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.

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2.15.2019 The “Total” data elements for Medicare in Table PCR-C must match the “Total Medicare” data elements in Table PCR-D. Are organizations required to report the totals in both tables?

Plan All-Cause Readmissions (PCR)

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.

2.15.2019 May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?

Language in denial letters

Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.

When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.
 

2.15.2019 The “Total” data elements for Medicare in Table PCR-A must match the “Total Medicare” data elements in Table PCR-B. Are organizations required to report the totals in both tables?

Plan All-Cause Readmissions (PCR)

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-A. Remove the “Total Medicare” row from Table PCR-B that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-A. The asterisked language may also be removed under these two tables.

2.15.2019 When pharmacy data are classified as supplemental data, the following data elements must be present: the generic name (or brand name), strength/dose, route and date when the medication was dispensed to the member. If all the required data elements are included except the dispense date, can a start date be used instead?

Supplemental Data

No. When pharmacy data are used as supplemental data, a dispense date is required; a start date may not be used as a proxy. There are no exceptions to the requirements for pharmacy data, as described in General Guideline 30.

1.15.2019 In HEDIS 2019, step 4 of the numerator calculation was revised to indicate that the ratio should be rounded to the nearest whole number using the .5 rule. Should the value that is calculated using the formula in the measure be multiplied by 100 before rounding to the nearest whole number using the .5 rule?

Medication Management for People With Asthma (MMA) and Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)

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.

1.15.2019 Is death a valid exclusion for HEDIS measures?

Death as an Exclusion in HEDIS

NCQA expects plans to disenroll deceased members. Members who died during the continuous enrollment period would not meet the measure’s eligible population criteria (e.g., continuous enrollment and anchor date requirements) and would not be included in the measure denominator. However, a member who meets the continuous enrollment criteria remains in the measure. For example, when reporting the MRP measure, a member who was discharged on July 1 and died on August 1, but enrollment data indicates the member is enrolled in the organization during the continuous enrollment period (the date of discharge through 30 days after discharge) must remain in the measure.

Keep in mind that organizations may not use other data sources (e.g., medical record data) when removing deceased members.
 

1.15.2019 When calculating the number of days covered for the COU measure’s numerators, must the days be consecutive?

Risk of Continued Opioid Use (COU)

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.
 

1.15.2019 If documentation in a 2018 visit note indicates “No Diabetic Retinopathy as of Ophtho note on 9/2017,” does this meet criteria as a negative retinal exam?

Comprehensive Diabetes Care (CDC)

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).

1.15.2019 There was a change to the ICD-10 coding guidelines, effective October 1, 2018, related to the codes for reporting body mass index (BMI). The change allows providers to bill for BMI codes only if the member has a clinically relevant condition, such as obesity. How does this change affect reporting the ABA measure?

Adult BMI Assessment (ABA)

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.
 

1.15.2019 There was a change to the ICD-10 coding guidelines, effective October 1, 2018, related to the codes for reporting body mass index (BMI). The change allows providers to bill for BMI codes only if the member has a clinically relevant condition, such as obesity. How does this change affect reporting the BMI percentile documentation indicator of the WCC measure?

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

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.
 

1.15.2019 When using supplemental data for measures that require a result, does the actual numeric result need to be present in the supplemental data to meet criteria?

Supplemental Data

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.