FAQ Directory

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI or BMI percentile code only when there is an associated diagnosis (e.g., overweight, obesity) that meets the new requirements. “Healthy weight” is not considered an associated diagnosis. As a result, members in the denominator, whose only visit is in October, November, or December of 2018, without an appropriate ICD-10 code, due to the lack of an associated diagnosis, will not have claims that meet the current numerator criteria.

NCQA’s analysis shows that, because this measure is reported primarily through the hybrid-reporting option, the effect will be small. This change does not affect organizations using the hybrid method, because the rule pertains to only the use of ICD-10 codes on claims. It does not prohibit providers from measuring and documenting a BMI in the medical record.
 

HEDIS 2019

Yes. This meets criteria for HEDIS 2019 reporting because the documentation indicates that the eye exam was completed by an eye care professional (optometrist or ophthalmologist), the date when the procedure was performed was within the appropriate time frame and the results are present (a negative retinal exam in the year prior to the measurement year).

HEDIS 2019

Yes. The new rounding directions in step 4 are meant to treat the calculated decimal result as a whole number from 0%–100% for the SAA and MMA measures. For example, if a member has 291 total days covered by a medication during a 365-day treatment period, this calculates to 0.7972. Multiply this number by 100, convert it to 79.72% and round it to 80%, the nearest whole number.

HEDIS 2019

No. The covered days are not required to be consecutive when reporting the numerators of the measure. Review all dispensed opioids on the IPSD through the 30-day or 62-day period and follow the instructions for calculating number of days covered for the numerator. For example, if the IPSD is 1/1/18 and the member has an eligible prescription with a 5-day supply and another eligible prescription with a 10-day supply on 1/10/18, the member meets criteria for the ≥15 Days Covered numerator.
 

HEDIS 2019

NCQA considers the implementation date as the date when the delegate can start performing delegated activities. But because the organization and delegate may have mutually agreed on and implemented delegated activities before signing the delegation agreement, NCQA is changing the policy for evidence of the implementation date.

When reviewing a delegation agreement, NCQA will consider the effective date or start date specified in the agreement as the mutually agreed-upon implementation date, for Element A (of the delegation standards), factor 1. This date may be before or after the signature date on the delegation agreement. If the agreement does not contain an effective date/start date, NCQA considers the date when the agreement was signed as the mutually agreed-upon implementation date.

NCQA may also accept other evidence of the implementation date: a letter, meeting minutes or other form of communication between the organization and the delegate that references their agreement on the delegated activity start date.

If an organization references the effective date/start date of the delegation agreement as the implementation date, NCQA will require submitted evidence for all other delegation factors to conform to that date as the implementation date.

The language in the explanation will be updated in a future Policy Update for applicable 2019 publications.

HP 2019

Yes. The intent is to allow organizations to apply the optional exclusion for both the administrative and hybrid specifications. When using the administrative specification, organizations must use the codes in the value sets to identify members who meet optional exclusion criteria. When using the hybrid specification, organizations should look for evidence of ESRD, kidney transplant, dialysis, pregnancy or a nonacute inpatient admission during the measurement year in order to identify members who meet optional exclusion criteria.

Keep in mind that all exclusions are subject to auditor review.

HEDIS 2019

No. Plans do not need to be able to populate information directly into a provider EMR to meet this requirement. Plans can meet the requirement if they can provide requested information (phone, secure email, direct feed, provider portal, file request) to providers who are treating their members. Plans should have documented processes for providing information on how this works to be reviewed as part of the audit.

HEDIS 2019

Yes. Plans may use administrative data to report HEDIS ECDS measures. Administrative data are a relevant data source and are one of four categories of data for ECDS reporting. If a plan’s administrative data files contain all the information it needs for a measure, it does not need additional data.

HEDIS 2019

Any practitioner who provides care to or makes care decisions for or about a member’s care is part of the care team. Please note, if a measure has a practitioner type requirement the services required by the measure must still be performed by the appropriate practitioner type. However, the care team requirement for the data to qualify for ECDS reporting is not restricted by the practitioner type requirement.

HEDIS 2019

Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.

HEDIS 2019

No. Although this plan type may have a slight advantage in accessing medical records because of its integrated system, EMRs do not necessarily contain comprehensive information on individuals. Many other data sources qualify as ECDS data sources, and plans are encouraged to utilize every reliable source of member data.

HEDIS 2019

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events when the diagnosis category is the same for both events. For example, an ED visit for alcohol disorder that resulted in an inpatient stay for alcohol disorder is reported only once in the “Inpatient Stay” category. However, an ED visit for alcohol disorder that resulted in an inpatient stay for opioid disorder is reported in both the ED category (alcohol diagnosis category) and the Inpatient Stay category (opioid diagnosis category). An ED visit for alcohol disorder that resulted in an inpatient stay for something other than an alcohol, opioid or other or unspecified drug disorder (e.g., heart attack) is reported only once in the “ED” category.

HEDIS 2019