No. Remove code 506.4 from the emphysema row. This will be corrected in the MY 2013 manual.
FAQ Directory
Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
Filter Results
- Save
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
- Email
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
- Print
Print this page.
Print this page.
1.16.2013 Asthma Medication Ratio (AMR) In Table AMR-D, ICD-9-CM Diagnosis code 506.4 is listed under both the emphysema and COPD rows. Is this correct?
1.16.2013 Comprehensive Diabetes Care (CDC) Can CPT Category II code 4010F be used to identify ACE inhibitor/ARB therapy for the Medical Attention for Nephropathy indicator?
1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?
Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.
HEDIS 2013
1.16.2013 Medical Record Review Validation If during MRR validation, a plan fails two samples, and informs the auditor they corrected the problem, what follow-up items are required to validate that the corrections were appropriate?
The auditor may use one or more methods to validate the chart error corrections. Follow-up actions should include:
· reviewing the error investigation and results
· reviewing policies and procedures to correct the error
· reviewing the corrected sample to ensure the updated numerator counts are correct and performing final hybrid rate review
· re-sampling charts for a new validation
Examples:
1. For the exclusions or data errors in the diabetes measure records, the auditor identified a pattern: she found two cases where the chart reviewer said the members did not have diabetes, but the chart showed that both members had elevated blood sugars and above average HbA1c results. One member had a PCP diagnosis of metabolic syndrome that placed him in the measure. The other member had a diagnosis of insulin resistance. The auditor required the plan to re-review all CDC exclusions and submitted charts for the remaining correct exclusions from the measure. The auditor approved reporting.
2. For the two MRRV samples, there were two errors found _ one in each sample. The auditor required the plan to do an analysis and demonstrate corrective actions.
The plan reported that one abstractor made the errors by incorrectly identifying the prior years CDC eye exams. The plan re-reviewed 100% of that abstractors hits and reversed 12 hits to misses. The plan had originally reported 100 admin hits and 200 hybrid hits for CDC eye exam. Of the 200 hybrid hits, 160 were measurement year eye exams, and 40 were negative retinopathy cases from the prior year. The auditor pulled another sample of 16, found no errors, and confirmed that the reported rate for the measure dropped from 73% to 70% as a result.
The auditor approved reporting.
3. The auditor found four errors in the first sample for AWC. He notified the plan and required them to do an analysis and demonstrate corrective actions. The plan submitted:
· the error investigation and results
· the policies and procedures that corrected the error
· a new sample of 16 that proved to have zero errors
· a new sample of 16 that proved to have zero errors
The auditor approved reporting.
HEDIS 2013
1.15.2013 Look-back period for review of delegates for Interim Surveys Do Interim Surveys include review of the program elements (QI 12C, UM 15C, CR 9D, RR 7D, MEM 9D)?
1.15.2013 Complex case management automated systems Must the entire clinical practice guideline be imbedded in the complex case management automated system?
12.17.2012 Qualifications for practitioners who review medical necessity denials Does a practitioner have to be actively participating in an organization to review medical necessity denials?
No. Being an actively practicing practitioner is not a requirement for reviewing medical necessity denials, although NCQA does require practitioners to have the education, training and experience in clinical or medical practice and be currently licensed in order to meet the requirements to make UM decisions.
12.17.2012 Interim Surveys including MED category Does the Interim Survey include the Medicaid (MED) elements?
12.16.2012 Meaningful Use of Health IT Domain The Submitting the survey instructions in the Domain Structure of the Meaningful Use of Health IT domain specifications state that physician organizations must attach documentation for each measure, including documentation that thresholds for individual measures are being met. What kind of documentation is required, and how much?
POs must attach either a global report produced by the EHR detailing the entire POs performance on each measure, or dashboard reports detailing the performance of individual PCPs. Reports are required for 5% of all PCPs reported as using certified software. Documentation is required for a minimum of two and a maximum of five PCPs. For example, if 60 PCPs are reported as using certified software, documentation will be required for 5% of the PCPs (3 PCPs). If 120 PCPs are reported as using certified software, however, documentation is only required for 5 PCPs. Although 5% of 120 is 6, the maximum number of PCPs for whom NCQA requires documentation is 5.
12.16.2012 Annual Monitoring for Patients on Persistent Medications (MPM) The Measure Updates section for MPM states that LOINC code 62425-4 was added to Table MPM-B, but in Table MPM-B LOINC code 6425-4 was added. Is the code listed in Table MPM-B missing a digit?
12.16.2012 Osteoporosis Management in Women Who Had a Fracture (OMW) When determining the eligible population for the OMW measure, access to inpatient claim/encounter data is necessary if a member had a fracture requiring an inpatient stays. Specifically, the inpatient claim/encounter data are required to calculate admission and discharge dates. Many self reporting POs are not at risk for inpatient stays and as such we do not have access to inpatient claim/encounter data. How are we suppose properly calculate the eligible population if we do not have inpatient claim/encounter data?
Physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. In this scenario, the physician organization uses the physicians first visit with the member as a proxy for the admission date and uses the last visit as a proxy for the discharge date. This alternative method may be used only by physician organizations that do not have access to inpatient claim/encounter data.