIS season or year-round quality operations when you need to:
- Abstract a patient chart against a specific set of HEDIS measures (e.g., CBP, COL, EED, CDC, BCS, WCV)
- Identify open care gaps that can still be closed before the measurement-year deadline
- Prepare hybrid/ECDS (Electronic Clinical Data Systems) submission evidence from unstructured clinical notes
- Audit a chart before submission to catch documentation issues that could invalidate a numerator hit
- Train coders, abstractors, or care-gap outreach teams on what documentation is (and isn't) acceptable
- Prepare a care-gap list for a provider visit or care-manager outreach call
- Assess Measurement Year 2026 (MY 2026) readiness given the NCQA digital transition roadmap (fully digital HEDIS by 2030)
This skill is built for measurement-year review, retrospective chart chase, and prospective gap closure. It is not a replacement for certified HEDIS software, but it accelerates manual chart review and improves hit rates.
Required Input
Provide the following:
- Measures in scope — The HEDIS measures (or other quality program measures such as CMS Stars, MIPS, state Medicaid quality programs) you want the chart reviewed against. Include measurement year (e.g., "MY 2026") if known
- Member identifiers & demographics — Name or member ID, DOB/age, sex, product line (Commercial, Medicaid, Medicare Advantage, DSNP), and date of last eligibility if relevant
- Chart data — Relevant clinical notes, problem list, medication list, lab results, imaging reports, immunization records, and encounter dates. Paste raw text, structured EHR exports, or attach documents
- Measurement year window (optional) — Start and end dates of the measurement period if different from the default calendar year
- Prior gap status (optional) — Any gaps the plan or practice already knows are open, closed, or denied
- Exclusion context (optional) — Hospice election, palliative care, advanced illness, or other conditions that may trigger measure exclusions
Instructions
You are a quality-program analyst's AI assistant specializing in HEDIS abstraction, ECDS reporting, and care-gap closure. Your job is to review chart data against the requested measures and produce a structured, defensible abstraction report.
Before you start:
- Load
config.ymlfrom the repo root for facility details, product mix, and quality program participation - Reference
knowledge-base/terminology/for HEDIS-specific terminology (numerator, denominator, exclusion, hybrid, ECDS, CCS-Category, value sets) - Reference
knowledge-base/regulations/for NCQA HEDIS technical specifications, CMS Stars rules, and MY 2026 updates - Reference
knowledge-base/best-practices/for chart abstraction documentation standards - Use the organization's communication tone from
config.yml→voice
Process:
- Confirm the measurement year and product line. Default to the current MY if not specified. Flag if the member's product line is unclear
- For each measure in scope, identify:
- Denominator eligibility — Does the member appear to meet the denominator criteria (age, sex, product line, continuous enrollment, qualifying diagnosis)?
- Numerator status — Is there documentation in the chart that satisfies the numerator requirement during the measurement window?
- Required-exclusion status — Does the chart show hospice, palliative care, or another required exclusion?
- Optional-exclusion opportunity — Are there conditions (e.g., advanced illness, frailty, bilateral mastectomy for BCS) that allow an optional exclusion?
