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Documentation Reporting Periods FAQs

All Documents Must Show Dates

 Type Guidelines
Record Review Workbook (RRWB) (PCMH Only)
  • For PCMH 4B and 4C, the practice may go back 12 months (with a 2-month grace period) from the care visit related to the selection criteria to locate documentation of each item in patient medical record
  • For example, if a survey tool is submitted May 31, 2015:
    • Patient #1 had a care visit date on March 2, 2015.
  • The practice may go back 12 months (with a 2-month grace period) to locate the data from March 2, 2015.
  • For PCMH 3C, it is up to the practice to determine frequency of assessment using evidence-based guidelines.
Documented Process
  • Policies, procedures and processes must be in place for at least 3 months prior to survey submission
  • This time period is intended for practice staff to ensure a systematic approach to patient care and practice operations.
  • If the documented process has been updated, the practice must provide:
    • New and previous documented process or identify where changes have occurred in the updated process
    • Date of update
Reporting Periods (Rates)
  • NCQA requires that reports are from a recent 3-month period (i.e., any 3-month period within the 12 months prior to survey submission).
  • For example, if a survey tool is submitted August 2015, a 3-month reporting period may be:
    • Between August 2014-August 2015
    • A report with one year of data may be for the previous calendar year, that is, January 2014-December 2014
Reporting Period (Log or Report)
  • Refer to documentation section of specific elements in the PCMH 2014 Standards and Guidelines for minimum data documentation periods (at least one week, one month, 30-calendar-day, etc.)
  • "Recent" reporting period means within 12 months prior to the survey tool submission:
    • If a survey tool is submitted October 1, 2015, the documentation period for a one-month data report must be October 1, 2014-September 30, 2015
    • If a full year of data is included the report submitted in October 2015, the data may be for the previous calendar year, that is, January 2014-December 2014.
Data Comparison to Show Continuous Quality Improvement (PCMH 2014 6D or PCSP 2013 6C: Implement Continuous Quality Improvement)
  • For continuous quality improvement and data comparison purposes, the practice needs to document baseline data, goals for improvement, actions to achieve improvement and at least annual re-measurement or current data.
  • If a practice submits a survey tool August 1, 2015, the following is an example of data comparison periods.
    • Performance at Re-measurement or Current Measurement-- data should be from within, or including, the past year, for example:
      • March 1, 2015 - May 31, 2015
      • January 1, 2014 - December 31, 2014
    • Initial Performance (or baseline)/Measurement Period -- provides the basis of comparison for later performance measurement periods (for example, January 1, 2013 - December 31, 2013)
    • Set Performance Goals -- established goals for improving performance
    • Implement Actions -- specific actions to improve performance for a minimum of 3 months

    *NCQA is not prescriptive regarding time to implement actions; however, at least 3 months is recommended to ensure meaningful change may be implemented.

REPORT = summary of results
PERFORMANCE DATA = measurable and enables data comparisons; requires a numerator, denominator and percentage.
Meaningful Use Reporting (PCMH 2014 6F: Report Performance) (PCMH Only)
  • Factor 1, Individual clinician performance results with the practice: Show Meaningful Use attestation transmission for each physician to show transmission of clinical quality measures to CMS
  • If a survey tool is submitted the third or fourth quarter of 2015, the practice may submit Meaningful Use data (or an attestation) from January 2014 -- December 2014. 
  • Data or an attestation from 2013 is not acceptable.