Frequently Asked Questions (FAQ) Pay for Performance Measurement Year 2014 June 2015

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1 P4P Controlling Blood Pressure for People with Hypertension (CBPH) Posted 6/29/15 Question: Why are there are no codes that encompass the BP range that is new for senior hypertensive patients (BP control for members 60-85: <150/90 mm HG)? Answer: Unfortunately, the AMA has not released a CPT II code for a systolic reading of between 140 and 150 mmhg, or under 150 mmhg. We updated the CBPH measure to align with new blood pressure guidelines; if there are patients whose systolic reading falls between 140 and 150 and it is captured in other kinds of supplemental data, they can be included in the numerator. Our data suggests that use of CPT II codes to retrieve this data is uncommon. This data is available in EHRs as well as via supplemental sources such as registries and laboratory data. There is a note to this effect in the specification for the CBPH measure on page 50 of the manual ( pdf). This is similar to the way the HbA1C <8.0% is calculated, as there is not a CPT II code specific to <8.0%. More information can be found in the manual on page 66 ( pdf). P4P High Risk Medication (HRM) Posted 3/26/15 Question: According to the last paragraph on page 149, plans and POs should use the first two prescription fills to calculate average daily dose to determine numerator compliance. Should other fills during the treatment period be considered when calculating average daily dose? Answer: When calculating average daily dose all fills during the treatment period should be considered. The last paragraph on page 149 should state: Average Daily Dose: Use all fills during the treatment period to calculate average daily dose for each high-risk medication fill with the following equation: (quantity dispensed x dose)/ days supply. If the average daily dose for any two fills of the HRM exceed the threshold, then the member is numerator compliant. P4P Proportion of Days Covered by Medications (PDC) Posted 3/26/15 Question: An answer to an FAQ posted on 2/17/15 states, Exclude members whose ESRD diagnosis is noted any time during the measurement year. The MARx System output, which contains the RxHCC codes, does not release the entire 2014 dates of service until after the IHA reporting deadline. Does the FAQ apply to both the RxHCC and ICD-9-CM code? Answer: The intent is to use the most current information for the ESRD exclusion. If ICD-9- CM is used, then any code from the value set during the measurement year excludes the member from the denominator. If the MARx System output is used, then the most recent version applies. Although the time frames are not consistent between ICD-9-CM and RxHCC, it is the most current information to identify patients with ESRD. ICD-9-CM is preferred, but if it is not available, the most current MARx System output can be used. P4P Meaningful Use of Health IT Posted 3/26/15

2 Question: An FAQ about e-measure reporting posted on 1/29/15 states, You should use the same definition of PCP as outlined in the NPI data file specification instructions. Providers in your denominator should include employed and contracted PCPs (MD or DO) in the following specialties: Family/General Practice, Internal Medicine and Pediatrician/Adolescent Medicine. The Controlling High Blood Pressure e-measure is specified for members 18 years and older, should pediatricians be excluded from the denominator? Answer: POs have the option of excluding pediatricians from the Controlling High Blood Pressure e-measure denominator.

3 P4P Controlling High Blood Pressure for People with Hypertension (CBPH) Posted 2/17/15 Question: In the Controlling High Blood Pressure for People with Hypertension specifications, there are three rates in the description. In the clinical file layouts, only one rate is included. Is this intentional? Answer: No. The two additional rates were inadvertently left out of the clinical file layouts. Three rates should be reported for this measure: The percentage of non-diabetic members years with a diagnosis of hypertension whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year. The percentage of non-diabetic members years with a diagnosis of hypertension whose blood pressure was adequately controlled (<150/90 mm Hg) during the measurement year. The total rate. Revised Clinical File Layouts have been posted for health plans and physician organizations ( to reflect this change. P4P Proportion of Days Covered by Medications (PDC) Posted 2/17/15 Question: The ESRD Value Set includes the code RxHCC 121. Is the RxHCC code system new? Where is this type of code found? Answer: Yes, the RxHCC code system and code were added to the Value Set Directory when we created the ESRD Status Value Set. This code is used to identify patients with ESRD for the denominator exclusion in Diabetes: Appropriate Treatment for Hypertension and Proportion of Days Covered by Medications. The RxHCC code can be found in the CMS Medicare Advantage and Prescription Drug System (MARx), which provides a monthly report of members RxHCCs to plan sponsors. For MY 2014, use the 2013 model software of the RxHCC system. P4P Proportion of Days Covered by Medications (PDC) Posted 2/17/15 Question: The DTX and PDC measures include a denominator exclusion for ESRD status. Does the status need to be any time in the member's history, or just during the measurement year? Answer: Exclude members whose ESRD diagnosis is noted any time during the measurement year. P4P Evidence Based Cervical Cancer Screening (ECS) Posted 2/17/15 Question: The service date example in Rate 2, step 2 states, If the service date for cervical cytology was November 27 of the measurement year, the HPV test must include a service date on or between December 1 and December 5 of the measurement year. This does not align with the other service data examples in Rate 1 and Rate 3 of the Administrative Specifications. Should the service dates in Rate 2, step 2 align with the other examples? Answer: Yes. The service date example in Rate 2, step 2 should align with the examples in Rate 1 and Rate 3. The dates were inadvertently switched in the Rate 2 example and should state: For example, if the service date for cervical cytology was December 1 of the measurement year, the HPV test must include a service date on or between November 27 and December 5 of the measurement year.