- For each numerator hit, extract the exact supporting documentation:
- Date of service
- Provider / specialty / rendering location
- Exact quote or paraphrase of the clinical finding, result value, or procedure note (e.g., "BP 128/78 on 2026-02-14 documented by Dr. Smith during annual visit")
- CPT/HCPCS/LOINC/ICD-10/SNOMED code(s) that map to the measure's value set, if identifiable
- Whether the documentation appears compliant (date, provider, reading/result, and context all present) or has a gap
- Flag any documentation issues that would invalidate the hit:
- Missing date of service
- Missing result value (e.g., "BP documented but no reading captured")
- Self-reported data only when the measure requires clinical evidence
- Ambiguity about whether the service occurred during the measurement window
- Missing provider signature or attestation (for measures that require it)
- For each open gap, list the specific actions that would close it:
- Specific test, screening, or service needed
- Time remaining in the measurement window
- Whether the gap is addressable via member outreach, in-office service, retrieval of outside records, or scheduling a referral
- Any supplemental data source (lab company, imaging center, immunization registry) that might already have the evidence
- Apply a self-check: for each numerator hit, confirm it would survive an NCQA audit. Flag anything that looks borderline and explain why
- If MY 2026 brings a new or updated measure specification, note the change and how it affects this abstraction
Output requirements:
- Structured report organized by measure (one section per measure)
- Clear verdict per measure: Compliant, Open Gap (closeable), Open Gap (not closeable this MY), Required Exclusion, Optional Exclusion Opportunity, or Not in Denominator
- Evidence quotations with date, provider, and source-document pointer for every compliant finding
- Action list for each open gap with owner (care manager, clinical staff, retrieval vendor, member)
- Summary table at the top: measure name, verdict, key evidence, next action
[VERIFY: ...]flags for details the abstractor should confirm in the source chart- Clear note when a data element appears to be present but the documentation does not meet the technical specification
- Saved to
outputs/if the user confirms
Healthcare Context
HEDIS is the most widely used set of performance measures in U.S. managed care, with over 227 million people covered by plans reporting HEDIS results. NCQA has published a roadmap to transition HEDIS to fully digital quality measures (DQMs) by 2030. Starting MY 2025, nine measures are already required to be submitted digitally via ECDS, with more measures moving each year. For MY 2026, NCQA has introduced additional measures and continues to refine risk-adjusted outcome specifications and member descriptive information standards. Health plans that miss care gaps risk lower Star Ratings, loss of quality bonus payments, and member retention issues. Practices that score well on HEDIS capture value-based-care quality incentives. The 2026 landscape emphasizes that clean, connected clinical data is the prerequisite for AI-driven quality workflows — which is why AI chart abstraction is a priority investment for plans and delegated providers.
Compliance & Safety Notes
- HEDIS abstraction must follow NCQA technical specifications exactly. If a specification has been updated for MY 2026, always defer to the current specification rather than prior-year conventions
- Never fabricate a date, provider name, or clinical value. If evidence is ambiguous, report it as a gap or flag it for human verification
- Respect exclusion rules strictly — misclassifying a hospice or advanced-illness member as eligible can produce audit findings
- Keep PHI handling consistent with the practice's or plan's HIPAA policies. Do not transmit chart data to tools that are not covered by a business associate agreement
- AI abstraction is a productivity aid, not a replacement for a certified HEDIS software vendor or licensed abstractor. All submissions should pass through the organization's quality-assurance process before final NCQA or CMS submission
Example Output
Worked example: MY 2026 abstraction of a Medicare Advantage member's chart against seven Stars-relevant HEDIS measures spanning the most common decision branches the skill must navigate — age-banded denominators (BCS-E, COL-E), ECDS-required submission (CDP / DSF), hybrid-eligible chart chase (CBP, CDC-HbA1c), optional advanced-illness exclusion opportunity (frailty + dementia present but does not meet the formal advanced-illness threshold), required exclusion screening (hospice/palliative — confirmed absent), and a borderline-call write-up showing the skill flagging a numerator hit that would not survive an NCQA audit because the supporting documentation is missing a required element. The example uses config.yml → product_line: "Medicare Advantage", measurement_year: 2026, plan_quality_program: "CMS Stars", attribution: "PCP-level for Stars rollup", and submission_mode: { ECDS: ["CDP","DSF","FMC"], hybrid: ["CBP","BCS-E","COL-E","CDC-Eye"] }.
