Post on 27-May-2015
PCP Cluster Meeting:Keeping You in the Loop
November 13, 2013Dolce Vita, Monroe MI
Tonight’s Focus
Medicare Correct Coding Initiative Choosing Wisely Campaign Advance Care Planning Patient-Centered Medical Home Blue Cross
designation and national accreditation Patient-Centered Medical Home-Neighborhood Organized System of Care and Accountable Care
Organization
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Optimizing Risk Adjustment, Risk Scoring and Stars
MEDICARE ADVANTAGECMS Risk Adjustment
Why Care About Risk Adjustment?
• Compliance with CMS submission requirements
• Improve Care Management services
• Receive proper reimbursement from CMS to keep premiums as low as possible and improve the health of the Michigan economy
• The projection of CMS funding directly impacts Medicare Advantage premiums
• A 1 percent improvement in risk scores can lower member premiums by roughly 10 percent
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Risk Adjustment: Basic Demographics
Risk score uses five demographics:
• Age (member is 72 years old)
• Gender (member is female)
• Medicaid (member does or does not have an active Medicaid status)
• Disability (member is or is not classified by CMS as disabled)
• Original reason for Medicare status (ESRD?)
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CMS Risk Burden
Hierarchical condition category (CMS – HCC) model
• Begins with classification of 14,000 ICD-9CM diagnosis codes
• Maps each ICD-9 to one of 805 diagnostic groups (DXGs)
• DXGs aggregated into 189 Condition Categories (CC)
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CMS Risk Burden
Hierarchical condition category (CMS – HCC) model
• Each Chronic Condition describes broader set of similar diseases
• CMS uses 79 of 189 HCCs to best predict Medical expenditures
• CMS imposes hierarchies among related Condition Categories (person is coded for only the most severe manifestation among related diseases)
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Risk Adjustment Medical Record Documentation
• Providers must have medical record documentation to support chronic conditions
• Each diagnosis must conform to the ICD-9 coding guidelines
• The medical chart must document that the condition was:− Managed− Evaluated− Assessed− Treated
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Risk Adjustment Medical Record Documentation
• The medical chart must document that the condition was− Managed− Evaluated− Assessed− Treated
• Only one is necessary
• The M.E.A.T. documentation on actively treated conditions must be on the date of service. Document other chronic conditions present at least annually
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CMS Risk Adjustment Physician Records
The diagnosis code: result of a face-to-face visit with a physician, nurse practitioner or physician assistant from an inpatient, outpatient or professional provider encounter
Medical records have to support a currently treated or addressed condition and be signed, credentialed and dated by the appropriate provider
Although claims can be used as a proxy to submit a diagnosis code to CMS for risk adjustment purposes, the medical record is the only source of truth
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Acceptable Physician Specialties and Providers
Addiction Medicine Family PracticeAllergy/Immunology GastroenterologyAnesthesiology General PracticeAudiologist General SurgeryCardiac Surgery Geriatrics/GerontologyCardiology GynecologistCertified Clinical Nurse Specialist Hand SurgeryCertified Nurse Midwife HematologyCertified Registered Nurse Anesthetist Hematology/OncologyChiropractic Infectious DiseaseClinical Psychologist Internal MedicineColorectal Surgery Interventional RadiologyCritical Care Licensed Clinical Social WorkerDermatology Maxillofacial SurgeryEmergency Medicine Multispecialty Clinic or Group PracticeEndocrinology Continued…
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Unacceptable Provider Types
Registered Nurse Licensed Practical/Vocational Nurse (LPN/LVN) Speech Language Pathologist (SLP) Pharmacist
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Acceptable Physician Signatures
Purpose of the Physician Signature• For risk adjustment data submission and validation, the
provider of the face-to-face encounter must be properly identified on the medical record by name, signature and credentials
CMS Provider signature requirement: three specific provider signature elements must be present:
• Full, legible name or initials• Acceptable provider credentials• Either a handwritten signature or electronic
authentication
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Acceptable Physician Signatures
Signature stamps are not acceptable as of 09.03.2007
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Acceptable Electronic Physician Signatures Approved by Digital signed Signature on file
