Back to dashboard
Medicare AdvantageDocumentationMedium impact

HEDIS Advanced Illness and Frailty Exclusion

Medical Mutual of Ohio·OH · Family Medicine, Internal Medicine, Geriatrics +4 more·In the News
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply
—

Summary

Medical Mutual of Ohio has implemented HEDIS exclusion guidelines for advanced illness and frailty patients. Billing teams must use specific ICD-10 codes to exclude eligible patients (ages 66-80 with both conditions, or 81+ with frailty) from certain HEDIS quality measures like cancer screenings and diabetes management.

Action Required

Action needed
Immediately: Billing team must incorporate advanced illness and frailty ICD-10 codes into supplemental data files or claims when clinically appropriate. Contact Medical Mutual's Supplemental Data team (Rick Hein richard.hein@medmutual.com and Nadia Dumevi nadia.dumevi@medmutual.com) to establish or update supplemental data files. Ensure proper coding for patients ages 66-80 with advanced illness AND frailty, or patients 81+ with frailty to optimize HEDIS scores and reduce medical record requests.

Affected Billing Codes

I11.0
I13.0
I50.20
I50.22
I50.23
I50.32
I50.33
I50.42
I50.43
I50.9
J43.9
J96.11
J96.21
J96.90
F03.90
F03.918
G35
N18.5
N18.6
C25.9
C78.7
C79.51
C79.9
C91.00
K74.60
R26.2
R26.89
R26.9
R53.1
R53.81
R54
R62.7
R63.4
R63.6
R64
L89.150
L89.152
L89.153
L89.154
L89.159
L89.312
L89.90
M62.81
M62.84
R29.6
W01.0XXA
W19.XXXA
W19.XXXD
Z91.81
Z74.01
Z74.09
Z74.1
Z74.2
Z74.3
Z99.11
Z99.3
Z99.81
Z99.89

Related policy hubs