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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7.02.2024 July 2024 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 10?

KM 09: DiversityAdded “Middle Eastern or North African” to the race/ethnicity combined category.

Also, added this note, “The OMB updated the combined Race and Ethnicity categories in 2024 to include the Middle Eastern or North African population; this is reflected in the publications. If this option is not yet available, work with your vendor to ensure compliance with the OMB.” 

CC 16: Post-Hospital/ED Visit Follow-UpAdded a note, "All discharged patients should be contacted, although not every patient may require a follow-up in the primary care practice." 
AR-QI 1: Clinical Quality Measures and AR-QI 2: Resource Stewardship MeasuresAdded this note, “Practices should review measure data before submission, to ensure data are captured accurately and that numbers reflect practice performance and patient population.”
AR-QI 1: CQMsRemoved three retired measures. CMS 127: Pneumococcal vaccination status for older adults; CMS 147: Influenza immunization; CMS 161: Adult major depressive disorder: Suicide risk assessment.

Adult practices may submit a custom immunization measure and pediatrics practices must select CMS 117: Childhood immunization status: Combination 10.

Adult practices do not need to submit a request for a custom immunization measure.

AR-QI 1C: Chronic/Acute Clinical Quality MeasurePediatric practices do not need to submit a request via My NCQA to request a custom measure if they were granted a custom chronic/acute measure in 2024.
 
AR-QI 1: CQMsTwo new eCQM measures added. CMS 314v1: HIV Viral Suppression (chronic/acute) and CMS 1188v1: Sexually Transmitted Infection Testing for People with HIV (other preventive).
Appendix 6: MAC PolicyChanged contact email to rpsig@ncqa.org and removed the mailing address.

PCMH 2017

7.02.2024 July 2024 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 7?

KM 06: DiversityAdded “Middle Eastern or North African” to the race/ethnicity combined category.
Also, added this note, “The OMB updated the combined Race and Ethnicity categories in 2024 to include the Middle Eastern or North African population; this is reflected in the publications. If this option is not yet available, work with your vendor to ensure compliance with the OMB.” 
AR-QI 1: Clinical Quality Measures and AR-QI 2: Resource Stewardship MeasuresAdded this note, “Practices should review measure data before submission, to ensure data are captured accurately and that numbers reflect practice performance and patient population.”
Appendix 4: MAC PolicyChanged contact email to rpsig@ncqa.org and removed the mailing address.

PCSP 2019

6.24.2024 Is there a threshold for CMS 68: Documentation of Current Medications in the Medical Record?

No, unless otherwise stated in the specifications, quality measures do not have thresholds that must be met.  

With that said, CMS 68 is similar to KM-15 (core): Maintaining an up-to-date list of medications for more than 80% of patients. Both sets of data require the same action of updating the medication list. However, they differ in that CMS 68 is for patients age 18+ and must be captured at every visit, whereas KM-15 is for all patients at any given time. It is unlikely that there would be a large variance between CMS 68 and KM-15. NCQA requests a note be added in QPASS if CMS 68 differs greatly from KM-15's 80% requirement. This is to provide context to the Review Oversight Committee to better understand your practice and environment. 

If your practice is in Annual Reporting, practices attest that they are in compliance with all core criteria and could provide evidence that they are meeting the more than 80% requirement of KM-15. 

PCMH 2017

6.14.2024 RxNorm codes for Asthma Medication Ratio (AMR) Can RxNorm codes be used when identifying the required exclusion for members who had no asthma controller or reliever medications dispensed during the measurement year?

No. Although the Asthma Controller and Reliever Medication List includes RxNorm codes, they should not be used to identify dispensing events for this required exclusion. Only use pharmacy data (NDC codes) when assessing asthma controller or reliever medication dispensing events for this required exclusion. Because a dispensing event is required to calculate the numerator, members who had no dispensing events should be removed from the measure.

HEDIS 2024

5.21.2024 Inpatient Stay Value Set for Emergency Department Visits for Hypoglycemia in Older Adults with Diabetes (EDH) The HEDIS MY 2024 Value Set Directory (VSD) states that the Inpatient Stay Value Set was deleted from the EDH measure. Please clarify if it should be used for risk adjustment.