Authenticated by Digitally reviewed and approved
Signed, but not meticulously reviewed
Approved electronically Digitally signed Status signedAuthorized by Electronic signature verified Signed by
Authorizing provider Electronically authenticated Validated by
Automatic authentication Electronically signed by Verified by
Closed by Electronically verified Signature
Completed by Entered data sealed by Manually signed byCo-signed Finalized by Confirmed byDictated and authenticated Reviewed by Sealed byDictating provider if initialed by doctor
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Unacceptable Electronic Physician Signatures
Added by/Amended by Initiated by Rendered by
Author Interpreted by Signed out by proxy
Created by Last generated by Status preliminary
Dictated by Marked as primary doctor To be electronically authenticated
Documentation generated by Marked by To be signed
Documented by Performed by Transcribed by
Entered by Provider/provider of service Unauthorized
E-scription Recorded by
I, the undersigning provider, identify the patient
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Authentication Table (Electronic)Elements Acceptable Unacceptable
Acceptable authentication and provider name with credentialsExample:
X
Unacceptable authentication, and provider name with credentialsExample:
X
Unacceptable authentication, without provider name and/or credentials X
Unsigned encounter note X
Authentication Table (Electronic)(Not all Inclusive)
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Markus Welby, MD
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Acceptable Provider Credentials
Adult Nurse Practitioner = ANP Doctor of Osteopathy = DO
Adult Registered Nurse Practitioner = ARNP Doctor of Podiatry = DP
Advanced Practice Registered Nurse = APN Family Nurse Practitioner = FNP
Certified Clinical Nurse specialist = CCNS Geriatric Nurse Practitioner = GNP
Certified Nurse Midwife = CNM Licensed Clinical Social Worker = LCSW
Certified Nurse Practitioner = CNP Medical Doctor = MD
Certified Registered Nurse Anesthetist = CRNA Nurse Practitioner = NP
Certified Registered Nurse Practitioner = CRNP Occupational Therapist = OT
Clinical Nurse Specialist = CNS Physical Therapist = PT
Dentist = DDS Physicians Assistant = PA
Doctor of Optometry = OD
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Missing Digits and Undercoding on ClaimsReal examples of potential lost revenue due to incomplete coding of claims or documentation
Diagnosis Specificity
Claims Actual
ICD-9 Description HCC Revenue ICD-9 Description HCC Revenue
250.00 Diabetes without complications 19 $1,133 250.42 Diabetes with Chronic Complications
18 $3,533
493.00 493.20 COPD 111 $3,322
Total Annual Revenue $1,133 Total Annual Revenue $6,855
Under Coded Claim
Claim Documentation
ICD-9 Description HCC Revenue ICD-9 Description HCC Revenue
250.00 Diabetes without complications 19 $1,133 250.42 Diabetes with Chronic Complications
18 $3,533
585.4 Chronic Kidney Disease Severe (Stage 4)
137 $2,150
Total Annual Revenue $1,133 Total Annual Revenue $5,683
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Risk Adjustment Case Study
85 year old female, symptoms of UTI Patient is tired, less energy and poor appetite with
history of MI one year ago. She has mild malnutrition, is frail and has lost 30 lbs in the past six months. Urinalysis performed shows white cells, leukocyte esterase and microalbuminuria. Serum creatinine is 1.4. Patient has been complaining of urinary discomfort, weakness, and has had dry and itchy skin for the past six months.
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Risk Adjustment Case Study
PMH: Stable diabetes mellitus (DM), chronic kidney disease (CKD) exacerbated by diabetes, stable BKA, stable history of MI, UTI w/serum creatinine 1.3 six months ago. Lab findings revealed CKD stage 4
Plan: Glucophage 500 mg b.i.d. for DM. Cipro for UTI. Ensure supplements for malnutrition. RTC in three months. Referral to nephrologist for CKD4
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Risk Adjustment Case Study
Scenario 1 – What would actually be coded and reported by many physicians
Condition ICD-9 Code
CMS Risk Score
Demographic Score
Total RAF Score
Total Payment$800 (Illustrative
Purposes) x RAF Score
Diabetes Mellitus
250.00 0.118 0.677 0.795 - 0.0826**
UTI 599.0 0.0 0.7124 $569.92
Scenario 2 – What can be coded and reported by the physician
Diabetes Mellitus w/Renal Manifestations
250.40 0.368 0.677 2.761 - 0.2869** 2.4741
$1,979.28
UTI 599.0 0.0
Diabetic Nephropathy
583.81 0.0
CKD Stage 4 585.4 0.224
Mild Degree Malnutrition
263.1 0.713
Old MI 412 0.0
BKA Status V49.75 0.779 22
Data provided reflects 2014 payment year for 2013 dates of service.**Includes CMS normalization and coding intensity factors that reduce RAF scores.