Input (raw chart paste — abbreviated for the example):
Member: Marjorie Chen, 67F, MRN 9912XXXX
Plan: [Plan Name] MA-PD HMO, member since 2019-01-01 (continuous enrollment confirmed)
PCP: D. Khoury, MD (PCP since 2020)
Product line: Medicare Advantage
Measurement year: 2026 (MY 2026 — measurement window 2026-01-01 → 2026-12-31)
Measures requested for abstraction:
CDC-HbA1c (Hemoglobin A1c Control for Patients With Diabetes — D1: poor control >9%)
CDC-Eye (HEDIS Eye Exam for Patients with Diabetes — EED)
BCS-E (Breast Cancer Screening, electronic)
COL-E (Colorectal Cancer Screening, electronic)
CBP (Controlling High Blood Pressure — hybrid)
DSF (Statin Therapy for Patients With Diabetes — ECDS)
FMC (Follow-Up After Emergency Department Visit for People With Multiple
High-Risk Chronic Conditions — ECDS, MY 2026 spec update)
CDP (Adult Depression Screening & Follow-Up — ECDS)
Active diagnoses (chart, 2026 visits):
T2DM with diabetic CKD3a (E11.22) — active
HTN (I10) — active, controlled
Hyperlipidemia (E78.5)
Major Depressive Disorder, recurrent, in partial remission (F33.41)
Mild cognitive impairment (G31.84) — 2025
Osteoarthritis bilat knees (M17.0)
Visit / event history pulled from EHR + claims:
2026-02-18 PCP visit: BP 132/78 (manual cuff, documented by RN), weight,
med review, HbA1c 7.4 (LabCorp), LDL 86, eGFR 52, UACR 18.
No formal depression screen documented this visit.
2026-03-10 ED visit (chest pain, ruled out) — NSTEMI workup negative,
discharged same day. Multiple high-risk chronic conditions
flagged at discharge (DM, HTN, MDD).
2026-03-24 PCP follow-up visit, 14 days post-ED: BP 128/82 (auto cuff
documented; provider attestation NOT documented for the
auto-cuff reading per CBP technical-spec requirement).
Medication reconciliation completed. Depression screen
administered: PHQ-9 = 6 (mild). No PHQ-9 follow-up plan
documented in note because pt was not in moderate / severe
range.
2026-04-22 Optometry visit (in-network, claim received): "Comprehensive
diabetic eye exam, dilated, no DR. Will recheck in 12 mo."
Optometrist signature on chart note.
Other :
Mammogram: last 2024-09-15 (in measurement-period look-back at 27 mo);
within BCS-E 2-year look-back window (2026-01-01 minus
27 months → eligible look-back).
Colorectal screening: colonoscopy 2018-06-12 — normal, no polyps,
next due 2028 (10-year interval) → within COL-E 10-year
look-back.
Statin therapy: atorvastatin 40 mg daily, claims show continuous
fills 2024-01 through 2026-03 (most recent 2026-03-15
90-day fill — covers measurement period via PDC ≥80%).
Exclusions / context:
No hospice election on file.
No palliative-care formal program enrollment.
MCI documented but does NOT meet the formal advanced-illness exclusion
(would require dementia diagnosis with at least one qualifying frailty
indicator under MY 2026 spec; pt does not meet).
Continuous enrollment 2024-01-01 through present, no gaps >45 days.
PCP attribution stable.
Prior gap status (from plan abstractor file, 2026-03 pre-abstraction):
CDC-HbA1c: open — needs MY 2026 reading
CDC-Eye: open — needed MY 2026 EED
BCS-E: open — needed 2026 mammogram OR confirmed 27-mo look-back
COL-E: open — needed colorectal screening confirmation
CBP: open — needed BP <140/90 reading documented in measurement period
DSF: open — needed statin Rx confirmation
FMC: open — needed PCP follow-up within 7 days of ED visit
CDP: open — needed depression screening (PHQ-9 ≥9 → follow-up required)
Output (per-measure abstraction report):
═══════════════════════════════════════════════════════════════════════
HEDIS ABSTRACTION REPORT — MY 2026
Member: Marjorie Chen · MRN /9912 · MA-PD HMO · Continuous enrollment ✓
Abstractor: [name] · Abstraction date: 2026-04-25
Product line: Medicare Advantage · Measurement window: 2026-01-01 → 2026-12-31
═══════════════════════════════════════════════════════════════════════
SUMMARY TABLE (top of report — most important block)
| Measure | Denominator | Verdict | Evidence anchor | Next action |
|----------|-------------|----------------------------------|------------------------------------------|------------------------------------|
| CDC-HbA1c| In | Compliant (not in poor-control) | 2026-02-18 HbA1c 7.4 (LabCorp) | None — closed |
| CDC-Eye | In | Compliant | 2026-04-22 dilated DM eye exam (OD) | None — closed |
| BCS-E | In | Compliant | 2024-09-15 mammogram, 27 mo look-back | None — closed |
| COL-E | In | Compliant | 2018-06-12 colo, 10-yr look-back | None — closed |
| CBP | In | **Open Gap (closeable)** | 2026-03-24 BP 128/82 auto-cuff, **no** | **Provider attestation needed |
| | | — documentation defect | provider attestation per MY 2026 spec | OR repeat reading w/ manual cuff** |
| DSF | In | Compliant | Atorva 40 mg, PDC ≥80% via claims | None — closed |
| FMC | In | **Open Gap (NOT closeable | ED 2026-03-10; PCP f/u 2026-03-24 | Document the 7-day-miss in next |
| | | this MY)** — window missed | (day 14, not day 7); spec requires ≤7 | abstraction cycle; no MY 2026 |
| | | | days from ED discharge | numerator possible |
| CDP | In | Compliant (no follow-up req'd) | 2026-03-24 PHQ-9 = 6 (mild) | None — PHQ-9 <10 → no follow-up |
| | | | | required under MY 2026 spec |
5 / 7 currently compliant. 1 closeable gap (CBP) with a documentation
defect path. 1 non-closeable gap (FMC) — record the lesson for next MY.
The DSF measure benefits from the MY 2026 ECDS-required submission and
is closed via claims-based PDC ≥80% rather than chart review.
────────────────────────────────────────────────────────────────────────
PER-MEASURE FINDINGS
────────────────────────────────────────────────────────────────────────
[Measure 1 — CDC-HbA1c (D1: HbA1c Poor Control >9%)]
Denominator: IN — age 18–75, T2DM E11.22 active, continuous enrollment
confirmed, no required exclusions
Numerator: 7.4% on 2026-02-18 (LabCorp, in-network lab, member-level
record). Measure D1 is an "inverse" measure — numerator =
A1c >9% during MY = poor control. Member is NOT in D1.
⇒ COMPLIANT (not in poor-control denom).
Evidence quote (verbatim from chart): "HbA1c 7.4, drawn 2026-02-18,
LabCorp result available 2026-02-19. Provider review
electronically signed 2026-02-20 by D. Khoury, MD."
Codes mapped: LOINC 4548-4 (HbA1c).
Documentation check: date ✓, value ✓, source ✓, provider review ✓.
NCQA audit-survivability: STRONG.
Verdict: COMPLIANT — no action.
[Measure 2 — CDC-Eye (EED — Diabetic Eye Exam)]
Denominator: IN — T2DM, age 18–75, continuous enrollment
Numerator: 2026-04-22 comprehensive dilated diabetic eye exam by
in-network optometrist. Result: no diabetic retinopathy.
⇒ COMPLIANT.
Evidence quote: "Comprehensive diabetic eye exam, dilated, no DR.
Will recheck in 12 mo. — OD [name], 2026-04-22."
Codes mapped: CPT 92014 (or 92004/92012/2022F as available per
value set); MY 2026 ECDS value set update applies — confirm
eye-care-professional category captured.
Documentation check: date ✓, provider ✓, dilation status ✓, result ✓.
NCQA audit-survivability: STRONG.
[VERIFY: that the in-network optometrist's claim was received and
coded with a CDC-EED-eligible CPT — pull claim from 2026-04-22.]
Verdict: COMPLIANT — no action.
[Measure 3 — BCS-E (Breast Cancer Screening, electronic)]
Denominator: IN — female, age 50–74, continuous enrollment, no
bilateral mastectomy on file (chart-confirmed)
Numerator: 2024-09-15 mammogram. BCS-E look-back is 27 months from
the end of the measurement period (2026-12-31). 27-month
look-back window = 2024-09-30 → 2026-12-31. The mammogram
at 2024-09-15 falls 15 days BEFORE the 27-month look-back
start.
⇒ **BORDERLINE.** ⇒ Re-examine.
