Cluster meeting fall 2013 final monroe


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  • 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 provider’s typed name with credentials Example: signed: _____________________ John Doe, MD XUnsigned encounter note X
  • To computer payment…Add 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 there’s 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 shouldn’t—sometimes even when they know they shouldn’t. 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 health—and 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 Wisely® 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.That’s why Consumer Reports is collaborating with an unusual array of employers, medical groups and health-care advocates to develop theChoosing Wisely Employer Toolkit—to 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.  
  • 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
  • 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 don’t be afraid to ask questions or ask for clarification when you don’t 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.Don’t 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 worsen—or get better—if you don’t 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
  • 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 aren’t 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 don’t have to complete the same test twice. Find out more from Consumer Reports at
  • 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 news—preventing 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
  • Cluster meeting fall 2013 final monroe

    1. 1. PCP Cluster Meeting: Keeping You in the Loop November 13, 2013 Dolce Vita, Monroe MI
    2. 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
    3. 3. Optimizing Risk Adjustment, Risk Scoring and Stars MEDICARE ADVANTAGE CMS Risk Adjustment
    4. 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. 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. 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. 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. 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. 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. 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. 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. 12. Unacceptable Provider Types  Registered Nurse  Licensed Practical/Vocational Nurse (LPN/LVN)  Speech Language Pathologist (SLP)  Pharmacist 12
    13. 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
    14. 14. Acceptable Physician Signatures Signature stamps are not acceptable as of 09.03.2007 14
    15. 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. 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. 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. 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. 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. 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. 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. 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
    23. 23. STAR BONUS PROGRAM 23
    24. 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. 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. 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. 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. 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
    29. 29. Advance Care : Starting the Conversation
    30. 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. 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. 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. 33. Concepts underlying advance care planning  Advance directive  Health care agent or proxy  Do not resuscitate (DNR) orders  Patient Self Determination Act
    34. 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,
    35. 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. 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?
    37. 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. 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. 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. 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. 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. 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
    43. 43. POLST It’s a Conversation 43
    44. 44. Learning Objectives Define POLST and why it is important Describe the POLST form How do illustrate how to complete a POLST
    45. 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. 46. POLST Conversations Focus is on the conversation It is important to talk about and document your wishes before you become seriously ill
    47. 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
    48. 48. 48
    49. 49. Who Would Benefit from Having a POLST Form? Chronic, progressive illness Serious health condition Medically frail
    50. 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. 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. 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. 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
    54. 54. POLST in California Effective January 1, 2009
    55. 55. POLST in California One form for entire state Use not mandated Honoring form is mandated
    56. 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. 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. 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. 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. 60. Getting the most from your health care New resources for you and your family
    61. 61. More doesn’t equal better 30% 70% Up to 30% of health care in the U.S. is unnecessary 61
    62. 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 62
    63. 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. 64. Consumer Reports resources Tip sheet series Video series To read, watch or download, visit 64
    65. 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. 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. 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. 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. 69. Tips and Resources See the full set of Choosing Wisely and Consumer Reports employee resources at
    70. 70. PCMH 70
    71. 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
    72. 72. PCMH-Neighborhood 72
    73. 73. Organized System of Care: MichCare 73