4 P4P Meaningful Use of Health IT Posted 1/29/15 Question: Not all providers will have the required Medi-Cal population to attest to the State of California s Meaningful Use incentive program. This change to the MUHIT domain may disqualify pediatricians who are meeting the Meaningful Use measures with the EHR. Might POs provide supplemental information for pediatricians who were unable to attest to Meaningful Use but are meeting Meaningful Use measure specifications? Answer: In response to public comments received, the Technical Measurement Committee (TMC) considered that pediatricians who do not take Medi-Cal may not be eligible for incentive payments from the State of California or CMS. The TMC concluded that medical groups would have similar distributions of pediatricians. We have received several questions about this policy; it is too late to change it for the MY 2014 measurement year, but staff will bring the issue to the committees again. IHA s mission is to promote quality improvement and affordability of health care for all Californians, including the 30% of Californians who are covered by Medi-Cal. As a result, staff feel that it is not unreasonable that pediatricians who do not see the required threshold of Medi-Cal patients will not qualify for the numerator in the MUHIT survey. Ultimately, a PO s payor mix will have implications for performance measurement and paymentsometimes resulting in higher scores and payments, and other times not. P4P Meaningful Use of Health IT Posted 1/29/15 Question: May providers who did not see patients during the measurement year be excluded from our NPI submission and e-measures provider denominator? Answer: Physicians who are PCPs and who meet the criterion (MD or DO) in family/general practice, internal medicine or pediatrician/adolescent medicine should be included in submission, regardless of panel size. Providers who meet the criterion but are employed in an administrative-only role (e.g., medical director) may be excluded. P4P Meaningful Use of Health IT Posted 1/29/15 Question: Should providers who were with our PO for less than three months of the measurement year be included in our NPI file submission? Answer: Providers who were with a PO for less than six months of the measurement year may be excluded.

5 P4P Meaningful Use of Health IT Posted 1/29/15 P4P Question: What must POs report for e-measures, and how are these measures reported? Which providers should be included in reporting for the two e-measures? Answer: The MUHIT domain comprises three rates, the first is the percent of providers who have attested to the national or state Meaningful Use EHR Incentive programs, and the second two are e-measures. To receive credit, POs must report: A.csv file with a list of the PO s providers national provider identifiers (NPIs). Instructions on file requirements were sent on January 7, 2015, and were discussed on the January Webinars. The two e-measures, Controlling High Blood Pressure and Screening for Clinical Depression and Follow-Up Plan. For self-reporting POs, these measures are reported via the PO Clinical File Layout ( There is a separate file layout provided for non-self-reporting PO submission. For each measure, two metrics are collected: The percentage of providers who can report the e-measure. The aggregated numerator and denominator, for providers who can report the e- measure. To calculate, pull the numerators and denominators from the EHR systems of all providers who can report the measures; specifications are programmed in the certified EHR systems of providers who can report. Refer to pp of the MY 2014 P4P Manual, released December 1, You should use the same definition of PCP as outlined in the NPI data file specification instructions. Providers in your denominator should include employed and contracted PCPs (MD or DO) in the following specialties: Family/General Practice, Internal Medicine and Pediatrician/Adolescent Medicine. As with the NPI file submission, POs have the option of excluding providers who were with the PO for less than six months of the measurement year. Childhood Immunization Status, 24 month Continuous Enrollment (CIS) Posted 1/29/15 Question: The specifications for Childhood Immunization Status, 24-Month Continuous Enrollment list Combination 3 and Combination 7. The MY 2014 Measure Set document, posted on January 12, 2015, lists ( Measure-Set pdf), only Combination 3. Which combinations should be reported? Answer: Report only Combination 3. Combination 7 was listed in the manual in error and should not be reported. Per the MY 2014 Measure Set, only Combination 3 will be reported for this measure. The correction will be reflected in the PO and Health Plan Clinical Measure File. Note: Combination 3 and Combination 7 are reported for CIS, 12-Month Continuous Enrollment. P4P Cervical Cancer Screening Posted 1/29/15 Question: The P4P CCS testing measure specification states that there are no modifications from HEDIS, but the HEDIS CCS measure exclusion is optional and the P4P CCS measure exclusion is required. Should the P4P CCS exclusion be optional as well, to align with HEDIS? Answer: No. The exclusion in the P4P CCS measure is required. The P4P CCS specification should list this change under Modifications From HEDIS.