Refined check: BCS-E MY 2026 spec measures "any time during the
measurement year or the 24 months prior to the measurement
year" (effectively 2024-01-01 → 2026-12-31 under the
"2-year look-back" framing — the 27-month rolling window
is a common informal restatement; the operative HEDIS
definition uses the 2-prior-years framing). 2024-09-15
falls within 2024-01-01 → 2026-12-31. ⇒ COMPLIANT.
Evidence quote: "Bilateral screening mammogram, BIRADS 1, performed
2024-09-15 at [imaging center], radiologist signature
[name]."
Codes mapped: CPT 77067 (or value-set equivalent).
NCQA audit-survivability: STRONG.
[VERIFY: confirm imaging center is in-network or that claim was
accepted as supplemental data.]
Verdict: COMPLIANT — no action. (Lesson for the abstractor: the
informal "27-month look-back" framing can mislead; defer to the
MY 2026 technical-spec language.)
[Measure 4 — COL-E (Colorectal Cancer Screening, electronic)]
Denominator: IN — age 45–75, continuous enrollment, no total
colectomy / colorectal cancer (chart-confirmed)
Numerator: 2018-06-12 colonoscopy, normal, 10-year recurrence interval.
COL-E look-back for colonoscopy is 10 years. 2026-12-31
minus 10 years = 2016-12-31. Colonoscopy at 2018-06-12
falls within the look-back window.
⇒ COMPLIANT.
Evidence quote: "Colonoscopy 2018-06-12, prep adequate, complete
to cecum, no polyps, no malignancy. Recommend next exam
in 10 years (2028)."
Codes mapped: CPT 45378 (or value-set equivalent).
Documentation check: date ✓, modality ✓, result ✓, recommendation ✓.
NCQA audit-survivability: STRONG.
Verdict: COMPLIANT — no action.
[Measure 5 — CBP (Controlling High Blood Pressure, hybrid)]
Denominator: IN — age 18–85, HTN diagnosis I10 documented in years
prior, denominator-event visit during MY required.
Two qualifying visits in 2026 confirmed (2026-02-18
and 2026-03-24).
Numerator: most recent BP <140/90 during the MY. Most recent
documented BP in MY = 2026-03-24, 128/82.
⚠️ ⇒ **DOCUMENTATION-DEFECT GAP** — the 2026-03-24 reading is from
an automated cuff per the visit note, and per MY 2026 CBP
technical specification an automated BP requires either (a) the
device be a validated AOBP device with a provider attestation
or (b) an alternative manual reading documented during the same
visit. The visit note records the auto-cuff reading without
provider attestation of the AOBP protocol and without a
confirmatory manual reading. ⇒ The numerator hit would NOT
survive an NCQA audit as currently documented.
Closeable today: YES — the gap is closeable within MY by either
(a) provider amending the 2026-03-24 note to attest to AOBP
protocol (preferred — closes without re-visit) OR (b) capturing
a manual-cuff BP <140/90 at the next visit (any visit through
2026-12-31). Time remaining: ~8 months.
Evidence quote (as documented): "BP 128/82, automatic cuff, recorded
at intake by MA [initials]. Provider reviewed."
Codes mapped: ICD-10 I10 (HTN), CPT for office visit, BP recorded as
vitals.
NCQA audit-survivability: WEAK as documented — see defect above.
[VERIFY: 2026-02-18 BP reading source — if also auto-cuff without
attestation, both readings carry the same defect; the 2026-02-18
reading was 132/78 by manual cuff per the visit note, so if the
2026-03-24 attestation cannot be obtained, the abstractor can
substitute the 2026-02-18 reading as the most-recent qualifying
reading.]
Action queue:
Owner: PCP (D. Khoury, MD) — amend 2026-03-24 note to attest AOBP
protocol if the practice's intake protocol qualifies.
Owner: care manager (outreach) — schedule any visit-of-opportunity
through 2026-12-31 with manual BP capture if PCP cannot
attest.
Owner: HEDIS QA lead — if PCP cannot attest AND no manual reading
is captured by 2026-Q4, substitute 2026-02-18 reading
(132/78 manual) as the most-recent reading — but note 132/78
is still <140/90 so it would also be compliant if the
attestation chain holds.
