Administrative bulletin: 2026-05-003 Quality information

Professional and facility Providers

Breast Cancer Screening (BCS)

KEY POINT: Breast cancer is the most common cancer among U.S. women (excluding some skin cancers). Providers should routinely recommend and ensure mammography for patients ages 40–74 as screening saves lives, expands treatment options, and lowers overall health care costs.

Best practices:

• Utilize Theon™ for open gap reports, to manage returned records, and supplemental data submissions.
• Submit the appropriate ICD-10 diagnosis code for a history of bilateral mastectomy or any of the other exclusionary codes, as this is an administrative measure.
• Contact your Population Health Consultant for questions or concerns.

Exclusions:

• Members who died during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
• Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
• Living long-term in an institution any time during the measurement period.
• Members 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
• Frailty. At least two indications of frailty with different dates of service during the measurement period.
• Advanced illness. Either of the following during the measurement period or the year prior to the measurement period:
• Advanced illness on at least two different dates of service.
• Dispensed dementia medication.
• Members who had a bilateral mastectomy or both right and left unilateral mastectomies any time during their history through the last day of the measurement period.
• Any combination that indicates a mastectomy of both the left and right sides on the same date of service or different dates of service.
• Gender-affirming chest surgery with a diagnosis of gender dysmorphia at any time in the member’s history through the end of the measurement period.

Resources:

Breast Cancer Screening (BCS) - NCQA

Cervical Cancer Screening (CCS)

KEY POINT: Cervical cancer is the fourth most common cancer in women and other people with a cervix globally. Providers should recommend and deliver routine screening to detect precancerous changes early, when treatment can stop cancer before it starts.

Population-based screening, applied to asymptomatic average-risk individuals, remains the core of prevention and focuses on the risk of high-grade cervical precancers and cancers.

Description:

This measure evaluates the percentage of members 21-64 years of age who were recommended for routine cervical cancer screening. Screening for cervical cancer falls within one of the three criteria:

• Members 21–64 years of age who were recommended for routine cervical cancer screening and had cervical cytology performed within the last 3 years.
• Members 30–64 years of age who were recommended for routine cervical cancer screening and had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
• Members 30–64 years of age who were recommended for routine cervical cancer screening and had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years.

Best practices:

• Always include dates of service, specific test names, and results in the medical record.
• Educate members that cervical cancer screenings are covered preventive services.
• Utilize Theon™ for open gap reports, to manage returned records, and supplemental data submissions.
• Maintain documentation for history of total hysterectomy (TAH or TVH), or radical abdominal or vaginal hysterectomy and bill ICD-10 codes for any of the following:
• Acquired absence of both cervix and uterus, cervix with remaining uterus, or agenesis and aplasia of cervix.
• Documentation of a “hysterectomy” alone will not meet the intent of the exclusion.

Exclusions:

• Members who died during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Persons with a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix anytime during the members’ history through December 31 of the measurement year.
• Persons with sex assigned at birth of male.

Resources:

Cervical Cancer Screening - Cervical Cancer Screening - PubMed, Cervical Cancer Screening - NCI;

Cancer.gov Cervical Cancer Screening (CCS) - NCQA

Depression screening

KEY POINT: Depression is a leading cause of disability worldwide and increases the risk of chronic conditions like heart disease and diabetes. Screen all patients age 12 and older at least once per measurement period to identify depressive disorders that can affect the most vulnerable populations.

Measure description:

For all patients aged 12 years and older, a depression screening is required once per measurement period, not at all encounters. An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record.

• This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative.
• Each standardized screening tool provides guidance on whether a particular score is considered positive for depression.
• The depression screening must be reviewed and addressed by the provider on the date of the encounter.
• The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter.

Screening and follow-up

A depression screen is completed on the date of the encounter or up to 14 calendar days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of, or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression.

• For example: If the encounter is on Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through Wednesday (day 2) to complete follow-up plan documentation.
• The follow-up plan MUST still be provided and discussed with the patient during the qualifying encounter.

Documented follow-up for a positive depression screening must include one or more of the following.

• Referral to a provider for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen.
• Pharmacological interventions.
• Other interventions or follow-up for the diagnosis or treatment of depression.

Examples of standardized depression screening tools include, but are not limited to:

• Adolescent Screening Tools – (12-17 years) Patient Health Questionnaire (PHQ-9), (PHQ-2)
• Adult Screening Tools – (18 years and older) Patient Health Questionnaire (PHQ-9), (PHQ-2)

Exceptions:

• Patient Reason(s): Patient refuses to participate in or complete the depression screening. OR
• Medical Reason(s): Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence, and to delay treatment would jeopardize the patient’s health status).

Best practices:

• Scheduling patient follow-up appointments for medication management.
• Reminding patients of their appointments.
• Educating members on the importance of medication adherence, side effects, benefits of the medication, the expected time required for a medication to begin to take effect, and the risks of stopping their medication.
• Encourage the member to sign a release of information for all treating providers.
• Communicate with other providers involved with the member’s treatment to ensure continuity and coordination of care to support a whole-person approach.
• Ensure appropriate documentation, accurate coding, and submit claims in a timely manner.

Resources:

Cancer.gov Quality ID #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Follow-up After Emergency Department Visit for Patients with Multiple High-Risk Chronic Conditions (FMC)

KEY POINT: Providers are encouraged to conduct and document follow up service within 7 days of the ED visit (8 total days, including same day visits) for members 18 years of age and older who have multiple high-risk chronic conditions. Tips and best practices for the FMC measure are outlined below.

