FAQ Directory

No, unless otherwise stated in the specifications, quality measures do not have thresholds that must be met.  

With that said, CMS 68 is similar to KM-15 (core): Maintaining an up-to-date list of medications for more than 80% of patients. Both sets of data require the same action of updating the medication list. However, they differ in that CMS 68 is for patients age 18+ and must be captured at every visit, whereas KM-15 is for all patients at any given time. It is unlikely that there would be a large variance between CMS 68 and KM-15. NCQA requests a note be added in QPASS if CMS 68 differs greatly from KM-15's 80% requirement. This is to provide context to the Review Oversight Committee to better understand your practice and environment. 

If your practice is in Annual Reporting, practices attest that they are in compliance with all core criteria and could provide evidence that they are meeting the more than 80% requirement of KM-15. 

PCMH 2017

No. Although the Asthma Controller and Reliever Medication List includes RxNorm codes, they should not be used to identify dispensing events for this required exclusion. Only use pharmacy data (NDC codes) when assessing asthma controller or reliever medication dispensing events for this required exclusion. Because a dispensing event is required to calculate the numerator, members who had no dispensing events should be removed from the measure.

HEDIS 2024

Yes, as described in the Guidelines for Risk Adjusted Utilization Measures, organizations must use the Inpatient Stay Value Set for the risk adjustment comorbidity category determination (use the Inpatient Stay Value Set to identify acute and nonacute inpatient discharges with a discharge date during the classification period). The value set was mistakenly deleted from the EDH measure in the VSD. Because the guidelines clearly state that the value set must be used, NCQA does not intend to reissue the VSD.

HEDIS 2024

Yes, replace Total Score LOINC Code “55758-7” with “89208-3” in the Depression screening instrument table for the Instruments for Adolescents (≤17 years), Beck Depression Inventory-Fast Screen (BDI-FS)®.

Exchange 2024

Yes, as described in the Required exclusions section of the CCS measure, use LOINC code 76689-9 to exclude members with a sex assigned at birth of male any time in the patient’s history. The code was mistakenly removed from the CCS measure in the 4-1-2024 release of the VSD (Direct Reference Code spreadsheet). Because the information needed for reporting is in the measure specification NCQA does not intend to reissue the VSD.

Exchange 2024

Yes, as described in the Required exclusions section of the CCS measure, use LOINC code 76689-9 to exclude members with a sex assigned at birth of male any time in the patient’s history. The code was mistakenly removed from the CCS measure in the 4-1-2024 release of the VSD (Direct Reference Code spreadsheet). Because the information needed for reporting is in the measure specification NCQA does not intend to reissue the VSD.

HEDIS 2024

When only a single code exists for a service or condition, it is included directly in the measure specification, and referred to as a Direct Reference Code (DRC). It is a best practice to not create value sets that include only a single code; some code systems prohibit this because it results in assigning another code (an OID) to a concept that already has a code.
DRCs are listed in the measure specifications and in a Direct Reference Codes spreadsheet in the value set directory.
For MY 2024, a number of single code value sets were converted to DRCs. The Summary of Changes – Value Sets spreadsheet indicates the value set was deleted. The Summary of Changes – Codes spreadsheet indicates the code was added as a DRC (filter Column A on “Direct Reference Code”).

HEDIS 2024

The numerator criterion is an eGFR and a uACR any time during the measurement year. These separate tests may occur on different dates.
The 4-day proximity language is specific to a reporting option for uACR, where a quantitative urine albumin test and a urine creatinine test may be billed separately. In practice, the quantitative urine albumin and urine creatinine tests are performed on the same date, from the same urine sample, to produce a single ratio. The 4-day proximity language intends to account only for potential billing lags between the separate quantitative urine albumin and urine creatinine administrative codes that indicate a single uACR evaluation; it is not intended for separate samples from different dates.

HEDIS 2024

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

HP 2024

Any coded response (i.e., any non-null response—positive or negative) on a pre-specified instrument for food, housing and transportation counts for completed screening numerators (numerators 1, 3, 5). The PRAPARE Food Insecurity Instrument question (LOINC code 93031-3) is an exception. Based on how the question is structured and responses are coded, a “No” or “None of the above” response cannot be coded and must be left null. Therefore, a null response meets criteria for this item only. 

HEDIS 2024

No. If the medical record review retrieval and/or abstraction operations for HEDIS MY 2023 reporting of your organization were not impacted by the Change Healthcare cyberattack, then the timeline modifications do not apply to you. You must follow the HEDIS MY 2023 Audit Timeline published on NCQA.org.
Affected organizations (defined above) should work with their auditor on HEDIS MY 2023 timeline modifications. All HEDIS Compliance Audit Licensed Organizations will share this information with the relevant organizations.

HEDIS 2023

Battelle replaced NQF as the consensus-based entity for CMS; the Battelle Partnership for Quality Measurement (PQM) Submission Tool and Repository Measure Database can be found here: https://p4qm.org/. Organizations may only use measures classified as “Endorsed."

MBHO 2013