PCP Cluster Meeting Discusses Risk Adjustment, Star Ratings
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PCP Cluster Meeting Discusses Risk Adjustment, Star Ratings
- 1. PCP Cluster Meeting: Keeping You in the Loop November 13, 2013 Dolce Vita, Monroe MI
- 2. Tonightâs Focus ï¶ Medicare Correct Coding Initiative ï¶ Choosing Wisely Campaign ï¶ Advance Care Planning ï¶ Patient-Centered Medical Home Blue Cross designation and national accreditation ï¶ Patient-Centered Medical Home-Neighborhood ï¶ Organized System of Care and Accountable Care Organization 2
- 3. Optimizing Risk Adjustment, Risk Scoring and Stars MEDICARE ADVANTAGE CMS Risk Adjustment
- 4. Why Care About Risk Adjustment? âą Compliance with CMS submission requirements âą Improve Care Management services âą Receive proper reimbursement from CMS to keep premiums as low as possible and improve the health of the Michigan economy âą The projection of CMS funding directly impacts Medicare Advantage premiums âą A 1 percent improvement in risk scores can lower member premiums by roughly 10 percent 4
- 5. Risk Adjustment: Basic Demographics ï¶ Risk score uses five demographics: âą Age (member is 72 years old) âą Gender (member is female) âą Medicaid (member does or does not have an active Medicaid status) âą Disability (member is or is not classified by CMS as disabled) âą Original reason for Medicare status (ESRD?) 5
- 6. CMS Risk Burden ï¶ Hierarchical condition category (CMS â HCC) model âą Begins with classification of 14,000 ICD-9CM diagnosis codes âą Maps each ICD-9 to one of 805 diagnostic groups (DXGs) âą DXGs aggregated into 189 Condition Categories (CC) 6
- 7. CMS Risk Burden ï¶ Hierarchical condition category (CMS â HCC) model âą Each Chronic Condition describes broader set of similar diseases âą CMS uses 79 of 189 HCCs to best predict Medical expenditures âą CMS imposes hierarchies among related Condition Categories (person is coded for only the most severe manifestation among related diseases) 7
- 8. Risk Adjustment Medical Record Documentation âą Providers must have medical record documentation to support chronic conditions âą Each diagnosis must conform to the ICD-9 coding guidelines âą The medical chart must document that the condition was: Managed â Evaluated â Assessed â Treated â 8
- 9. Risk Adjustment Medical Record Documentation âą The medical chart must document that the condition was Managed â Evaluated â Assessed â Treated â âą Only one is necessary âą 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 9
- 10. CMS Risk Adjustment Physician Records ï¶ 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 ï¶ Medical records have to support a currently treated or addressed condition and be signed, credentialed and dated by the appropriate provider ï¶ 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 10
- 11. Acceptable Physician Specialties and Providers Addiction Medicine Allergy/Immunology Anesthesiology Audiologist Cardiac Surgery Cardiology Certified Clinical Nurse Specialist Certified Nurse Midwife Certified Registered Nurse Anesthetist Chiropractic Clinical Psychologist Colorectal Surgery Critical Care Dermatology Emergency Medicine Endocrinology Family Practice Gastroenterology General Practice General Surgery Geriatrics/Gerontology Gynecologist Hand Surgery Hematology Hematology/Oncology Infectious Disease Internal Medicine Interventional Radiology Licensed Clinical Social Worker Maxillofacial Surgery Multispecialty Clinic or Group Practice Continued⊠11
- 12. Unacceptable Provider Types ï¶ Registered Nurse ï¶ Licensed Practical/Vocational Nurse (LPN/LVN) ï¶ Speech Language Pathologist (SLP) ï¶ Pharmacist 12
- 13. Acceptable Physician Signatures ï¶ Purpose of the Physician Signature âą 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 ï¶ CMS Provider signature requirement: three specific provider signature elements must be present: âą Full, legible name or initials âą Acceptable provider credentials âą Either a handwritten signature or electronic authentication 13