6 P4P P4P Overview Posted 12/11/14 Question: Page 7 of the P4P manual, states that quality preliminary reports are released on June 3, 2015 and the final date to submit an appeal is June 24, This does not match the dates on the quality timeline on pages 8-9. The table on page 8 indicates that the PO Quality Preliminary Reports are posted on May 25, The first column of the table states that the Quality Results Questions and Appeals period have a June 16-24th timeframe, but the timeline in the second column says May 25- June 15 th. Please clarify the dates for the Quality Results Questions and Appeals period. Answer: Thank you for pointing this out. The correct dates are as follows: Page 7 Page 8-9 Quality preliminary reports are released on May 25, 2015, and the final date to submit an appeal is June 15, IHA works with health plans and vendors to research and respond to PO questions about results provided in the PO Quality Preliminary Reports. Quality Results Questions and Appeals Period: IHA works with POs and Health Plans to address any data issues or questions related to quality results. Plans and POs may submit an appeal during this time. May 25 May 29: POs submit initial questions to IHA. May 30 June 5: IHA works with health plans and vendors to research and respond to PO questions. June 6 15: Back-and-forth between POs, IHA and health plans to resolve questions or escalate to an appeal. May 25 June 15, 2015 The P4P staff will update this timeline and post to the IHA website alongside the December 1, 2014 release of the MY 2014 Value Based P4P Manual.

7 P4P Cervical Cancer Overscreening (CCO) Posted 12/11/14 Question: The specifications indicate that three rates are reported (two rates for steps 1 and 2 and a total rate). The measure description describes each rate but it is unclear what the denominator for each rate should be. Are the denominators the same for the three rates? Answer: The eligible population for the measure is all women years of age as of December 1 of the measurement year, except those that meet the required exclusion. The denominator for each individual reported rate is also the total eligible population. The denominator for the step 1 rate is all women 24 64; the numerator for step 1 is all women who had two or more Pap tests in the MY or the two years prior. The denominator for step 2 is all women The numerator is those who had two or more co-tests in the MY or the four years prior. The description of the three rates should read as follows: Women age with more than one cervical cytology performed every three years (denominator is the total eligible population). Women age with more than one cervical cytology/hpv co-test performed every 5 years (denominator is the total eligible population). Total rate (the sum of the two numerators divided by the eligible population).

8 P4P General Guidelines: Supplemental Data Posted 12/11/14 Question: The Supplemental Data section of the P4P General Guidelines no longer includes information about supplemental data portability between health plans and POs, but there is still a note referring to this policy under general guideline #49. Are plans allowed to use audited PO supplemental data? Answer: You are correct, the sections about supplemental data portability were removed from the December release of the MY 2014 P4P Manual, but they should be reinstated. The section under the Supplemental Data Timeline on page 26 of the MY 2014 P4P Manual should read: P4P Health plans that use audited PO supplemental data should receive the audited data files and audit results from the PO by the April deadline listed in the P4P Data Collection and Reporting timeline. The health plan should receive all supporting documents for each supplemental data source (e.g., Roadmap section, file layouts, training materials, [PSV samples], etc.,) at the time the Roadmap is submitted to the auditor. The PO is responsible for sending the health plan all necessary documentation to support the use of supplemental data. The note under Identifying and Validating Supplemental Data on page 27 of the MY 2014 P4P Manual should read: Note: Only health plans that participate in the P4P program can use audited PO supplemental data for their P4P and HEDIS data submissions. The PO must provide the health plan with a completed Roadmap section for each supplemental data source, all applicable attachments, the auditor s review findings and PSV results. The P4P health plans are not required to also collect the proof-of-service documents for these audited and approved PO data. (see P4P Audit Review Guidelines, released in November 2014). And the following Activity or Milestone and deadline should be added to the P4P Data Collection and Reporting Timeline on page 8 of the MY 2014 P4P Manual. Supplemental Data to Health Plans: P4P Health plans receive the audited supplemental data files and audit results from the PO. April 15, 2015 Please also note, that although this policy is applicable to MY 2014, NCQA is currently reviewing many policies for P4P and HEDIS reporting; we expect to reassess these guidelines and others for MY 2015.

