Quality measures were intended for a general adult population that may not always be appropriate for those with limited life expectancy or advanced illness and frailty.

To address this, NCQA implemented exclusions across select HEDIS measures to help focus on the patients who are most likely to benefit from measured services. We created a process alert to assist with adding appropriate diagnosis for these patients.

An alert was added in NextGen to display for users to review frailty diagnosis codes when an Advanced Illness diagnosis is documented.

Patients need at least 2 diagnoses of frailty on different dates of service in a calendar year to be excluded from certain quality measures below.

This alert will ONLY appear with the following criteria:

• Member is 66 to 80 years old.
  • Members ages 81 and older as of Dec 31 of the measurement year only need 2 frailty codes.
• Encounter is billable.
• An advanced illness diagnosis code is selected when entering diagnosis codes on the Assessments template.
  • For example - Malignancy OR Heart failure
• Two frailty codes have not been coded yet in a calendar year.

In Assessment, if the above applies, you will see:

When you click on the blue info button to the right, you will see your patient will be excluded from the following measures:

To clear the alert, please review the frailty codes and code if applicable:

If nothing applies, click save & close and the check box will be marked as reviewed. 

Note - If the check box remains unchecked, you will be unable to proceed.