- 14. Acceptable Physician Signatures Signature stamps are not acceptable as of 09.03.2007 14
- 15. 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 signed Authorized by Electronic signature verified Signed by Authorizing provider Electronically authenticated Validated by Automatic authentication Electronically signed by Verified by Electronically verified Signature Completed by Entered data sealed by Manually signed by Co-signed Finalized by Confirmed by Dictated and authenticated Reviewed by Sealed by Closed by Dictating provider if initialed by doctor 15 15
- 16. 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 16 16
- 17. Authentication Table (Electronic) (Not all Inclusive) Authentication Table (Electronic) Elements Acceptable authentication and provider name with credentials Example: Unacceptable authentication, and provider name with credentials Example: Acceptable Unacceptable X X Unacceptable authentication, without provider name and/or credentials Markus Welby, MD X Unsigned encounter note X 17
- 18. 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 18 18
- 19. Missing Digits and Undercoding on Claims Real examples of potential lost revenue due to incomplete coding of claims or documentation Diagnosis Specificity Claims ICD-9 Description 250.00 Diabetes without complications Actual HCC $1,133 493.00 Total Annual Revenue $1,133 ICD-9 Description 250.42 Diabetes with Chronic Complications 18 $3,533 493.20 19 Revenue HCC COPD 111 $3,322 Total Annual Revenue Revenue $6,855 Under Coded Claim Claim ICD-9 Description 250.00 Diabetes without complications Documentation 19 Revenue ICD-9 Description $1,133 250.42 Diabetes with Chronic Complications 18 $3,533 585.4 Total Annual Revenue HCC Chronic Kidney Disease Severe (Stage 4) 137 $2,150 $1,133 Total Annual Revenue HCC Revenue $5,683 19
- 20. Risk Adjustment Case Study ï¶ 85 year old female, symptoms of UTI ï¶ 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. 20
- 21. Risk Adjustment Case Study ï¶ 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 ï¶ 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 21
- 22. Risk Adjustment Case Study Scenario 1 â What would actually be coded and reported by many physicians Condition Diabetes Mellitus UTI ICD-9 Code CMS Risk Score 250.00 0.118 599.0 Demographic Score 0.677 0.0 Total RAF Score Total Payment $800 (Illustrative Purposes) x RAF Score 0.795 - 0.0826** 0.7124 $569.92 Scenario 2 â What can be coded and reported by the physician Diabetes Mellitus w/Renal Manifestations UTI 250.40 0.368 599.0 0.0 Diabetic Nephropathy 583.81 0.0 CKD Stage 4 585.4 0.224 Mild Degree Malnutrition 263.1 0.677 2.761 - 0.2869** 2.4741 $1,979.28 0.713 Old MI BKA Status 412 V49.75 Payment = Planâs Base Payment x Total RAF Score Data provided reflects 2014 payment year for 2013 dates of service. **Includes CMS normalization and coding intensity factors that reduce RAF scores. 0.0 0.779 22
- 24. STAR Quality Program ï¶ Driven by Health Care Reform ï¶ A government report card of Medicare Advantage Programs ï¶ A pay for performance program ï¶ Fifty-three metrics are measured âą 36 Part C medical measures âą 17 Part D pharmacy measures ï¶ By 2014, all Medicare Advantage Plans must be a 4 Star or lose bonus capabilities for 2015 24
- 25. Measures Fall into Four Categories 70% of scores are related to quality and service by physicians HEDIS (Health Effectiveness Data and Information Set) CMS administrative measures CAHPS (Consumer Assessment of Healthcare Providers and Systems) Health Outcomes Survey 25
- 26. New Preventive Services ï¶ Welcome to Medicare exam ï¶ Annual wellness exam ï¶ Personalized prevention plan with advice, screening schedules, referrals, education based on health situation ï¶ Bone mass measurement for osteoporosis 26
