FAQ Directory

No. Because CPT Category II codes and HCPCS are standard codes they are not eligible for mapping (the value sets include all standard codes that have been identified as appropriate for use in HEDIS reporting). The Category II and HCPCS codes included in PQRS measures were created specifically for use in PQRS reporting and are not appropriate for use in reporting HEDIS measures. If a service or procedure was rendered by a provider, the expectation is that the provider will submit a claim to the health plan for the service or procedure; the codes expected to be on the claim are included in the HEDIS value sets and identify the member for the HEDIS measure.

This applies to the following Programs and Years:

Yes. The W15 measure does not have exclusions and this data element was included in error. It will be deleted in future publications.

This applies to the following Programs and Years:

Yes. The following changes were made and were not listed in the Summary of Changes spreadsheets.

• In the Acute Conditions value set, diagnosis codes that starts with a V were mislabeled “ICD9PCS.” The label was changed to “ICD9CM.”
• In the Potentially Planned Procedures value set, the ICD9 procedure codes were mislabeled “ICD9CM.” The label was changed to “ICD9PCS.”

This applies to the following Programs and Years:

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

This applies to the following Programs and Years:

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

This applies to the following Programs and Years:

Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.

This applies to the following Programs and Years:

Yes, Off-Market plans are required to be in the commercial product line when submitting for health plan accreditation.

This applies to the following Programs and Years:

Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.

This applies to the following Programs and Years:

Yes, you are correct; the date in the last sentence under Supplemental Data Validation Deadline should state:

“Auditor finalizes approval of all supplemental data. Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to February 15 unless the organization finished all supplemental data processes, collection and entry.”

We will update this for the final version of the MY 2015 Value Based P4P Manual, released on December 1, 2015.

This applies to the following Programs and Years:

When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.

The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).

This applies to the following Programs and Years:

No. The organization is responsible for meeting NCQA requirements even if it terminates the delegation agreement. 

This applies to the following Programs and Years:

The organization may submit one analysis report for all its product lines, including Marketplace, but the analysis for the Marketplace line must be separate in order to receive credit for QI 12, Element C.

This applies to the following Programs and Years: