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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3.15.2014 Definition of SPMI What is the definition of severe and persistent mental illness (SPMI)?

A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority.

This applies to the following Programs and Years:

3.15.2014 Plan Sponsors Individual and Family Plans (Exchanges) Should RR 5, Element C be scored NA for individual or family plans within an Exchange product line because there are no plan sponsors (i.e., employer, employee organization or association, committee, joint board of trustees, or other similar group)?

Yes. RR 5, Element C is NA for individual plans and family plans offered under the Exchange because they are purchased directly by individuals and not plan sponsors.

This applies to the following Programs and Years:

3.11.2014 Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) The MY 2013 P4P Value Set Directory does not include a Cervical Cancer Value Set for the Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) measure. Where can I find these codes?

The Cervical Cancer Value Set was not included in the MY 2013 P4P Value Set Directory. The codes included in the Hypertension Value Set are:

  • ICD-9-CM 180.0.
  • ICD-9-CM 180.
  • ICD-9-CM 180.1.
  • ICD-9-CM 180.8.
  • ICD-9-CM 180.9.
  • ICD-9-CM 233.1.
  • ICD-9-CM V10.41.

The other NCS Value Sets can be found by filtering for Value Set Name in the P4P Value Sets to Codes tab of the P4P VSD file. These Value Sets for NCS already exist as part of other measures. The Cervical Cancer Value Set will be included in the next release of the P4P Value Set Directory, which will also list the NCS measure separately.

This applies to the following Programs and Years:
IHA P4P

3.11.2014 Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women (ECS) In Rate 3, step 3 of the ECS measure, the cervical cytology without co-tests specification states, If two or more claims/encounters with qualifying numerator codes for cervical cytology occur within 120 days of each other, count only the first one. <p>Should this rule apply to women with multiple cervical cytology and HPV co-tests in the third or fourth year prior to the measurement year? In these cases, should the cervical cytology tests be >120 days apart?

The 120-day rule should also apply to Rate 3, step 3 of the ECS measure. If there are multiple cervical cytology and HPV co-tests during the three or four years prior to the measurement year, and these occur within 120 days of each other, count only the first test.

This applies to the following Programs and Years:
IHA P4P

3.11.2014 Meaningful Use of Health IT (MUHIT) Under the “Who We Measure” section of the MUHIT domain, the MY 2013 P4P Manual states, “P4P defines PCPs as ‘physicians or nonphysicians (e.g., physician assistants, nurse practitioners) who offer primary care services.’ ” Should pediatricians be included in the denominator?

A physician organization (PO) may select three definitions to use in determining the denominator for the MUHIT measures: the definition of “primary care practitioner,” or the CMS definition of “eligible professional” for Medicare or the CMS definition of “eligible professional” for Medicaid. All three definitions include physicians.

If a PO uses the “primary care practitioner” definition, it must include all physicians who are considered PCPs and are serving the commercial HMO/POS population. Because pediatricians serve as PCPs for children, they are included.

If a PO uses the CMS “eligible professional” definitions, all physicians serving the commercial HMO/POS population must be included. Because the focus of P4P is the commercial population, physicians are not required to have attested to CMS or the state for MU, to be included.

This applies to the following Programs and Years:
IHA P4P

3.11.2014 Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women (ECS) The following codes appeared in the MY 2012 specifications and code tables but do not show up in the MY 2013 P4P Value Set Directory under a value set or in the Measure Updates as a removal. Should the following codes be used for reporting in MY 2013?
• ICD-9-CM 91.46.
• CPT 88155.
The following code appears in the MY 2013 P4P Value Set Directory but does not show up in the Manual Updates as an addition. Should this code be used for reporting in MY 2013?
• ICD-9-CM V7647.

The MY 2013 P4P Value Set Directory is correct. ICD-9-CM 91.46 and CPT 88155 were deleted from the Cervical Cytology value set and ICD-9-CM V76.47 was added to the Hysterectomy value set. These changes were not listed in the MY 2013 P4P Measure Updates.

