2. 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
2
4. 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
4
5. 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?)
5
6. 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)
6
7. 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)
7
8. 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
−
8
9. 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
9
10. 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
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
13. 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
13
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
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.
20
21. 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
21
22. Risk Adjustment Case Study
Scenario 1 – 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 – 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 = Plan’s 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
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
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
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
26
27. 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 faceto-face behavioral counseling for alcohol abuse
Annual depression screening
27
28. 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
28
30. 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
31. 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
32. 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
33. Concepts underlying advance care planning
Advance directive
Health care agent or proxy
Do not resuscitate (DNR) orders
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
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?”
36. 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
37. 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
38. 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
39. 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
40. Step 5: Apply directives when indicated
Review the advance directive
Consult with the proxy
Use ethics committee for disagreements
Carry out the treatment plan
41. 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
42. 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
45. 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.
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?
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
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?
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
52
53. 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
53
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 doesn’t equal better
30%
70%
Up to 30% of health care
in the U.S. is unnecessary
61
62. 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
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:
• 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
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
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
66. 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?
66
67. Imaging and screenings
Know the facts
How does it relate to your symptoms, care or
disease
Share your results with your doctor
67
68. 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
70%
• 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
30%
69. Tips and Resources
See the full set of Choosing Wisely and
Consumer Reports employee resources at
http://consumerhealthchoices.org
71. 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?
71