No. Practices must track important referrals, such as those made for high-risk patients.
PCMH 2017
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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5.29.2018 CC 04C Are practices required to track every referral?
5.29.2018 QI 15 & QI 16 Is it acceptable to demonstrate only how reports from QI 01 are shared with staff, the public and patients?
5.29.2018 CM 07 Are practices required to document that they assess and address patient barriers to meeting treatment goals?
Yes. Practices must assess whether there are barriers to meeting goals and should address any identified barriers. Both components must be listed in the medical record in order to select “Yes” in the Record Review Workbook. If the practice assesses potential barriers and none are identified, the practice may answer “Yes.”
Note: Practices must provide an example of how they meet each criterion and complete the Record Review Workbook. Examples are not required if a practice provides a report as evidence.
PCMH 2017
5.29.2018 CM 05 May practices make the individualized care plan available via patient portal, or are they required to provide the document in writing?
Although the care plan can be made available via the patient portal, it is essential that all patients have access to the document. If patients are not registered for the portal, they will not have access. In those cases, practices should use an alternative method to provide the written care plan to patients to ensure that all patients have access after an appointment. Please note practices must document that the care plan is provided to the patient in the patient’s medical record.
PCMH 2017
5.29.2018 CM 04 Does a clinical summary meet the requirement for a “plan of care”?
If the clinical summary also includes the details of the patient’s care plan (i.e., information outlined in the criterion guidance), then it would meet the requirement. A clinical summary alone that does not include the patient’s care plan information would not meet the requirement.
PCMH 2017
5.24.2018 QI 01 B May practices use well-child visits for two different preventive care measures?
Practices may only count well-child visits for different age groups as distinct preventive care measures if the measures are aimed at assessing completion of age-specific screenings and tests (e.g. autism screen at 2-year check-up, adolescent depression screen), according to evidence-based guidelines. Assessing patient access to well visits for two different pediatric age groups would not be considered two different measures.
PCMH 2017
5.24.2018 KM 16 Do excerpts from medical records indicating that new medications and side effects were reviewed with the patient/family/caregiver meet the requirement?
No. For KM 16, the practice must both (1) generate a report that demonstrates more than 50 percent of patients have documentation in their medical record that they were assessed and provided education on new prescriptions and (2) demonstrate evidence of the process, which could include showing a patient medical record during virtual review. It is up to the practice to determine the best method for sharing new medication information with patients, and the practice should consider patient language, literacy and health literacy in providing information or materials.
PCMH 2017
5.24.2018 KM 02 I Is a patient’s advance directive required to be included in the medical record?
No. While advance care planning could include a completed advance directive, it’s not required to meet KM 02. The practice must demonstrate that it documents results of advance care planning discussions with patients to meet this requirement. If a practice has an advance directive on file and documented in the patient medical record, that would also meet the intent.
PCMH 2017
5.24.2018 KM 16 May practices provide new prescription information only for medications relevant to a specific disease of interest?
No. The requirement to provide new information applies to all new medications prescribed to a patient, especially for patients identified in Concept CM as needing care management. Patients may have multiple comorbidities and medications, so it is crucial that they receive information about all medications prescribed to them
PCMH 2017
5.24.2018 KM 20 What types of evidence are acceptable as examples of demonstrating implementation of clinical decision support?
Use of flow sheets, demonstration of EHR prompts or other evidence of guideline implementation with which the provider is alerted when a specific service or action is needed at the point of care, based on evidence-based guidelines, would meet the intent of KM 20. In addition to the evidence, practices must also provide information on the condition addressed by the clinical decision support and the source of the evidence-based guideline on which the clinical decision support is based.
Flow charts, copies of guidelines or empty templates do not demonstrate implementation of clinical decision support. These items show the guideline, but do not demonstrate its use at the point of care
PCMH 2017
5.24.2018 KM 20 G What qualifies as an overuse or inappropriateness issue?
KM 20 G requires evidence-based guidelines on appropriate use of services, which could include a prompt at the point of care to consider appropriateness of laboratory test ordering, avoidance of MRI as a first-line diagnostic test for back pain, appropriateness of antibiotics use, or appropriateness of specific referrals.
NCQA encourages practices to look at ABIM’s Choosing Wisely website for more information on overuse/appropriateness (www.choosingwisely.org).
PCMH 2017