- 27. New Preventive Services ï¶ Colorectal cancer screening (colonoscopy) ï¶ Immunizations including flu shots, pneumonia ï¶ Mammograms ï¶ Prostate screening ï¶ Face-to-face behavioral counseling for obesity ï¶ Annual alcohol misuse screening and brief faceto-face behavioral counseling for alcohol abuse ï¶ Annual depression screening 27
- 28. Six Things to Remember ï¶ No rule outs ï¶ Appropriate signatures ï¶ Supportive documentation of diagnosis ï¶ Face-to-face visit ï¶ STAR measurements ï¶ New CPT codes for transitions of care and also Advance Directives (S0257) in 2014 28
- 29. Advance Care : Starting the Conversation
- 30. Learning objectives ï¶ Define advance care planning and explain its importance ï¶ Describe the steps of the advance care planning process ï¶ Describe the role of patient, proxy, clinician, and others ï¶ Identify pitfalls and limitations in advance care planning
- 31. What is advance care planning? ï¶ A communication process rather than a legal process ï¶ A way of planning for future medical care ï¶ A mechanism for ensuring that care received matches patientâs values and goals
- 32. Why is advance care planning important? ï¶ Some patients have an unpredictable course of illness ï¶ Builds trust ï¶ Helps to avoid confusion and conflict ï¶ Permits peace of mind
- 33. Concepts underlying advance care planning ï¶ Advance directive ï¶ Health care agent or proxy ï¶ Do not resuscitate (DNR) orders ï¶ Patient Self Determination Act
- 34. 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
- 35. Step 1: Introduce the topic ï¶ Allow adequate time and privacy ï¶ Ask what the patient knows: âHave you thought about having a living will?â ï¶ Explain the process: âItâs helpful for us to talk about it before making any decisions.â ï¶ Determine comfort level: âDo you feel ready to talk more about this today?â
- 36. Step 2: Structure the discussion (Five Wishes) ï¶ Who do you want to make health care decisions for you when you can't make them [proxy]? ï¶ What kind of medical treatment do you want or don't want? ï¶ How comfortable do you want to be? ï¶ How do you want people to treat you? ï¶ What do you want your loved ones to know? www.agingwithdignity.org
- 37. Use an advance care planning document ï¶ A number are available: âą Five Wishes âą Living Wills ï¶ Easy to use ï¶ Reduces chance for omissions ï¶ Patients, proxy, family can take home
- 38. Step 3: Document patient preferences ï¶ Review advance directive ï¶ Sign the documentation ï¶ Put it in the patientâs chart or medical record ï¶ Encourage patient to have copies to provide to different medical settings âą Proxy may assist with this
- 39. Step 4: Review, update ï¶ Use clinical events as triggers to review documents ï¶ As disease progresses, allow for evolution in patient understanding and preferences ï¶ Discuss and document changes
- 40. Step 5: Apply directives when indicated ï¶ Review the advance directive ï¶ Consult with the proxy ï¶ Use ethics committee for disagreements ï¶ Carry out the treatment plan
- 41. Pearls ï¶ Advance care planning can reduce family burden ï¶ Family members may not be the best proxies ï¶ Focus on what kind of care is desired rather than what should be withdrawn
- 42. Summary ï¶ Advance care planning is a fundamental palliative care skill ï¶ Advance care planning reduces family burden at end-of-life ï¶ The identification of the proxy is an important goal ï¶ The discussion is more important than the documents
- 44. Learning Objectives Define POLST and why it is important Describe the POLST form How do illustrate how to complete a POLST
- 45. Why POLST? Patient wishes often are not known â The Advance Healthcare Directive (AHCD) may not be accessible â Wishes may not be clearly defined in AHCD Allows healthcare professionals to know and honor your wishes for care.
