FAQ Directory

Yes. For all measures that require a result, the actual numeric value of the result must be present in the supplemental data to meet criteria. For example, when reporting the BP control indicator of the CDC measure, documentation of the code 3078F alone in the supplemental data cannot be used to indicate a diastolic level that is less than 80. The actual diastolic value (e.g., 79) must be present in the supplemental data to meet criteria. It is appropriate for the approved data to be mapped to code 3078F (or applicable codes) to integrate into vendor or internal systems for measure calculation. Mapping would need to be reviewed and approved by the auditor.

The only exceptions to this are described in a General Guideline FAQ posted 11/15/2018. The exceptions described in the 11/15 FAQ are for the ABA and WCC measures. When reporting the BMI indicators for both measures, height and weight do not need to be in the supplemental data, but the actual BMI value or BMI percentile, with the date, must be present. For the counseling for physical activity indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria. For counseling for nutrition indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria.

This applies to the following Programs and Years:

The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a 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.
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.

This applies to the following Programs and Years:

EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.

This applies to the following Programs and Years:

Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.

• Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:

This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).

• Option 2: If you have access to the LIS History (LISHIST) File, it can be used to determine LIS eligibility. CMS describes the file as the most complete picture of LIS eligibility over a period not to exceed 36 months. This data file includes LIS activity for past, present and future enrollees. A full copy of the Plan-Communications-User-Guide-v122-August-31-2018, which describes the file, can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Plan-Communications-User-Guide-v122-August-31-2018.pdf. Below is an example of the corresponding records in the LISHIST file for the member shown above.

 
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
 
NOTES:

1. If the LowIncomePeriodEndDate is blank, the member is still eligible.
2. Plans should use a copy of this file from December 2018 or later.

 
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
 

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

No. Rural Health Clinics are not addressed in the updated PCP definition in Volume 2. All providers billing under the Rural Clinic facility codes must meet the definition of “PCP” in Appendix 3 in order to be included in the PCP-based HEDIS measures.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: