High Intensity Care Management November 4 2014 Webinar Additional 2014 Clinical Model Elements 2 Clinical Model Goal Outreach to 100 of patients on the accepted list within 90 days of finalizing list outreach defined as initial attempt to reach patient via telephonic or inperson verbal c ID: 772780
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High Intensity Care ManagementNovember 4, 2014Webinar
Additional 2014 Clinical Model Elements2Clinical Model GoalOutreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact) Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months Quarterly review/update of care plan for engaged patients Hospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient needsSNF to home transition initial contact within 24-48 hours of discharge for engaged patientsSNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patientsSNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs The following elements of the clinical model cannot be tracked/measured via the claims system, but are identified as important goals within the clinical model. Physician Organizations should track these metrics. Metrics will be discussed at joint meetings, in addition, Physician Organizations may be asked to submit data to BCBSM.
Phase 1 Launch10-1-14Full Launch 4-1-15HICM Common Clinical Model ComponentsSubset of Core ModelCore ModelComprehensive Clinical Model 1.24/7 phone access to clinical decision-maker with electronic access to pt record ●●●2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority for July 1, 2014 start●●●3. In-home health care assessment by PCP, NP, or PA for homebound●●4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments●●5. Patient-specific comprehensive care plan (updated at least quarterly)●● ● 6. Care management team includes pharmacist and nutritionist ● ● 7. Access to in-home PT and OT ● ● ● 8. Care transitions management – Hospitals ● ● ● 9. Care transitions management – SNFs ● 10. Access to palliative care team ● 11. Access to hospice ● ● ● 12. Transportation for non-emergent medical visits and Rx 2016 13. Remote patient monitoring (weight, BP, glucose) 2016 14. Standardized staff training ● ● ● 15. Review of all patients on monthly patient lists, c ommon outreach script (2 nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list ● ● ●
Medicare Advantage STAR Recognition Program
Medicare STAR Ratings The CMS star rating program is a pay-for-performance program for Medicare Advantage plansPlans will now receive revenue based on outcomes and the quality of their performanceThe higher the quality ranking, the higher the payments and the more competitive the plan is in the marketplaceThis is an attempt by CMS to create a new paradigm to bend the cost curve
What’s Measured6STAR ratings measure a Plan’s performance in delivering quality outcomesSTAR ratings are based on 53 key quality measures (36 related to Medicare and 17 related to prescription drug coverage) across the five following domains (subset of HEDIS measures)
What do CMS STARS Rating MeasureStaying Healthy: screenings, tests, and vaccinesManaging chronic (long term) conditions Ratings of health plan responsiveness and careMember complaints, problem getting services, and choosing to leave the plan Health plan customer service 7
What’s It Look Like8Clinical quality and outcomes HEDIS Plan administrative performance and complianceMember assessment of their health (Health Outcomes Survey)Member perceptions of Plan, providers and careCAHPS
2014 Provider Outreach ActivitiesDiagnosis coding education where DDDS is not part of practiceHEDIS/STARS for all targeted providersActivities include:Address and close HEDIS/STARS treatment opportunity gapsAddress and close Enterprise and BCNA risk adjustment diagnosis gaps9
2014 Provider Outreach ActivitiesActivities include:Support HEB education and sign-up Support provider staff on scheduling member appointments Provide education to providers Provide reference tools and materials to providers Retrieve medical records related to treatment opportunity gaps if necessary10
2014 Provider Outreach ActivitiesActivities include:Retrieve medical records for BCNA risk adjustment diagnosis gaps, BCNA onlyComplete focus-driven activities as specifiedReport on outreach activities completed by practice unit/providers11
Provider Recognition Program12
