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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12.16.2012 General Guidelines Some cells in the HEDIS 2013 Pharmacy Standard Pricing Table (SPT-Pharm) include dashes (-) instead of prices. Are the dashes equivalent to $0.00?

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?

Yes. The LOINC code added to Table MPM-B should be 62425-4. This will be corrected in the MY 2013 manual.

12.16.2012 Guidelines for Relative Resource Use Measures The table under step 9 on page 350 of the HEDIS 2013 Volume 2 should be used when assigning members to a RRU risk group. This year, the final risk score is rounded to 4 decimal places. In the table, Risk Group 1 is between 0.0000 and 0.2490. Risk Group 2 is between 0.2500 and 0.4990. To which risk group should a member be assigned whose risk score is 0.2495? The score does not fall in either group.

All the last digits of "0" in the table should be replaced with "9" for the upper score. For example, Risk Group 1 should be revised so it is between 0.0000 and 0.2499. A score of 0.2495 should be assigned to group 1.

HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia The CMC event/diagnosis criteria were revised in the Volume 2 Technical Update to include both facility and professional claims when identifying an AMI or CABG event. Should both facility and professional claims be included when identifying AMI or CABG for the SMC measure?

Yes. Organizations should include AMI and CABG from inpatient claims only, but may use both facility and professional claims to identify these events for HEDIS 2013 reporting.

HEDIS 2013

11.16.2012 General Guidelines If a member was included in the denominator because of inaccurate claims data, may we remove the member from the measure? How do we do this?

Members who are in the denominator because of inaccurate claims data may meet the criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review. If a member is in the denominator because of a claim with a code specified for the measure, the medical record must contain evidence that the member does not meet measure criteria; a silent chart is not evidence that the member does not have the condition being measured. If the valid data error criteria are met, the member should be removed from the sample and replaced with a member from the oversample.

Finding valid data errors is not intended to be a method of correcting improper billing practices, and they cannot be identified through supplemental data. Additional information and examples of valid data errors can be found in the Substituting Medical Records in the Guidelines for Calculations and Sampling (page 51).

HEDIS 2013

11.16.2012 Care for Older Adults May a yes/no checklist be used for the advance care planning indicator?

If "yes" is checked, it may be counted as evidence that the member executed an advance care plan. If "no" is checked, evidence of an advance care planning discussion must be documented. A checklist does not count as evidence of a discussion.

HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia In the Volume 2 Technical Update, the Continuous Enrollment criteria were revised to read "the measurement year and the year prior to the measurement year." Should the Allowable Gap criteria also include the year prior to the measurement year?

Yes. Members should have no more than one gap in enrollment of up to 45 days during each year of continuous enrollment.

HEDIS 2013

11.16.2012 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the Counseling for Nutrition and Counseling for Physical Activity indicators, do educational materials sent to members via mail or e-mail count toward the numerators?

No. The intent of the measure is to identify instances where a member received counseling for nutrition and physical activity; therefore, educational materials sent via mail or e-mail do not indicate that counseling occurred. The intent of including "member received educational materials" in the measure specifications is to allow for occasions where a provider gave educational materials to a patient during a face-to-face visit.

HEDIS 2013

11.16.2012 Race/Ethnicity Diversity of Membership The note below table RDM-C-1/2/3 indicates that the "Unknown" category includes only members for whom the organization has not sought direct or indirect race/ethnicity information. If an organization sought this information but could not obtain it from the member, is this included in the "Unknown" category?

Yes. The Unknown category should be used in cases when the organization did not obtain race/ethnicity information using the direct or indirect data collection method or did not receive a "Decline" response. If the plan attempted to collect the information and the member gave a "Decline" response, the member is counted in the Direct Data Collection percentages (because the plan asked about the members race/ethnicity and received a response). The plan receives credit for attempting to collect the information, even though the member refused to provide it.

HEDIS 2013

11.16.2012 Medication Reconciliation Post-Discharge If a member's discharge is followed by a readmission or direct transfer to a nursing home or long term care facility, is the discharge included in the measure's denominator?

If there is evidence that the member remained in the nursing home or long-term care facility through December 1 of the measurement year, the discharge must be excluded from the denominator. If there is evidence that the member was discharged from the nursing home or long term care facility by December 1 of the measurement year, the discharge must be included in the denominator. Organizations may not assume that the member remained in a nursing home or long-term care facility through the end of the measurement year, based solely on the discharge status; there must be a method for identifying the members status for the remainder of the measurement year.

HEDIS 2013

11.16.2012 Use of High-Risk Medications in the Elderly When calculating the Average Daily Dose for medications in Table DAE-C, should organizations use rounding rules before comparing the dose to the specified threshold? How should organizations calculate average daily dose for elixirs and concentrates?

Organizations should not round when calculating average daily dose. To calculate average daily dose for elixirs and concentrates multiply the volume dispensed by dose and divide by days supply.

HEDIS 2013