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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3.16.2012 Encounter Rate Threshold for Clinical Measures Table ENR-F Option A states to use the CMS ASC Approved HCPCS Codes and Payment Rates file and to only use the spreadsheet titled, "Addendum AA_ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2011". This exact file name is not found in the zip file on the CMS website. Please confirm the file and tab that should be used.

The file name has been updated on the CMS website. To reflect this change, the note under Table ENR-F should read as follow: * These codes can be found on the CMS Web site (http://www.cms.hhs.gov/ASCPayment/11_Addenda_Updates.asp#TopOfPage/). Click October 2011 ASC Approved HCPCS codes and Payment Rates. Use only the spreadsheet titled, Oct11_ASC_Add_AA-BB-DD1_ExtAct.xlsx, and the tab titled Oct11_ASC_AddAA-ExtAct. Only use 5-digit all-numeric CPT codes (Level 1 HCPCS) in the spreadsheet; do not include any codes with an alpha value. This update will be reflected in the September 2012 release of the MY 2012 manual.

3.16.2012 Breast Cancer Screening (BCS) On the Clinical Measure file layout the BCS measure is listed as Breast Cancer Screening: Ages 52-69 but the measure description indicates that it is for ages 50 _ 69. Is there an error in the Clinical Measure file layout?

The Clinical Measure file layout is correct. The age band is described as starting at age 52 to account for the two year look-back period for this measure.

3.16.2012 Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis (AAB) In the November 2011 release of the MY 2011 P4P specifications, Table AAB-E: Antibiotic Medications does not match exactly with Table AAB-D in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table AAB-E: Antibiotic Medications,

the first two rows, 5-aminosalicylates and Amebicides should not be in the table,

in the row Aminoglycosides the drug Neomycin should not be in the table,

in the row First generation cephalosporins, the drug Cephradine should not be in the table,

in the row Miscellaneous antibiotics the drug Vancomycin should be included in the table,

the row sulfamethoxazole-trimethoprim DS should not be in the table,

in the row natural penicillins the drug Penicillin G benzathine should be included in the table,

in the row Third generation cephalosporins, the drugs Cefditoren and Cefpodoxime should be included in the table,

in the row Third generation cephalosporins, the drug Cefoperazone should not be in the table.

These errors will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Annual Monitoring for Patients on Persistent Medications (MPM) In the November 2011 release of the MY 2011 P4P specifications, Table MPM-A: Drugs to Identify Members on ACE Inhibitors or ARBs does not match exactly with Table CDC-L in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In the Table MPM-A: Drugs to Identify Members on ACE Inhibitors or ARBs, in the row Antihypertensive combinations the drugs Aliskiren-valsartan, Amlodipine-hydrochlorothiazide-valsartan, Amlodipine-hydrochlorothiazide-olmesartan and Amlodipine-telmisartan should be included in the table.

This error will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Appropriate Testing for Children With Pharyngitis (CWP) In the November 2011 release of the MY 2011 P4P specifications, Table CWP-C: Antibiotic Medications does not match exactly with Table CWP-C in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table CWP-C: Antibiotic Medications,

in the row First generation cephalosporins, the drug Cephradine should not be in the table,

in the row Macrolides the drug Erythromycin estolate should not be in the table,

in the row Third generation cephalosporins, the drug Cefditoren should be included in the table.

These errors will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Asthma Medication Ratio (AMR) Based on the MY 2010 P4P Crosswalk to HEDIS 2011 NDC List document, P4P Table AMR-C crosswalks to the HEDIS table ASM-C for the NDC list, but long-acting inhaled beta-2 agonists are no longer included in Table AMR-C. Should they be used in the Asthma Medication Ratio measure for P4P?

No. Do not include long-acting inhaled beta-2 agonists when calculating the Asthma Medication Ratio measure.

3.16.2012 Continuous Enrollment and Allowable Gaps Over Multiple Years In the MY2011 P4P Manual, are the dates correct in the example for Continuous Enrollment and Allowable Gaps Over Multiple Years? They do not seem to match up to the description of gaps in enrollment.

There is an error in the manual. The first date in the example should be November 30, 2010. The full example should read as follows:

For example, in the MY 2011 Breast Cancer Screening measure (which requires 2 years of continuous enrollment), a member who disenrolls on November 30, 2010 (the year prior to the measurement year), and re-enrolls on February 1, 2011 (the measurement year), is considered continuously enrolled as long as there were no other gaps in enrollment during either year. The member has one gap of 31 days (December 1_31) in 2010 and one gap of 31 days (January 1_31) in 2011.

This error will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Diabetes Care (CDC) In the November 2011 release of the MY 2011 P4P specifications, Table CDC-A: Prescriptions to Identify Members With Diabetes does not match exactly with Table CDC-A in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table CDC-A: Prescriptions to Identify Members With Diabetes, in the row Miscellaneous antidiabetic agents, the drug Liraglutide should be included in the table.

This error will be corrected in the September 2012 release of the MY 2012 manual.

3.15.2012 QI Work Plan Must the QI work plan address all the items listed under Work plan in the explanation to receive credit for QI 1, Element A, factor 9?

Yes. To receive credit for factor 9, the work plan must address all ten items listed Work Plan in the explanation.

3.15.2012 Cultural preference If an organization only assesses language and gender and matches member and practitioner based on linguistic and gender data, is this acceptable for QI 4, Element A, factor 1?

No. Organizations must assess members cultural, racial, ethnic and linguistic needs then take actions based on its findings. Leaving out one or more of the required assessment areas would not meet the intent of the element.

3.15.2012 Analysis of complaint and appeal data May organizations analyze complaint data by the five specified complaint categories and analyze appeal data by the type of procedures appealed?

No. While the organization may have different complaints and appeal category for business purposes, it must analyze and report both complaint and appeal data by the five specified categories for NCQA purposes. Even if the organization has no complaints or appeals in one or more reporting categories, it must still demonstrate its analysis and report the number of complaints and appeals for all five categories.

3.15.2012 Demonstrating improvement Must an organization achieve significant improvement on identified opportunities to meet this element?

No. Data collection methodology must be sound enough to produce valid and reliable results but achievement of significant improvement is not required for QI 10 Element A.