MeasureCodesAdults’ Access to Preventive/ Ambulatory Health Services (AAP)CPT® codes to identify preventive/ ambulatory health services: Office or other outpatient services: 99201-99205, 99211-99215, 99241-99245 Home services: 99341-99345, 99347-99350 Nursing facility care: 99304- 99310, 99315, 99316, 99318 Domiciliary, rest home or custodial care services: 99324-99328, 99334-99337 Preventive medicine: 99381- 99387, 99391-99397, 99401- 99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, S0620, S0621Ophthalmology and optometry: 92002, 92004, 92012, 92014 General medical examination: ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9Adult Body Mass Index (ABA) AssessmentCPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456HCPCS: G0402, G0438, G0439ICD-9-CM Codes to identify BMI: V85.0-V85.5Exclusions: Members with a diagnosis of pregnancy in the measurement year or the year prior to the measurement year.ICD-9-CM: 630-679, V22, V23, V28Breast Cancer Screening (BCS)Claims Coding Reference13
MeasureCodesAnnual Monitoring for Patients on Persistent Medications (MPM)Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics: Drug serum concentration for serum potassium: CPT®: 80051, 84132 Drug serum concentration for serum creatinine: CPT®: 82565, 82575Drug serum concentration for blood urea nitrogen: CPT®: 84250, 84525 *Drug serum concentration for Digoxin:CPT®: 80162 Monitoring for Anticonvulsants: Drug serum concentration for phenobarbital: CPT®: 80184Drug serum concentration for carbamazepine: CPT®: 80156, 80157Drug serum concentration for phenytoin: CPT®: 80185, 80186Drug serum concentration for valproic acid and divalproex sodium: CPT®: 80164 Lab panel codes: CPT®: 80047, 80048, 80050, 80053, 80069 Claims Coding Reference 14
Claims Coding Reference15MeasureCodesBreast Cancer Screening (BCS)CPT®: 77055-77057 HCPCS: G0202, G0204, G0206 ICD-9-PCS: 87.36, 87.37 Exclusions: Members with a bilateral mastectomy. Any of the following meet criteria for bilateral mastectomy:Bilateral mastectomyICD-9: 85.42, 85.44, 85.46, 85.48Unilateral mastectomyCPT®: 19180, 19200, 19220, 19240, 19303-19307ICD-9-PCS: 85.41, 85.43, 85.45, 85.47Two unilateral mastectomies*50 and 09950 modifier codes indicate the procedure was bilateral and performed during the same operative session.Cholesterol Management for Patients with Cardiovascular Conditions (CMC)CPT®: 80061, 83700, 83701, 83704, 83721 PlusCPT® II: 3048F, 3049F, 3050F
Claims Coding ReferenceClaims Coding Reference16MeasureCodesColorectal Cancer Screening (COL) FOBT Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013: CPT®: 82270, 82274 HCPCS: G0328 Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013:CPT®: 45330-45335, 45337-45342, 45345 HCPCS: G0104 ICD-9-PCS: 45.24Colonoscopy between 1/1/2004 and 12/31/2013:CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 HCPCS: G0105, G0121 ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, 45.43AND/ORChart documentation of previously performed colorectal cancer screening tests.Exclusions: Members with a history of either of the following:Colorectal cancerHCPCS: G0213-G0215, G0231ICD-9-CM: 153, 153.0-153.9, 154.0, 154.1, 197.5, V10.05Total colectomyCPT®: 44150-44158, 44210-44212ICD-9-PCS: 44.80-45.83
HEDIS Coding ReferenceHEDIS Claims Coding Reference17MeasureCodesComprehensive Diabetes Care (CDC) – Eye ExamCPT®: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 CPT® II codes: 2022F, 2024F, 2026F, 3072F HCPCS codes: S0620, S0621, S0625, S3000Exclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
HEDIS Claims Coding Reference18MeasureCodesComprehensive Diabetes Care (CDC) – HbA1c CPT®: 83036, 83037 PLUSCPT® II: 3044F, 3045F, 3046F Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0Comprehensive Diabetes Care (CDC) – LDL-CCPT®: 80061, 83700, 83701, 83704, 83721 PLUSCPT® II: 3048F, 3049F, 3050FExclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
MeasureCodesComprehensive Diabetes Care (CDC) – Nephropathy ScreeningCPT®: 82042, 82043, 82044, 84156 PLUSCPT® II: 3060F, 3061F, 3066F, 4010FICD-9-CM: 250, 403-405, 580-588, 753, 791Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)ICD-9-CM codes to identify rheumatoid arthritis:714.0, 714.1, 714.2, 714.81HCPCS codes to identify pharmacy claims for DMARD in the measurement year:J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)COPD:Chronic bronchitis: 491Emphysema: 492COPD: 493.2, 496 CPT® codes to identify spirometry testing:94010, 94014-94016, 94060, 94070, 94375, 94620HEDIS Claims Coding Reference19
MeasureCodesOsteoporosis Management in Women Who Had a Fracture (OMW)Codes to identify bone mineral density test:CPT®: 76977, 77078-77083, 78350, 78351HCPCS: G0130ICD-9-CM: 88.98 AND/OR pharmacy claims for osteoporosis drug therapy: HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488 HEDIS Claims Coding Reference20
Open Discussion21