Yes, as described in the Guidelines for Risk Adjusted Utilization Measures, organizations must use the Inpatient Stay Value Set for the risk adjustment comorbidity category determination (use the Inpatient Stay Value Set to identify acute and nonacute inpatient discharges with a discharge date during the classification period). The value set was mistakenly deleted from the EDH measure in the VSD. Because the guidelines clearly state that the value set must be used, NCQA does not intend to reissue the VSD.

HEDIS 2024

5.15.2024 Depression screening instrument table for Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Should the Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) measure in the Depression screening instrument table for the Adolescents (≤17 years), Beck Depression Inventory-Fast Screen (BDI-FS)® LOINC Code be updated?

Yes, replace Total Score LOINC Code “55758-7” with “89208-3” in the Depression screening instrument table for the Instruments for Adolescents (≤17 years), Beck Depression Inventory-Fast Screen (BDI-FS)®.

Exchange 2024

5.15.2024 Direct reference code 76689-9 for Cervical Cancer Screening (CCS) LOINC code 76689-9 is included in the CCS measure specification but was deleted from CCS in the Value Set Directory (VSD). Please clarify if the code should be used when reporting Cervical Cancer Screening for MY 2024.

Yes, as described in the Required exclusions section of the CCS measure, use LOINC code 76689-9 to exclude members with a sex assigned at birth of male any time in the patient’s history. The code was mistakenly removed from the CCS measure in the 4-1-2024 release of the VSD (Direct Reference Code spreadsheet). Because the information needed for reporting is in the measure specification NCQA does not intend to reissue the VSD.

Exchange 2024

5.15.2024 Direct reference code 76689-9 for Cervical Cancer Screening (CCS) LOINC code 76689-9 is included in the CCS measure specification but was deleted from CCS in the Value Set Directory (VSD). Please clarify if the code should be used when reporting Cervical Cancer Screening for MY 2024.

Yes, as described in the Required exclusions section of the CCS measure, use LOINC code 76689-9 to exclude members with a sex assigned at birth of male any time in the patient’s history. The code was mistakenly removed from the CCS measure in the 4-1-2024 release of the VSD (Direct Reference Code spreadsheet). Because the information needed for reporting is in the measure specification NCQA does not intend to reissue the VSD.

HEDIS 2024

5.15.2024 Direct Reference Codes Why are some codes included in the measure specification and not included in a value set?

When only a single code exists for a service or condition, it is included directly in the measure specification, and referred to as a Direct Reference Code (DRC). It is a best practice to not create value sets that include only a single code; some code systems prohibit this because it results in assigning another code (an OID) to a concept that already has a code.
DRCs are listed in the measure specifications and in a Direct Reference Codes spreadsheet in the value set directory.
For MY 2024, a number of single code value sets were converted to DRCs. The Summary of Changes – Value Sets spreadsheet indicates the value set was deleted. The Summary of Changes – Codes spreadsheet indicates the code was added as a DRC (filter Column A on “Direct Reference Code”).

Exchange 2024

5.15.2024 eGFR and uACR Timing for Kidney Health Evaluation for Patients With Diabetes (KED) When does the “with service dates four days or less apart” specification apply?

The numerator criterion is an eGFR and a uACR any time during the measurement year. These separate tests may occur on different dates.
The 4-day proximity language is specific to a reporting option for uACR, where a quantitative urine albumin test and a urine creatinine test may be billed separately. In practice, the quantitative urine albumin and urine creatinine tests are performed on the same date, from the same urine sample, to produce a single ratio. The 4-day proximity language intends to account only for potential billing lags between the separate quantitative urine albumin and urine creatinine administrative codes that indicate a single uACR evaluation; it is not intended for separate samples from different dates.

HEDIS 2024

5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

UM-CR-PN 2024

4.15.2024 SNS-E Numerator Criteria for Completed Screenings For screening indicators, which responses to screening questions meet numerator criteria?

Any coded response (i.e., any non-null response—positive or negative) on a pre-specified instrument for food, housing and transportation counts for completed screening numerators (numerators 1, 3, 5). The PRAPARE Food Insecurity Instrument question (LOINC code 93031-3) is an exception. Based on how the question is structured and responses are coded, a “No” or “None of the above” response cannot be coded and must be left null. Therefore, a null response meets criteria for this item only. 

HEDIS 2024