FAQ Directory

No. The performance goal must be quantified (e.g., a number or percentage signifying a specific performance level).

PCMH 2017

No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
 

PCMH 2017

No. The practice needs to demonstrate that they collect both quantitative and qualitative data to meet the requirement.

PCMH 2017

No. Any standardized (non-proprietary) survey administered through measurement initiatives providing benchmark analysis external to the practice organization may be used to meet QI 06. Please note that the practice must administer the entire standardized survey (not just sections) so that it can be compared to available benchmarks.

PCMH 2017

Yes. Because the practice has only one clinician, practice-level data would be the same as clinician-level data, and therefore count for both.

PCMH 2017

Yes. Practices determine the area of patient experience on which to focus quality improvement efforts. This may be improvement of the results of a specific question on a survey, a section of a survey or the entire survey.

PCMH 2017

No. Practices must provide an example of having shared at least one report from each of the following criterion in Competency A: QI 01, QI 02, and QI 04

Yes. Use of PHQ-2/PHQ-9 meets the requirement if practices demonstrate its use in monitoring depression treatment and provide an example of the tool’s implementation in clinical care and decision making at the point of care. The intent of KM 20 A is to implement clinical decision support during treatment, not for screening or diagnosis of a mental health condition. Practices that use an evidence-based tool built into the EHR or as part of a workflow in accordance with clinical guidelines can meet the requirements if they demonstrate the guideline and an example of the guidelines implementation (i.e., the tool’s use).

PCMH 2017

Measures of care coordination address communication regarding patient referrals and care transitions. 

For example, a practice refers a patient to another provider or a community resource. A care coordination measure might assess whether the referral was completed (i.e., the practice receives the referral report, follows up with the resource or patient to assess use or patient experience).

PCMH 2017

Medical records should clearly indicate that the patient has been asked about the specific item by including a notation that the patient answered “No” or declined to answer. Practices do not lose credit if the patient says “No” or declines to answer as long as it is documented. 

PCMH 2017

No. Services must be distinct for each category.

PCMH 2017

No. PQRS reports and Medicare Shared Savings Program (MSSP) would not meet the requirement. For KM 13, practices must demonstrate they participate in an external program that assesses practice-level performance, using a common set of specifications to benchmark results. The external program should also publicly report results and have a process to validate measure integrity. 

PQRS is not a performance-based recognition program and is being rolled into MIPS under the Quality Performance category. The MSSP makes data on Accountable Care Organizations (ACOs), rather than at the practice level, publicly available. Because this criterion is not eligible for shared credit, data is required to be at the practice level. 

While participation in these programs does not meet KM 13, practices can use participation in MSSP to meet QI 19. Practices in Track 1 MSSP, would be eligible for QI 19 A (1 credit), and practices in Track 2 MSSP would be eligible for QI 19 B (2 credits).

PCMH 2017