The HEDIS^® measure evaluates the percentage of emergency department (ED) visits, on or between January 1 and December 24, for members 18 years of age and older who have multiple high-risk chronic conditions and who had a follow-up service within 7 days of the ED visit, including visits that occur on the date of the ED visit (8 total days).

Measure specifications:

Administrative only HEDIS^® measure. Medicare Star measure weight: 1.

Members who have been diagnosed with at least two of the following chronic conditions are included in this measure. (For example, COPD and asthma are considered the same chronic condition):

• COPD, asthma, or unspecified bronchitis.
• Alzheimer's disease and related disorders.
• Chronic kidney disease.
• Depression.
• Heart failure.
• Acute myocardial infarction.
• Atrial fibrillation.
• Stroke and transient ischemic attack.

The following meet criteria for follow-up:

• Outpatient visit, telehealth, or telephone visit.
• E-visit or virtual check-in.
• Transitional care-management services, case management visits, complex care management services.
• Outpatient or telehealth behavioral health services.
• Electroconvulsive therapy.
• Community mental health center visit.
• Intensive outpatient encounter or partial hospitalization.
• Substance use disorder service.
• Physician, Physician Assistant, Registered Nurse, Licensed Practical or Vocational Nurse, or Medical Assistant can conduct telephone visits.

Theon™ documentation requirements:

This measure is currently not available for supplemental data submission in Theon™.

Exclusions

Patients are excluded from this measure if they have any of the following:

• Had an ED visit resulting in acute or non-acute inpatient care on the day of the visit or within 7 days after the ED visit, regardless of the principal diagnosis for admission.
• Utilized hospice or hospice services in the measurement year.
• Persons with a date of death in the measurement year.

Best practices:

• Utilize FMC daily report (received via email daily from Capital).
• Utilize Admission, Discharge, and Transfers (ADT) alerts.
• Optimize electronic health record integration between ED and office.
• Evaluate workflow for timeliness of follow-up.
• Educate members and caregivers on the value of follow-up.
• Schedule follow-up on behalf of the member prior to discharge.
• Assess and address barriers: cognition, language, equity, Social Determinants of Health (SDOH), etc.
• Assess member need for additional support: Care management, Pharmacy.
• Utilize Theon™ Care Collaborator's Recent ED Visit icon on the patient panel dashboard.

Please refer to Capital’s Comprehensive Performance Measures Guide for more information related to applicable coding guidance. The guidelines will be periodically updated to include new coverage guidance.

Osteoporosis Management in Women Who Had a Fracture (OMW)

KEY POINT: To ensure timely osteoporosis care and prevent future fractures, women aged 67-85 years of age who have suffered a fracture should receive a bone mineral density (BMD) test or a prescription for a drug to treat osteoporosis within 180 days (6 months) after the fracture.

Intake Period: 12-month (one-year) window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The intake period is used to capture the first fracture.

Routes of closure: Claims or supplemental submission through Theon™

Medicare Star Measure Weight: 1

Codes Included in the Current HEDIS^® Measure

Exclusions

• Fractures of finger, toe, face, and skull are not included in this measure.
• A BMD in any setting during the 24 months prior to the date of the fracture.
• Members who, 12 months prior to the fracture:
• Had claims or encounters for osteoporosis therapy, OR
• Were dispensed prescription medication or had an active therapy to treat osteoporosis.
• Medicare enrollees, 67 years of age and older as of the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
• Enrolled in an Institutional SNP (I-SNP) any time during the intake period through the last day of the measurement period.
• Living long-term in an institution any time during the measurement period as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the intake period through the last day of the measurement period.
• Persons 67–80 years of age by the last day of the measurement period, with both frailty and advanced illness.
• Frailty. At least two indications of frailty with different dates of service during the measurement period.
• Advanced illness. Either of the following during the measurement period or the year prior to the measurement period: Advanced illness on at least two different dates of service. OR Dispensed dementia medication (Donepezil, Donepezil/Memantine, Galantamine, Memantine, Rivastigmine).
• Persons 81 years of age and older as of the last day of the measurement period, with frailty.
• Persons with at least two indications of frailty with different dates of service during the measurement period.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Members who died during the measurement year.

Theon™ documentation requirements:

• Member’s name.
• 2nd identifier (e.g., DOB).
• A 3rd identifier is required for a recent name change that does not match in Theon™. Accepted 3rd identifiers are the member's address, subscriber ID, or last 4 digits of social security number.
• Bone mineral density (BMD) test.
• Osteoporosis therapy.
• Dispensed osteoporosis medications.

Best ractices:

• Schedule members for an office visit as soon as possible after an event occurs.
• To help prevent women from being included in this measure incorrectly, please check that fracture codes are not used before a fracture has been verified through imaging.
• Utilize Theon™ for open gap reports, to manage returned records and supplemental data submissions. Use of data reports included in the clinical package had information on the members that are recoverable and non-recoverable.
• Contact your Population Health Consultant for questions or concerns.

Professional Providers only

QualityFirst Primary Care Recognition Program^SM PY2025 Final Scorecards

KEY POINT: QualityFirst 2025 Primary Care Recognition Program letters and final scorecards will be available soon.

The following information only applies to primary care providers who participate in the QualityFirst Primary Care Recognition Program.

Letters and final scorecards for Program Year 2025 will be posted on the Secure File Transfer by the end of May.