PCP Focus Meeting: Keeping You in the Loop

Fall Focus Meeting

2013

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 ADVANTAGE

CMS 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 Practice

Allergy/Immunology Gastroenterology

Anesthesiology General Practice

Audiologist General Surgery

Cardiac Surgery Geriatrics/Gerontology

Cardiology Gynecologist Certified Clinical Nurse Specialist Hand Surgery

Certified Nurse Midwife Hematology

Certified Registered Nurse Anesthetist Hematology/Oncology

Chiropractic Infectious Disease

Clinical Psychologist Internal Medicine

Colorectal Surgery Interventional Radiology

Critical Care Licensed Clinical Social Worker Dermatology Maxillofacial Surgery

Emergency Medicine Multispecialty Clinic or Group Practice

Endocrinology 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 signed

Authorized 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 by

Co-signed Finalized by Confirmed by

Dictated and authenticated Reviewed by Sealed by

Dictating 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 credentials Example:

X

Unacceptable authentication, and provider name with credentials Example:

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 Claims

Real 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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tatu

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d o

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ask

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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

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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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