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

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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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