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2024 PCMH Annual Reporting Requirements

Time to Ditch the Crystal Ball, PCMH Heroes! Here’s Your Future in Focus

Forget gazing into murky glass spheres – NCQA just handed you a high-definition telescope to identify your PCMH Annual Reporting (AR) requirements! With the updated 2024 AR requirements in full effect, we want to ensure you understand the new standardized measures reporting requirement and best practices when preparing to report.  

Key Changes for 2024: Stats Speak Louder Than Words 

The 2024 update isn’t just about buzzwords; it’s packed with concrete changes backed by hard data: 

  • Standardized Measures Reporting: You are now required to select standardized measures relevant to your practice, ensuring consistency and comparability from these different categories: 
    • Immunizations Measures 
    • Preventative Medicine Measures 
    • Behavioral Health  
    • Chronic or Acute Care Measures 
    • Care Coordination 
    • Health Care Costs 
  • Full calendar year data: You will have to submit data for the entire calendar year (January 1st to December 31st) no matter your annual reporting date. This means even if your annual reporting deadline is 12/1/24 you will have to provide 2023 quality data.  
  • Exceptions for specific circumstances: 
    • Pediatric practices and situations with data collection challenges may have alternative reporting options. 
      • In the event that no measures within a measure category are relevant to your patient population, please submit a case to NCQA detailing why. Also include the measure name and the numerator and denominator descriptions of the custom measure the practice would like to submit for consideration. 

Navigating the Upgrade: Practical Steps to Success 

Step 1: Choosing Your Measures  

Each practice will select measures based on their patient population that fall into each one of the different categories, including one repeat category. These are the specific areas NCQA wants to see your data on. Don’t worry, you won’t be flying blind – we are here to provide you a list of which eCQMs are included under each category:  

Behavioral Health 

  • CMS 161 Adult Major Depressive Disorder: Suicide Risk Assessment​ 
  • CMS 177 Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment​ 
  • CMS 159 Depression Remission at Twelve Months​ 
  • CMS 2 Screening for Depression and Follow-Up Plan​ 
  • CMS 137 Initiation and Engagement of Substance Use Disorder Treatment​ 
  • CMS 128 Anti-depressant Medication Management​ 
  • CMS 136 Follow-Up Care for Children Prescribed ADHD Medication​ 

​Preventive Care 

  • CMS 125 Breast Cancer Screening​ 
  • CMS 124 Cervical Cancer Screening​ 
  • CMS 153 Chlamydia Screening in Women​ 
  • CMS 130 Colorectal Cancer Screening​ 
  • CMS 139 Fall: Screening for Future Fall Risk​ 
  • CMS 349 HIV Screening​ 
  • CMS 69 Body Mass Index Screening and Follow-Up Plan​ 
  • CMS 22 Screening for High Blood Pressure and Follow-Up Documented​ 
  • CMS 155 Weight Assessment and Counseling for Nutrition and Physical Activity for Children​ 
  • CMS 138 Tobacco Use: Screening and Cessation Intervention​ 


  • CMS 117 Childhood Immunization Status: Combination 10​ 
  • CMS 127 Pneumococcal Vaccination Status for Older Adults​ 
  • CMS 147 Influenza​ 

Chronic or Acute Care​ 

  • CMS 165 Controlling High Blood Pressure​ 
  • CMS 149 Dementia: Cognitive Assessment​ 
  • CMS 131 Diabetes Eye Exam​ 
  • CMS 122 Diabetes HbA1C Poor Control ​ 
  • CMS 347 Statin Therapy for Presentation and Treatment of Cardiovascular Disease​ 

Health Care Cost​ 

  • CMS 146 Appropriate Testing for Pharyngitis​ 
  • CMS 154 Appropriate Treatment for Upper Respiratory Infection​ 

Care Coordination​ 

  • CMS 50 Closing the Referral Loop​ 
  • CMS 68 Documentation of Current Medications 

Step 2: Gathering Your Data 

Each measure will have specific instructions on how to collect and format the data. Some might require pulling information from your electronic health records, while others may involve analyzing surveys or administrative data. Be thorough, accuracy is key! 

Step 3: Getting Ready for Q-PASS  

Log in to Q-PASS using your My NCQA account. You’ll find everything you need to: 

  • Enroll in Annual Reporting: Tell NCQA you’re ready to play. 
  • Pay the Recognition Fee: This part is required to continue recognition!  
  • Upload Your Data: Drag and drop those files! 
  • Track Your Progress: See how your submission is going, step-by-step. 

Step 4: Reporting Deadlines and Extensions  

Remember that 30-day deadline before your recognition expiration date? Aim for that, but don’t panic if things get tricky. NCQA allows extensions under certain circumstances (think technical glitches or data delays). Just contact NCQA and explain your situation. 

Step 5: The Final Frontier: NCQA Review and Recognition 

Once you’ve submitted your data, NCQA takes over. They’ll review your submission and let you know if you’ve maintained recognition. Keep an eye on your inbox and Q-PASS for updates. If anything needs clarification, NCQA will reach out for more information.  

Embrace the Future of Healthcare: Best Practices from the Experts!  

Here’s your cheat sheet to rock the 2024 PCMH AR updates: 

  • Stay Informed: Dive into the updated AR requirements and see how they’ll impact your practice. 
  • Team Engagement: Get your staff on board! Their understanding and support are crucial for a smooth transition. 
  • Utilize Resources: Don’t go it alone DAS is Here to help! We immerse ourselves into PCMH and the NCQA’s materials and programs. We even have our very own PCMH CCE!  
  • Celebrate the Wins: Change can be challenging, so acknowledge your progress and reward your team along the way. 

Annual Reporting isn’t just about paperwork and reporting; it’s about ensuring the continuation of a healthcare landscape that’s data-driven, patient-centered, and downright transformative.  

Resources Galore: DAS Health Has Your Back 

As a valued partner in healthcare, we understand the importance of maintaining your Patient-Centered Medical Home (PCMH) recognition and can help support your efforts if you need.  

Why Choose Our Annual Reporting Assistance: 

  1. Expert Guidance: Our team of seasoned healthcare professionals is well-versed in the PCMH standards set by the National Committee for Quality Assurance (NCQA). We even have our very own PCMH certified content expert or CCE. We provide expert guidance to ensure your practice aligns seamlessly with these standards. 
  1. Streamlined Documentation: We assist you in compiling and organizing the necessary data and documentation for your PCMH Annual Reporting. Our goal is to simplify the process, saving you time and effort. 
  1. Quality Improvement Strategies: Beyond meeting the requirements, we collaborate with your practice to identify areas for continuous improvement. Our strategies are designed to enhance patient-centered care and overall practice performance. 
  1. Timely Submission: We understand the importance of meeting deadlines. With our support, you can rest assured that your Annual Reporting will be submitted accurately and on time. 

Don’t let the Annual Reporting process become a daunting task especially with the new requirements related to standardized measures reporting. Partner with us to navigate the complexities and provide an organized and efficient reporting strategy. 

 To learn more about our Annual Reporting Assistance Program and how it can benefit your practice, please reach out to our team. We are here to address any questions you may have.