9 P4P Meaningful Use of Health IT Posted 12/11/14 Question: The MUHIT Overview section of the MY 2014 P4P Manual released on December 1 states that POs report two clinical quality e-measures, Controlling High Blood Pressure and Screening for Clinical Depression and Follow-Up Plan in the Clinical Measure File Layout. Are health plans expected to report the two e-measures? May POs that do not self-report clinical measures submit the measures? Are the measures subject to P4P audit review and measure certification? Answer: The e-measures are part of the MUHIT Domain, but the numerators and denominators will be collected as part of the Physician Organization Clinical Measure File Layout. Health plans are not expected to report the measures, which will not be included in the Health Plan Clinical Measure File. Any PO may report the measures, even if it does not self-report P4P clinical measures. The measures are not subject to NCQA audit or measure certification. P4P Meaningful Use of Health IT Posted 12/11/14 Question: In the MUHIT Overview section, no changes are listed under the Measure Updates released in December for P4P MY Is this intentional? Answer: No. The changes for December 2014 was omitted from the final version of the MY 2014 P4P Manual. The Measure Updates for December 2014 should include: In the Computing the Results section, clarified that IHA will solicit NPI lists from either POs or health plans. In the Who We Measure and Computing the Results sections, specified that primary care physicians (MDs and DOs), including internists, family practitioners, GPs and pediatricians, will be the basis of the denominator for assigning credit. P4P Meaningful Use of Health IT Posted 12/11/14 Question: The first bullet of the September Updates on page 154 of the MY 2014 P4P Manual states, Starting in MY 2014, the use of a survey tool for collecting the Meaningful Use of Health IT (MUHIT) domain will be discontinued; POs will be assessed based on data publicly available from the CMS Medicare and Medi-Cal Meaningful Use Incentive programs. Only participation in these incentive programs will count as credit for the P4P MUHIT domain. Is this correct? Answer: Yes. Starting in MY 2014, self-reporting POs are no longer expected to complete a survey to receive credit for Meaningful of Use of Health IT. Participation in Meaningful Use will be assessed by P4P staff using publicly available files from CMS Medicare and Medi-Cal Meaningful Use Incentive Programs. P4P staff will solicit provider NPI lists from all POs in order to assign credit.

10 P4P Annual Monitoring for Patients on Persistent Medications (MPM) Posted 10/15/14 Question: The measure updates on page 43 of the MY 2014 P4P manual state that the numerator specifications for ACE/ARB, digoxin and diuretic rates no longer allow a blood urea nitrogen therapeutic monitoring test to count as evidence of annual monitoring. On page 45, numerator specifications for ACE/ARB state, At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Numerator specifications for digoxin state, At least one serum potassium, at least one serum creatinine and at least one serum digoxin, and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Answer: Numerator specifications no longer allow a blood urea nitrogen test. Incorrect references to blood urea nitrogen therapeutic monitoring were inadvertently left in the P4P MPM measure specifications and should be removed. This update will be made in the December release of the MY 2014 P4P manual. P4P Osteoporosis Management in Women (OMW) Posted 10/15/14 Question: The OMW measure s Osteoporosis Medications Value Set varies from HEDIS. HEDIS includes the HCPCS code J1000; the P4P measure does not include the code. Which value set should we use for the MY 2014 P4P OMW measure? Answer: The HCPCS code J1000 was deleted from the Osteoporosis Medications Value Set (refer to the HEDIS Volume 2 Technical Update memo released October 1, 2014, at The update aligns the HEDIS OMW value sets with the September release of the P4P OMW value sets. We included these updates in the September release of MY 2014 P4P to reduce the edits that P4P organizations must apply with the December release.