- 46. POLST Conversations Focus is on the conversation It is important to talk about and document your wishes before you become seriously ill
- 47. What is POLST? Doctorâs 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
- 48. 48
- 49. Who Would Benefit from Having a POLST Form? Chronic, progressive illness Serious health condition Medically frail
- 50. 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
- 51. Endorsed Programs Developing Programs No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force. National POLST Paradigm Programs *As of January 2011
- 52. What about Michigan? ï¶ The Michigan Coalition for Honoring Healthcare Choices has created a version of the POLST that is referred to as a MI-POST ï¶ 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 ï¶ Piloted in Jackson, Traverse City and Escanaba 52
- 53. More about MichiganâŠ ï¶ Michigan program follows an Oregon program ï¶ October 2012 draft, four classes of patients are considered eligible for a Michigan POST: âą Seriously ill patients with advanced illness âą Frail patients with significant weakness and difficulty with their activities of daily living âą Patients who may lose their mental capacity within the next year âą Persons with strong feelings about end of life care 53
- 54. POLST in California Effective January 1, 2009
- 55. POLST in California One form for entire state Use not mandated Honoring form is mandated
- 56. POLST vs. Advance Healthcare Directive POLST complements the Advance Healthcare Directive (AHCD) POLST does not replace Advanced Healthcare directives Both are legal documents
- 57. Where Does POLST Fit In? Advance Care Planning Continuum Age 18 C Complete an Advance Directive O N Update Advance Directive Periodically V E R S Diagnosed with Serious or Chronic, Progressive Illness (at any age) A T Complete a POLST Form I O N End-of-Life Wishes Honored
- 58. 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
- 59. 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
- 60. Getting the most from your health care New resources for you and your family
- 61. More doesnât equal better 30% 70% Up to 30% of health care in the U.S. is unnecessary 61
- 62. About the Choosing WiselyÂź campaign ï¶ Initiative of ABIM Foundation ï¶ Trusted resourcesâincluding more than 30 national medical organizations and Consumer Reports ï¶ Choosing Wisely encourages conversations between patients and physicians Read more about the campaign at http://consumerhealthchoices.org/campaigns/choosing-wisely 62
- 63. You can get better care when you know more Being informed helps you make smarter choices: âą The right care âą 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 63
- 64. Consumer Reports resources Tip sheet series Video series To read, watch or download, visit http://consumerhealthchoices.org 64
- 65. Your relationship with your doctor is key ï¶ It is a partnership ï¶ Come prepared to your visits âą Medications âą List of questions âą Paper and pen âą Bring a family member or friend ï¶ Talk to your doctorâspeak up! âą Ask questions âą Get clarification 65
- 66. Donât be afraid to say âWhoa!â Ask questions: âą Do I really need this test or procedure? âą What are the downsides? âą Are there simpler, safer options? âą How much does it cost? 66
- 67. Imaging and screenings ï¶ Know the facts ï¶ How does it relate to your symptoms, care or disease ï¶ Share your results with your doctor 67
- 68. A little prevention goes a long way ï¶ Lifestyle choices have the largest impact on your health ï¶ Taking care of yourself prevents health problems and saves you money ï¶ Simple actions âą Maintain a healthy weight 70% âą Pay attention to how you feel âą Take action when you sense something is wrong âą Get regular health care checkups and screenings 70% of diseases are preventable 30%
- 69. Tips and Resources See the full set of Choosing Wisely and Consumer Reports employee resources at http://consumerhealthchoices.org
- 70. PCMH 70
- 71. Principle Partner Agreements ï¶ What does it mean? ï¶ What problems has MNO encountered? ï¶ How can the PCP and the practice team help? ï¶ Can a Specialist belong to many organizations? ï¶ Can a behavioral health specialist and chiropractor join? 71
- 73. Organized System of Care: MichCare 73
Hinweis der Redaktion
- Illegible Signature NOT over a typed/printed name, NOT on letterhead and the documentation is not accompanied by: an attestation statement Example: signed: _______XHandwritten initials over a typed or printed name with credentialsXInitials NOT over a typed/printed name but accompanied by: an attestation statement XUnsigned encounter note with providerâs typed name with credentials Example: signed: _____________________ John Doe, MD XUnsigned encounter note X
- To computer paymentâŠAdd CMS Risk Score (based on diagnosis) and demographic score together which becomes total RAF Score minus CMS factors and then multiply by the dollar amount ($750) on chart which equals total payment.Example:CMS Risk Score = .162 and the demographic score is .637. Thus, the total RAF score is .162 + .637 = .799. Then thereâs the CMS factor reduction (normalization and coding intensity factors) that brings this RAF down to .716. This number is then multiplied by $750 to come to the total payment of $537.The CMS factor reduction amount includes a set percentage for coding intensity and an annual normalization value.