This applies to the following Programs and Years:
IHA P4P

2.15.2014 Clarifying delegation specificity requirement How specific must the delegation agreement be between the organization and the delegate with regards to outlining responsibilities?

The delegation agreement between an organization and its delegate must: 1. Specify activities performed by the delegate in detailed language relative to applicable NCQA standard categories. 2. Specify functions not delegated, but retained by the organization. Organizations may include a general statement in the agreement addressing retained functions (e.g., the organization retains all other QI functions not specified in this agreement as the delegates responsibility). Existing agreements may be updated with an addendum or communication (e.g., e-mail, spreadsheet, table) between the organization and the delegate, indicating that responsibilities were mutually agreed upon before the delegation agreement was final and outlining the responsibilities of each entity.

This applies to the following Programs and Years:

2.14.2014 Non-Recommended Cervical Cancer Screening in Adolescent Females In the Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) measure, how should the optional exclusions be handled given that a lower rate indicates better performance?

Based on the current guideline, organizations should look for optional exclusions only where administrative data indicate that the specified numerator service or procedure did not occur. For the NCS measure, the optional exclusions indicate a justification for screening so it is not inappropriate care if these members are screened. Therefore, the optional exclusions in the NCS measure were intended to be required exclusions. In HEDIS 2015, these members must be removed from the eligible population regardless of numerator compliance. NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

This applies to the following Programs and Years:
HEDIS 2014

2.14.2014 Inpatient Utilization General Hospital/Acute Care In step 4, the text under the "Medicine" bullet states for the Newborns/Neonates MS-DRG Value Set, "Do not include newborn care rendered from birth to discharge home from delivery; only report newborn care rendered if the baby is discharged home from delivery and is subsequently rehospitalized." In HEDIS 2013, this instruction also applies to "Total Inpatient." Should newborn care rendered from birth to discharge home from delivery also be excluded from Total Inpatient?

Yes. Exclude newborn care rendered from birth to discharge home from delivery before reporting Total Inpatient (step 3).

This applies to the following Programs and Years:
HEDIS 2014

2.14.2014 Osteoporosis Management in Women Who Had a Fracture When determining the eligible population, step 4 states to exclude members with a dispensed prescription to treat osteoporosis (Table OMW-C) during the 365 days (12 months) prior to the IESD. Does this include only osteoporosis prescriptions dispensed during the 365-day look-back period, or may it include an osteoporosis prescription that was dispensed prior to the look back period but is still “active” during the 365 days?

Members with an “active” prescription for osteoporosis treatment (Table OMW-C) during the 365 days prior to the IESD meet the step 4 exclusion criterion. The prescription does not need to be dispensed during the 365-day look-back period. NCQA does not specify how long organizations must look back prior to the IESD to identify an “active” prescription; organizations determine the look-back period, which should be applied consistently across all members.

This applies to the following Programs and Years:
HEDIS 2014

2.14.2014 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the BMI percentile indicator, does documentation of >99% or <1% meet criteria?

Yes. Documentation of >99% or <1% may be used when reporting because an exact BMI percentile value is evident (i.e., 100% or 0%). These examples are not considered ranges or thresholds, which are not permitted when reporting the BMI percentile indicator. Examples of non-permitted ranges and thresholds are "75-80th percentile" and ">90th percentile" because the exact BMI percentile value is not evident.

This applies to the following Programs and Years:
HEDIS 2014

1.24.2014 Meaningful Use of Health IT: Overview There appears to be an error in Table 1 of the Domain Structure in the Overview section of the MUHIT Survey. In the first column, there is an overlap in percentage groups 45_64 and 64_84. What are the correct percentage ranges for this table?

There is an error in the percentage ranges listed in Table 1: MUHIT Points for ONC-ATCB Certified Software. The range to receive 4 points is 65_84.

This applies to the following Programs and Years:
IHA P4P