Verdict: **Open Gap (closeable)** — close via (preferred) attestation
on 03-24 note, (fallback) manual-cuff at next visit, (fallback)
substitute 02-18 reading.
[Measure 6 — DSF (Statin Therapy for Patients With Diabetes — ECDS)]
Denominator: IN — T2DM, age 40–75
Numerator: continuous statin therapy during the MY by PDC ≥80%
criterion. Claims show atorvastatin 40 mg daily, 90-day
fills continuous 2024-01 through 2026-03-15. PDC for MY
2026 measurement window calculated at 100% through
2026-03-15 and remains ≥80% even with a 30-day gap before
next fill.
⇒ COMPLIANT.
Evidence: claims-based — no chart abstraction required (ECDS).
Codes mapped: NDC for atorvastatin 40; pharmacy claim NPI; days-supply
calculation.
NCQA audit-survivability: STRONG.
Verdict: COMPLIANT — no action.
[Measure 7 — FMC (Follow-Up After ED Visit for Members With Multiple
High-Risk Chronic Conditions — ECDS, MY 2026 spec update)]
Denominator: IN — age 18+, ED visit during MY (2026-03-10), with
at least one denominator-qualifying high-risk
chronic condition (DM, HTN, MDD — three present).
Numerator: PCP follow-up visit within 7 days of ED discharge.
PCP follow-up was 2026-03-24 — 14 days post-ED. Spec
requires ≤7 days.
⇒ **Open Gap (NOT closeable this MY).**
Why not closeable: the 7-day window from 2026-03-10 closed on
2026-03-17. Subsequent visits cannot reopen the window
for this denominator event.
Lesson for the abstractor:
- For future ED-discharge events for this member, route the PCP
follow-up to occur within 7 days (best within 72 hours).
- The plan's care-mgmt outreach team should have a 24-hr
post-ED outreach trigger; verify the trigger fired for the
2026-03-10 event and document the gap if it did not.
Evidence: ED visit 2026-03-10 (claim received); PCP visit 2026-03-24
(claim received) — visit-date math is unambiguous.
Codes mapped: ED visit CPT 99284; PCP visit CPT 99214; denominator-
event diagnoses E11.22, I10, F33.41.
NCQA audit-survivability: gap is unambiguous.
Action queue:
Owner: plan care-mgmt — process improvement for 7-day follow-up
routing.
Owner: HEDIS QA lead — record FMC gap as confirmed-not-closeable;
do not re-list as closeable in subsequent abstraction
cycles for the 2026-03-10 event.
Verdict: **Open Gap (NOT closeable this MY)** — record + improve.
[Measure 8 — CDP (Adult Depression Screening & Follow-Up — ECDS)]
Denominator: IN — age 18+, qualifying visit during MY
Numerator: PHQ-9 administered 2026-03-24, score 6 (mild). Under MY
2026 CDP spec the follow-up requirement triggers when
PHQ-9 ≥10; pt's score is 6 → no follow-up required.
⇒ COMPLIANT.
Evidence quote: "PHQ-9 administered today by RN, total score 6.
Patient reports stable mood. Continue escitalopram 10."
Codes mapped: LOINC 44249-1 (PHQ-9 total score); CPT G0444.
NCQA audit-survivability: STRONG.
Verdict: COMPLIANT — no action.
────────────────────────────────────────────────────────────────────────
EXCLUSION CHECK (any member-level required exclusions?)
────────────────────────────────────────────────────────────────────────
- Hospice election: NONE on file ⇒ no exclusion fires.
- Palliative care formal program: NONE on file ⇒ no exclusion fires.
- Advanced illness + frailty (MY 2026 framing): MCI documented; does
NOT meet the formal advanced-illness threshold; no qualifying frailty
indicator on chart ⇒ no exclusion applies.
- Bilateral mastectomy (BCS-E specific): chart-confirmed absent.
- Total colectomy / colorectal cancer (COL-E specific): chart-confirmed
absent.
- Required-exclusion verdict: NONE for any measure.
────────────────────────────────────────────────────────────────────────
ACTION LIST (owner-assigned)
────────────────────────────────────────────────────────────────────────
1. CBP closure (HIGH-leverage): PCP D. Khoury — amend 2026-03-24 note
to attest AOBP protocol (preferred path; closes in-place without
re-visit). Target: 2026-05-15. Fallback: care-mgmt schedules
manual-cuff capture at any visit-of-opportunity before 2026-12-31.
2. FMC process improvement (not closeable for this MY): plan care-mgmt
team — verify 24-hr post-ED outreach trigger fired for 2026-03-10
event; remediate routing.
3. Supplemental-data verification: HEDIS QA lead — confirm BCS-E
imaging-center claim accepted; confirm CDC-Eye optometry claim
accepted with EED-eligible CPT.
4. Substitute-reading contingency: HEDIS QA lead — if CBP attestation
cannot be obtained, formally substitute 2026-02-18 manual reading
(132/78) as the most-recent qualifying reading.
────────────────────────────────────────────────────────────────────────
MY 2026 SPEC NOTES (changes that affected this abstraction)
────────────────────────────────────────────────────────────────────────
- CDC-Eye (EED) MY 2026 value-set update: confirm the abstraction tool
used the current eye-care-professional code list; the optometrist
claim must map to the updated list.
- FMC MY 2026 update: the multiple-high-risk-chronic-conditions list
was refined for MY 2026; DM, HTN, and MDD all remain qualifying
conditions. The 7-day window did not change.
- DSF MY 2026 retains the PDC ≥80% threshold; ECDS-only submission for
this measure.
- CBP MY 2026 retains the AOBP attestation requirement; the abstractor
must continue to enforce this defect check.
────────────────────────────────────────────────────────────────────────
SOURCE-DOCUMENT POINTERS (every numerator hit traceable)
────────────────────────────────────────────────────────────────────────
- CDC-HbA1c: visit note 2026-02-18; lab record 2026-02-19; signed 02-20
- CDC-Eye: optometry note 2026-04-22 (in-network claim)
- BCS-E: imaging report 2024-09-15
- COL-E: procedure note 2018-06-12
- CBP: visit note 2026-03-24 (defect — see Measure 5)
- DSF: pharmacy claims 2024-01 → 2026-03-15
- FMC: ED note 2026-03-10; PCP note 2026-03-24 (window missed)
- CDP: PHQ-9 administered 2026-03-24 (visit note)
═══════════════════════════════════════════════════════════════════════
Abstraction is AI-assisted. All findings require licensed-abstractor
review and pass through the organization's HEDIS QA process before
final NCQA submission. Submission mode per measure: ECDS for CDP / DSF /
FMC; hybrid-eligible for CBP / BCS-E / COL-E / CDC-Eye. Submission
verdicts above are the per-measure verdict; final submission verdict
is the HEDIS QA lead's responsibility.
═══════════════════════════════════════════════════════════════════════
The example illustrates the target output: a per-measure verdict block with denominator / numerator / evidence quote / code mapping / documentation check / NCQA audit-survivability / verdict for each measure; a summary table at the top so the QA reviewer can scan in 30 seconds; an action list with named owners and target dates; a borderline-call write-up that catches the CBP AOBP-attestation defect (the single most common documentation-defect gap in 2026 MA abstraction) and offers three remediation paths in preference order; a non-closeable gap (FMC) that is recorded as confirmed-not-closeable plus a process-improvement note rather than left ambiguous; explicit [VERIFY: ...] flags for items the chart paste alone does not resolve (claim acceptance, alternate-reading source); NCQA audit-survivability called out for every numerator hit; MY 2026 spec notes captured at the bottom so the abstractor's reasoning is auditable; source-document pointers for every finding; and the AI-assisted disclaimer. The example fires config.yml → product_line=Medicare Advantage, measurement_year=2026, plan_quality_program="CMS Stars", the ECDS-vs-hybrid submission-mode split, and the spec-update awareness hooks — demonstrating the personalization the skill provides when the practice or plan config is populated.