- Doctors often order tests and recommend drugs or procedures when they shouldnâtâsometimes even when they know they shouldnât. The Congressional Budget Office says that up to 30 percent of the health care in the U.S. is unnecessary. All that unneeded care can be hazardous to your healthâand your wallet. For example, X-rays and CT scans expose you to potentially cancer-causing radiation and can lead to follow-up tests and treatment with additional risks. And the costs can be substantial. Though the idea that more health care is better seems to make intuitive sense, but recent research has shown that none of the above necessarily helps you live better or longer. To get better care, ask about pros and cons of the recommended treatment and push for coordination.
- The Choosing WiselyÂź campaign brings several passionate groups together to help physicians, patients and other health care stakeholders talk about the overuse of health care resources in the U.S. More than thirty national organizations representing medical specialists, as well as Consumer Reports and a number of consumer-focused organizations, are working with the ABIM Foundation to create a set of recommendations for physicians and patients to talk about together. The goal of Choosing Wisely is to encourage conversations between physicians and patients about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.Physicians and patients need to work together to make wise decisions about treatment. This means helping patients learn about care that is proven to be successful, safe and truly necessary for them.
- Informed patients make smarter choices. Patients can be safer, save moneyand get better sooner if they know how and where to shop for medical care.Thatâs why Consumer Reports is collaborating with an unusual array of employers, medical groups and health-care advocates to develop theChoosing Wisely Employer Toolkitâto distribute the best available information about doctors, hospitals, treatments, drugs and preventive health strategies.The Choosing Wisely Employer Toolkit provides you with information and resources on how you can take an active role in improving your health outcomes. The campaign provides information on how you can make wise health care choices by choosing the right care for your needs and how you can talk and work with your doctor to make wise decisions about treatments and care. Â
- Consumer Reports created a new set of tip sheets and videos for the Choosing Wisely Employer Toolkit to help you make informed decisions. Be sure to check them out at http://consumerhealthchoices.org/for-employees.
- Your doctor is your partner in helping you maintain your health or reach your goals. That means that you need to be involved in your health care and make your visits productive to ensure you receive the best care. When you are visiting a doctor, come prepared with information and questions. Bring items such as your medications, list of your health changes, list of questions, paper and pen, and maybe a family member who can help ask questions and remember the answers.Good communication is an important way to build a relationship with your doctor and get the care you need. Speak up and donât be afraid to ask questions or ask for clarification when you donât understand something.
- To get better care and to minimize receiving unneeded care, ask about pros and cons of the recommended treatment and push for coordination.Donât be afraidto ask your doctor questions to determine if you really need the care:Do I really need this test or procedure? The answer should be direct and simple. Tests should help you and your doctor decide how to treat your problem, and procedures should help you live a longer, healthier life. What are the downsides? Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself. Are there simpler, safer options? Sometimes lifestyle changes will provide all the relief you need. What happens if I do nothing? Ask if your condition might worsenâor get betterâif you donât have the test or procedure now. How much does it cost? Ask whether there are less expensive alternatives or generic versions of brand-name drugs. Find out more from Consumer Reports at http://consumerhealthchoices.org/for-employees.
- Imaging, such as X-rays, CT scans and MRIs, and screenings can be important tools in determining health issues and diseases. But they can also be unnecessary and costly. To make sure that getting imaging or screenings done is worth your time and money, it is important to know the facts regarding how the image or screening relates to your health, symptoms, care and diseases. It is also important to know which imaging and screenings have been completed, so they arenât repeated multiple times. For example, you may have a doctor who orders a screening, and another doctor treating you for another issue may order the same screening. In that case, it would be good to share your results so you donât have to complete the same test twice. Find out more from Consumer Reports at http://consumerhealthchoices.org/for-employees.
- Did you know that70% of diseases are preventable? Your lifestyle choices have more impact on your health and longevity than anything else.People who are actively involved in their health are 65% more likely to have their needs met by their care provider and 46% less likely to have a delay in their care or diagnosis.Taking care of yourself prevents health problems and saves money by reducing the number of office visits and medications you need. Self-care reduces the heavy costs of health care associated with disease. It has been well documented that lifetime medical costs, which average approximately $225,000 per person, are clearly linked to health habits. The good newsâpreventing disease and staying in good health can be as simple as being proactive and taking the following actions:Maintain a healthy weightPay attention to how you feel and take action when you sense something is wrong Get regular health care checkups and recommended health care screenings