11 P4P Chlamydia Screening in Women (CHL) Posted 10/15/14 Question: There is a discrepancy in the Sexual Activity Value Set between HEDIS 2015, released July 1, 2014, and the MY 2014 P4P Manual released September 2, The codes appear to relate to a change in the HEDIS value sets (page 89 of the HEDIS 2015 Technical Specifications manual): Revised value sets used for event/diagnosis criteria to ensure that supplemental data (e.g., LOINC codes) are not used to identify the denominator. Deleted Pregnancy Tests Value Set and Chlamydia Tests Value Set from the event/diagnosis criteria and added appropriate (e.g., CPT, UB Revenue) codes from these value sets to the Sexual Activity Value Set. The September 2 release of MY 2014 P4P Manual for measure CHL states that there are no modifications from HEDIS. The following codes are in the HEDIS Sexual Activity Value Set and are not in the IHA P4P Sexual Activity Value Set : CPT codes: 81025, 84702, UBREV code P4P also includes the Pregnancy Tests Value Set in the denominator; HEDIS 2015 removed this value set and uses it only in the optional exclusions. Answer: You are correct: The draft P4P manual states that there are no modifications from HEDIS. The differences you see are the result of anticipated P4P changes and updates to the Volume 2 CHL measure, per the HEDIS 2015 Volume 2 Technical Update released on October 1, 2014, at The HEDIS technical update changes aligns the HEDIS CHL measure specifications and value sets with the September release of the P4P CHL measure and value sets. We included these updates in the September release of MY 2014 P4P to reduce the edits that P4P organizations must apply with the December release.

12 P4P Evidence Based Cervical Cancer Screening (ECS) Posted 10/15/14 Question: The wording and example for the cervical cytology and HPV co-test date range do not match. The example (pages of the MY 2014 P4P manual) states, if the service date for cervical cytology was December 1 of the measurement year, then the HPV test must include a service date on or between December 1 and December 5 of the measurement year. If the date range can be four days prior to or four days after, the example should read, if the service date for cervical cytology was December 1 of the measurement year, then the HPV test must include a service date on or between November 27 and December 5 of the measurement year. Answer: Your example is correct. We will amend the example in the specifications for the final release of the P4P manual on December 1, For P4P reporting, the cervical cytology and HPV test dates must be four days or fewer apart during the measurement year or the four years prior to the measurement year. We do not specify that the date of the HPV test must be after the cervical cytology test; if cervical cytology is four days or less after an HPV test, it is acceptable. P4P Diabetes Care (CDC) Posted 10/15/14 Question: In the CDC measure (page 64 of the P4P manual), the ED Value Set was added to the Event/diagnosis section s two-visit category. The ED Value Set is also listed for the single-visit category. The logic for identifying members with diabetes for CBPH (page 48 of the P4P manual) does not list a single ED visit as a way to identify a member with diabetes. Should the logic be the same in CDC and CPBH? If so, which is correct? Answer: The logic for identifying a member with diabetes should be the same in CDC and CBPH: At least two ED visits are needed. The bullet on page 64 of the P4P manual was inadvertently placed in the Event/diagnosis section. The specification should read: Claim/encounter data. Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years): At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), ED visits (ED Value Set) or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits. At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set). This change will be reflected in the December release of the MY 2014 P4P Manual.

13 P4P General Guidelines Posted 9/15/14 Question: In the draft MY 2014 P4P Manual published in September 2014, there is no mention of whether to apply a 14-day rule to administrative data for numerators that require more than one service. It does mention to apply this rule in the new HbA1c 2 tests numerator for Diabetes Care. Should we apply this to CIS and HPV for P4P, as we will do for HEDIS 2015? Answer: The 14 day rule was added to the CDC specification because P4P had not adopted HEDIS 2015 General Guideline 44 for the September release of the MY 2014 P4P Manual. The guideline will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, This guideline, like HEDIS, will also apply to the CIS and HPV P4P measures, along with the Two HbA1c Tests indicator in the CDC measure. P4P General Guidelines Posted 9/15/14 Question: Should the change to the logic from HEDIS 2015 General Guideline 41 also be applied to IHA measures that require results from the most recent test? Answer: Yes. HEDIS 2015 General Guideline 41 will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, The guideline, like HEDIS, will apply to the CDC HbA1c control indicators. P4P Evidence-Based Cervical Cancer Screening (ECS) Posted 9/15/14 Question: The MY 2014 ECS update reads, Clarified that the lower age threshold in step 3 of Rate 1, step 2 of Rate 2 and step 3 of Rate 3, to account for the look back period, should be 33 instead of 30. Why does age 30 continue to be used in Rates 1, 2 and 3? In the Administrative Specification, Rate 1, step 3 reads, For women years as of December 31 of the measurement year Answer: The age band for this measure was not changed; the language and age referenced in the steps were clarified to account for the look-back period. For the steps pertaining to the cervical cytology and HPV co-tests, because a woman must have been 30 years or older on the date of both tests, and the tests must have been performed in the third or fourth year prior to the measure year, look only at women 33 and older. This change was inadvertently left out of Rate 1, step 3. The final release of the MY 2014 P4P Manual on December 1, 2014, will contain the correct language. For the descriptions of Rates 1, 2 and 3, however, the age bands have not changed; the measure aligns with current guidelines and looks at women years of age.