Payment = Plan’s Base Payment x Total RAF Score
STAR BONUS PROGRAM
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STAR Quality Program
Driven by Health Care Reform A government report card of Medicare Advantage
Programs A pay for performance program Fifty-three metrics are measured
• 36 Part C medical measures• 17 Part D pharmacy measures
By 2014, all Medicare Advantage Plans must be a 4 Star or lose bonus capabilities for 2015
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Measures Fall into Four Categories
HEDIS (Health
Effectiveness Data and
Information Set)
CMS administrative
measures
CAHPS (Consumer
Assessment of Healthcare
Providers and Systems)
Health Outcomes Survey
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70% of scores are related to quality and service by physicians
New Preventive Services
Welcome to Medicare exam Annual wellness exam Personalized prevention plan with advice,
screening schedules, referrals, education based on health situation
Bone mass measurement for osteoporosis
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New Preventive Services
Colorectal cancer screening (colonoscopy) Immunizations including flu shots, pneumonia Mammograms Prostate screening Face-to-face behavioral counseling for obesity Annual alcohol misuse screening and brief face-to-
face behavioral counseling for alcohol abuse Annual depression screening
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Six Things to Remember
No rule outs Appropriate signatures Supportive documentation of diagnosis Face-to-face visit STAR measurements
New CPT codes for transitions of care and also Advance Directives (S0257) in 2014
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Advance Care :Starting the Conversation
Learning objectives
Define advance care planning and explain its importance
Describe the steps of the advance care planning process
Describe the role of patient, proxy, clinician, and others
Identify pitfalls and limitations in advance care planning
What is advance care planning?
A communication process rather than a legal process
A way of planning for future medical care A mechanism for ensuring that care received
matches patient’s values and goals
Why is advance care planning important?
Some patients have an unpredictable course of illness
Builds trust Helps to avoid confusion and conflict Permits peace of mind
Concepts underlying advance care planning
Advance directive Health care agent or proxy Do not resuscitate (DNR) orders Patient Self Determination Act
5 steps for successful advance care planning
1. Introduce the topic
2. Structure the discussion
3. Document patient preferences
4. Review and update when clinical course changes
5. Apply directives when need arises
The EPEC Project, 1999, www.epec.net
Step 1: Introduce the topic
Allow adequate time and privacy Ask what the patient knows: “Have you thought
about having a living will?” Explain the process: “It’s helpful for us to talk
about it before making any decisions.”
Determine comfort level: “Do you feel ready to
talk more about this today?”
Step 2: Structure the discussion (Five Wishes) Who do you want to make health care decisions
for you when you can't make them [proxy]? What kind of medical treatment do you want or
don't want? How comfortable do you want to be? How do you want people to treat you? What do you want your loved ones to know?
www.agingwithdignity.org
Use an advance care planning document
A number are available:• Five Wishes• Living Wills
Easy to use Reduces chance for omissions Patients, proxy, family can take home
Step 3: Document patient preferences Review advance directive Sign the documentation Put it in the patient’s chart or medical record Encourage patient to have copies to provide to
different medical settings• Proxy may assist with this
Step 4: Review, update
Use clinical events as triggers to review documents As disease progresses, allow for evolution in
patient understanding and preferences Discuss and document changes
Step 5: Apply directives when indicated
Review the advance directive Consult with the proxy Use ethics committee for disagreements Carry out the treatment plan
Pearls
Advance care planning can reduce family burden Family members may not be the best proxies Focus on what kind of care is desired rather than
what should be withdrawn
Summary
Advance care planning is a fundamental palliative care skill
Advance care planning reduces family burden at end-of-life
The identification of the proxy is an important goal The discussion is more important than the
documents
POLST
It’s a Conversation
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Learning Objectives
· Define POLST and why it is important
· Describe the POLST form
· How do illustrate how to complete a POLST
Why POLST?
· Patient wishes often are not known– The Advance Healthcare Directive (AHCD) may not
be accessible
– Wishes may not be clearly defined in AHCD
· Allows healthcare professionals to know and honor your wishes for care.
