FAQ Directory: Patient-Centered Specialty Practice Recognition Program (PCSP)

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6.23.2023 July 2023 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 6?

TopicUpdate Highlights
Front Matter (Audit Section)Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).”

Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.”

KM 06Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”.
KM 09
Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.”
PM 20New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up

PCSP 2019

1.09.2023 PCSP January 2023 Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 5.1?

TopicUpdate Highlights
Front MatterAdded definitions of “electronic health record (EHR)” and “certified electronic health record technology (CEHRT).”
TC 05Added a note that beginning in 2024, practices will be required to have an EHR.
KM 09Added a note that gender identify and sexual orientation requirements apply to all patients 18 years of age and older.
CM 10Replaced “person-driven outcomes approach” with “person-centered outcomes approach.”

PCSP 2019

6.30.2022 PCSP July 2022 Summary of Updates What updates were made to the PCSP Standards and Guidelines for Version 5?

TopicUpdate Highlights
Policies and ProceduresSection restructured
Policies and ProceduresAddition of language regarding Corrective Action Plans
KM 06Addition of Sexual Orientation and Gender Identity as required topics of data collection. Added requirement that data be direct collection.
KM 06Added requirement that data be direct collection.
PM 19New elective criterion regarding person-driven outcomes.
Appendix 2 – GlossaryAdded “Age as a Vulnerability”

PCSP 2019

6.13.2022 AR KM 01 For AR-KM 01: Medication Management (aligns with PCSP Transform KM 9), is a reported rate <80% automatically marked as “Not Met”? (PCSP AR 2022)

Yes. AR-KM 01 confirms that practices meet PCSP Transform KM 09, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.

PCSP 2019

6.13.2022 Why do I need to provide more information for a low denominator or rate if there is no minimum requirement?

It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.

PCSP 2019

6.13.2022 When do I need to add additional information about the measure performance (PCSP AR 2022)?

Practices should submit an explanation when their performance falls below 80% for the following AR criteria:
•    AR-AC 1: Timely Clinical Advice by Telephone
•    AR-CC 4 (Option): Diagnostic Test Tracking (2 rates)

Practices should submit an explanation when their performance falls below 30% for the following AR criteria:
•    AR-CC 5: Secondary Referral Tracking

If the practice does not submit an explanation, NCQA will contact the practice and request context for their performance rates.

PCSP 2019

6.13.2022 Is there a minimum denominator requirement when reporting a rate for Annual Reporting?

No. There is no minimum denominator requirement. A sample of 30 (or more, because this increases the reliability of the sample) is expected to ensure statistical soundness, but there may be cases where it may be appropriate for the denominator to be <30. NCQA requests practices enter an explanation in the Notes from the Organization section in QPASS in this case.

If a practice reports a denominator <30 without a note, the evaluator may contact the practice to confirm data accuracy and to understand the data. The evaluation will be returned to the practice so they can enter an explanation in the Notes from the Organization section for the cited criteria.


PCSP 2019

6.13.2022 Is there a minimum threshold requirement when reporting a rate for Annual Reporting (PCSP AR 2022)?

It depends. If the AR requirement aligns with a PCSP criteria that explicitly specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%. 

An explanation in the Note section of Q-PASS is required for practices that report a rate less than 80% for the following criteria: AR-AC 01 [Timely Clinical Advice by Telephone], AR-CC 04 [Tracking Lab Test Results], and AR-CC 05 [Tracking Imaging Test Results].

PCSP 2019

6.13.2022 AR CC 04 For AR-CC 4: Diagnostic Test Tracking (aligns with PCSP Transform CC 5), must practices meet a percentage threshold to meet criteria? (PCSP AR 2022)

No. There is no percentage threshold for diagnostic test tracking measures. The expectation is that practices track all diagnostic tests routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.

For example, if data show a 30% return rate, that means 70% of the practice’s ordered tests never had a report returned to their PCP. 

PCSP 2019

6.13.2022 Is a minimum reporting period required for measures?

NCQA recommends using the previous calendar year (January 1–December 31) when possible. If there is not a calendar year of data, the practice may submit the reporting period it uses to regularly monitor performance.  

PCSP 2019

6.29.2021 July 2021 Summary of Updates What changes were made to the PCSP Standards and Guidelines in Version 4?

TopicUpdate Highlights
Policies and ProceduresAdded a section on Natural Disasters and Cybercrime.
Policies and ProceduresUpdated policy on eligibility to clarify that organizations that operate entirely remotely are eligible.
KM 17Updated the list of CDS examples in the guidance language.
AC 02Added language to the guidance to clarify that patient inquiries regarding prescription refills or appointment requests are not considered clinical advice.
PM 11Updated guidance language to detail how Person-Driven Outcome goals can be used to meet the criteria.
QI 01 A, B and CMeasures data must be input from the new ‘Measures Reporting’ tile of the Organization Dashboard.

PCSP 2019

6.25.2020 July 2020 PCSP Summary of Changes What changes were made to the PCSP Standards and Guidelines?

PCSP (Version 3) Summary of Changes
TopicUpdate Highlights
Standards and GuidelinesAdded the ‘Shared Credit’ symbol to all relevant criteria.
Standards and Guidelines/ Appendix 4The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03Updated language describing an appropriate external patient-centered collaborative activities and clarified than participation in an HIE will not meet the requirement.
TC 08Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
RM 11Highlighted that this criterion is particularly relevant to self-referred patients.
KM 04Specified that monitoring pain or functional health status may not be appropriate for all specialties, so if the category is not relevant or appropriate, a practice should make a different selection.
KM 05Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 06Specified that age and gender are not acceptable as a third aspect of diversity.
KM 15Clarified that patients should be proactively reminded of needed services related to the specialty.
KM 20Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01Clarified that the focus of the criterion is to ensure that patients have access to the practice for urgent needs.
AC 02 and AC 03Stated that the reports include calls or messages received both during and after office hours.
AC 04Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 05Stated that continuity of the medical record is inclusive of telehealth appointments.
PM 01 and PM 11Clarified the guidance in PM 01 by moving the reference to motivational interviewing and treatment goals to PM 11.
CC 09Highlighted that follow-up visits may be conducted through telehealth and that follow-up should be consistently documented.
CC 13Clarified that electronically exchanging information should include data both sent and received.
QI 01FClarified that the report provided should summarize collected feedback.
QI 01 Clarified that measures include activities conducted during telehealth visits.
QI 01D.Specified that major appointments may be conducted in person or via telehealth.
QI 01E.Clarified that the access category may include questions regarding telehealth.
QI 05Updated the vulnerable patient population definition.
Policies and ProceduresAdded a description of telehealth in NCQA recognition programs.
Policies and ProceduresUpdated the reconsideration process.
Policies and ProceduresDoctoral or master's level certified or licensed chemical dependency counselors have been added as eligible clinicians to the program.
Policies and ProceduresThe “Discretionary Audit” is now called the “Discretionary Review”.

PCSP 2019