The and use only should not be in the sentence. The sentences should read Include AMI and CABG from inpatient claims only. Use both facility and professional claims to identify AMI or CABG. This will be corrected in the MY 2013 manual.
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1.16.2013 Cholesterol Management for Patients With Cardiovascular Conditions (CMC) Under the event/diagnosis description on page 51 of the MY 2012 P4P manual, the sentence reads, Include AMI and CABG from inpatient claims only and use only. Use both facility and professional claims to identify AMI or CABG. Is the and use only a typo?
1.16.2013 Asthma Medication Ratio (AMR) In Table AMR-D, ICD-9-CM Diagnosis code 506.4 is listed under both the emphysema and COPD rows. Is this correct?
1.16.2013 Medical Record Review Validation Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?
Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.
The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.
This applies to the following Programs and Years:
HEDIS 20131.15.2013 Complex case management automated systems Must the entire clinical practice guideline be imbedded in the complex case management automated system?
1.15.2013 Look-back period for review of delegates for Interim Surveys Do Interim Surveys include review of the program elements (QI 12C, UM 15C, CR 9D, RR 7D, MEM 9D)?
12.17.2012 Interim Surveys including MED category Does the Interim Survey include the Medicaid (MED) elements?
12.17.2012 Qualifications for practitioners who review medical necessity denials Does a practitioner have to be actively participating in an organization to review medical necessity denials?
No. Being an actively practicing practitioner is not a requirement for reviewing medical necessity denials, although NCQA does require practitioners to have the education, training and experience in clinical or medical practice and be currently licensed in order to meet the requirements to make UM decisions.
This applies to the following Programs and Years:
12.16.2012 Osteoporosis Management in Women Who Had a Fracture (OMW) When determining the eligible population for the OMW measure, access to inpatient claim/encounter data is necessary if a member had a fracture requiring an inpatient stays. Specifically, the inpatient claim/encounter data are required to calculate admission and discharge dates. Many self reporting POs are not at risk for inpatient stays and as such we do not have access to inpatient claim/encounter data. How are we suppose properly calculate the eligible population if we do not have inpatient claim/encounter data?
Physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. In this scenario, the physician organization uses the physicians first visit with the member as a proxy for the admission date and uses the last visit as a proxy for the discharge date. This alternative method may be used only by physician organizations that do not have access to inpatient claim/encounter data.
This applies to the following Programs and Years:
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?
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 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.
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.
