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.
Yes. If an organization informs NCQA that it follows the Affordable Care Act requirements for external reviews (PHS Act section 2719), UM 8, Element E applies, even if the state where the organization operates does not comply with federal regulations.
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.
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.
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.
Yes, if the flat copay amount is specified on the organization’s Web site. Members must have no additional financial liability (i.e. co-insurance, deductibles, charges in excess of allowed amounts, differentials in cost between in-network care and out-of-network care, costs that vary for the formulary) for services and cannot be balance-billed by a practitioner, provider or other party.
This exception does not apply to Element B in MEM 3 and 5.
Yes. The 45-calendar day notice period for providing results and providing an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology.
The exception to the minimum 45-calendar-day notice period for action is when the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. It must still provide a process for the physician to request corrections or changes.
No. The HEDIS 2015 Value Set Directory will not include invalid ICD-9 codes; it will only include ICD-9 codes that are valid for billing. The HEDIS 2014 value sets included invalid ICD-9 codes; these will be removed, effective with HEDIS 2015.
Thank you for bringing this to our attention. When converting coding table references to value set references, the Option A UBTOB language and Option B POS language was inadvertently omitted. For OSU, Options A and B should include both POS and UB Type of Bill codes and should read as follows:
Any of the following code options meet criteria:
· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery POS Value Set .
· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery UBTOB Value Set.
· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery UBTOB Value Set.
· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery POS Value Set.
This will be corrected in the next release of the manual.
Thank you for bringing this to our attention. Unfortunately, the age breakdown in the brackets are historical, and the new guidelines that came out last year do not sync easily with them. For MY 2014, we can consider eliminating the age breakouts and simply collecting the overall versions of these measures.
Unfortunately, it is too late to change the file layout at this point because plans and POs are in the midst of programming. For MY 2013, women who are 30 should be included in the “Too Frequently No Hyst: Ages 24-30” row; women who are 31-65 should be included in the “Too Frequently No Hyst: Ages 31-65” row.
The December 2, 2013, release of the MY2013 P4P Value Set Directory (VSD) was incomplete for two value sets used to report the Encounter Rate by Service Type (ENRST) measure. Therefore, we are releasing a 2014-03-19 version of the VSD that contains the following changes:
· Laboratory and Pathology Services Value Set: Added 1331 CPT codes
· Radiology and Imaging Services Value Set: Added 21 CPT codes
The added codes can be identified in the VSD as follows:
· In the P4P Value Sets to Codes spreadsheet, set the filter in column C (Value Set Version) to “2014-03-19” to identify added codes.
· In the P4P Summary of Changes spreadsheet, set the filter in column F (Revised) to “2014-03-19” to identify added codes.
To access the correct value sets, go to the download center at https://downloads.ncqa.org/customer/Login.aspx and log in.
If you have any questions, contact p4p@ncqa.org.
No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during P4P MY 2014 and therefore will not be included in the P4P MY 2014 Value Set Directory.
Purchasers of the P4P MY 2014 Value Set Directory will receive a separate file with ICD-10 codes proposed for inclusion in future releases of P4P specifications, but the codes will not be considered part of the MY 2014 measure specifications.