POLST Conversations
· Focus is on the conversation
· It is important to talk about and document your wishes before you become seriously ill
What is POLST?
· Doctor’s order recognized by the entire medical system
· Portable document that goes with the patient
· Brightly colored, standardized form for entire state
· Allows individuals to choose medical treatments they want to receive, and identify those they do not want
· Provides direction for healthcare providers during serious illness
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Who Would Benefit from Having a POLST Form?· Chronic, progressive illness
· Serious health condition
· Medically frail
POLST History
· POLST development began in Oregon in 1991
· Expanded to more than half of US
· Studies have shown that POLST is effective in providing care that is consistent with patient wishes
Developing Programs
*As of January 2011
National POLST Paradigm Programs
Endorsed Programs
No Program (Contacts) Desi
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What about Michigan?
The Michigan Coalition for Honoring Healthcare Choices has created a version of the POLST that is referred to as a MI-POST
Began in 2011 after the "Michigan Commission on End of Life Care" endorsed the POLST program and recommended that such a program start in Michigan
Piloted in Jackson, Traverse City and Escanaba
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More about Michigan…
Michigan program follows an Oregon program October 2012 draft, four classes of patients are
considered eligible for a Michigan POST:• Seriously ill patients with advanced illness• Frail patients with significant weakness and
difficulty with their activities of daily living• Patients who may lose their mental capacity within
the next year• Persons with strong feelings about end of life care
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POLST in California
Effective January 1, 2009
POLST in California
· One form for entire state
· Use not mandated
· Honoring form is mandated
POLST vs. Advance Healthcare Directive· POLST complements the Advance Healthcare
Directive (AHCD)· POLST does not replace Advanced Healthcare
directives· Both are legal documents
Where Does POLST Fit In?
Advance Care Planning Continuum
Complete an Advance Directive
Complete a POLST Form
Age 18
End-of-Life Wishes Honored
Diagnosed with Serious or Chronic, Progressive Illness (at any age)
Update Advance Directive Periodically
C O N V E R S A T I O N
How Does a Patient Complete a POLST?
· Talk to your doctor about what kind of medical treatment you would want if you became seriously ill
· Talk to your doctor about POLST
· Talk to your family about your decisions
Can POLST be Changed?
· You can change your POLST at any time
· If you cannot speak for yourself, your healthcare decision-maker may request change based on the known desires of the individual
Getting the most from your health care
New resources for you and your family
More doesn’t equal better
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Up to 30% of health care in the U.S. is unnecessary
30%
70%
About the Choosing Wisely® campaign
Initiative of ABIM Foundation
Trusted resources—including more than 30 national medical organizations and Consumer Reports
Choosing Wisely encourages conversations between patients and physicians
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Read more about the campaign at http://consumerhealthchoices.org/campaigns/choosing-wisely
You can get better care when you know more
Being informed helps you make smarter choices:
• The right care• Better results
Many tools and resources help you understand options for medical care
Use Choosing Wisely and Consumer Reports resources to help you get started
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Consumer Reports resources
Tip sheet series
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To read, watch or download, visit http://consumerhealthchoices.org
Video series
Your relationship with your doctor is key
It is a partnership
Come prepared to your visits
• Medications
• List of questions
• Paper and pen
• Bring a family member or friend
Talk to your doctor—speak up!
• Ask questions
• Get clarification 65
Don’t be afraid to say “Whoa!”
Ask questions:• Do I really need this test or procedure?• What are the downsides?• Are there simpler, safer options?• How much does it cost?
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Imaging and screenings
Know the facts How does it relate to your symptoms, care or
disease Share your results with your doctor
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A little prevention goes a long way
Lifestyle choices have the largest impact on your health
Taking care of yourself prevents health problems and saves you money
Simple actions
• Maintain a healthy weight
• Pay attention to how you feel
• Take action when you sense something is wrong
• Get regular health care checkups and screenings 70% of diseases are preventable
70%
30%
Tips and Resources
See the full set of Choosing Wisely and Consumer Reports employee resources at
http://consumerhealthchoices.org
PCMH
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Principle Partner Agreements
What does it mean? What problems has MNO encountered? How can the PCP and the practice team help? Can a Specialist belong to many organizations? Can a behavioral health specialist and chiropractor
join?
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PCMH-Neighborhood
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Organized System of Care: MichCare
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