Yes. HEDIS 2015 General Guideline 41 will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, 2014. The guideline, like HEDIS, will apply to the CDC HbA1c control indicators.
IHA 2014
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.
The optional exclusion criteria may be applied only if the member did not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year. If the member was included in the measure based on claim or encounter data, as described in the event/diagnosis criteria, the optional exclusions do not apply because the member had a diagnosis of diabetes. If the member was included in the measure based on pharmacy data alone, the member may meet criteria for an optional exclusion if no diagnosis of diabetes was found in claim or encounter data or in the medical record.
For example, if a member was included in the measure based on pharmacy data but had a visit with a diagnosis of diabetes, the member does not meet optional exclusion criteria.
If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes, but medical record documentation indicated the member is a diabetic, the member does not meet optional exclusion criteria.
If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes and no evidence of diabetes in the medical record being reviewed, the member may meet optional exclusion criteria if there was a diagnosis of polycystic ovaries any time during the member’s history through December 31 of the measurement year, or a diagnosis of gestational diabetes or steroid-induced diabetes during the measurement year or the year prior to the measurement year.
HEDIS 2015
IHA 2014
Although the two diagnoses are clinically different, hypertensive retinopathy is not treated differently from diabetic retinopathy for the CDC measure. The intent of the eye exam indicator is to ensure that members with evidence of any type of retinopathy have an eye exam annually, while members who remain free of retinopathy (i.e., the retinal exam was negative for retinopathy) are screened every other year. If it is clear that a retinal or dilated eye exam was performed by an eye care professional in the year prior to the measurement year and there is documentation indicating that the member is negative for hypertensive retinopathy, this can count as compliant.
HEDIS 2015
An “active prescription” means that a member has a surplus of medication to take from a prescription dispensed previously. Therefore, in step 4 (required exclusions), the member is excluded if a prescription was dispensed during the 12 months prior to the IESD, or prior to that time frame if the member has remaining pills to take in the 12 months prior to the IESD.
HEDIS 2015
The age band for this measure was not changed; the language and age referenced in the steps were clarified to account for the look-back period. For the steps pertaining to the cervical cytology and HPV co-tests, because a woman must have been “30 years or older on the date of both tests,” and the tests must have been performed in the third or fourth year prior to the measure year, look only at women 33 and older.
This change was inadvertently left out of Rate 1, step 3. The final release of the MY 2014 P4P Manual on December 1, 2014, will contain the correct language.
For the descriptions of Rates 1, 2 and 3, however, the age bands have not changed; the measure aligns with current guidelines and looks at women 30–65 years of age.
IHA 2014
To determine if a stay should be excluded, identify the index hospitalization and the FIRST readmission (if there is one). If the FIRST readmission was planned for, drop the index.
So, for example 2:
Stay 1. Index hospitalization with unplanned readmission (stay 2): Include as index.
Stay 2. Index hospitalization with planned readmission (stay 3): Drop as index.
Stay 3. Index hospitalization with planned readmission (stay 4): Drop as index.
Stay 4. Index hospitalization with no readmission: Include as index.
Stay 1 is the index. Stay 2 is the first readmission to assess, but because it does not meet criteria for a “planned hospital stay,” stay 1 is not excluded.
HEDIS 2015
No, if a problem list is found in an office visit note then it would be considered a dated problem list and the date of the visit must be used. A true problem list is a standalone document in the medical record that records a member’s conditions. It is typically located in a centralized section of the medical record (usually the front of the chart) and lists all diagnoses. In an EHR a problem list is present at all routine office visits.
If the documentation is part of the member’s medical history, progress note or office visit note, the date of the visit must be used as the date of the HTN confirmation and must be on or before June 30 of the measurement year. The representative BP reading must occur after the date when the diagnosis of HTN was confirmed.
HEDIS 2015
General Guideline 28 outlines the requirements for using member-reported supplemental data, which may be accepted only when accompanied by proof-of-service documentation from the legal health record. If proof-of-service documentation is not available, member-reported information on services rendered (patient history) are acceptable only if taken by a PCP as part of the member’s history. Information must be signed, dated and maintained in the member’s legal health record. General Guideline 29: Date Specificity addresses measures that include date requirements in order to achieve numerator compliance. Dates must be specific enough to determine that the event occurred during the period specified by the measure.
IHA 2013