Annual HP Workshop EPSDT MCE Combined Presentation P0608 1 EPSDT – Screening Components The following components of a screening must be provided and documented to provide quality care to the members and receive enhanced reimbursement: Health and developmental history, including assessment of physical and mental health development Unclothed physical exam Nutritional assessment Developmental assessment Vision observation at each screen and direct referral to an optometrist Hearing observation at each screen and objective testing with audiometer at 4 years old Dental observation at each screen and direct referral to a dentist starting at 6 – 12 months old Laboratory tests, including blood level assessment appropriate for age and risk factors Immunizations administered or referred, if needed at time of the screen Health education, including anticipatory guidance This is often provided, but frequently not documented. P0608 2 EPSDT – MCE Billing The following billing procedures must be followed to permit correct reimbursement. Every claim for a HealthWatch/EPSDT visit must be coded with the following: The appropriate patient examination code (99381 – 99385, and 99391 – 99395) must be included on the first detail line of the medical claim form. The preventive health diagnosis code, V20.2, as the Primary diagnosis. Physicians are strongly encouraged to include all applicable diagnosis codes and procedure codes on the claim form. The usual and customary appropriate EPSDT reimbursement rate for the initial or established patient exam should be billed. The enhanced reimbursement rate is $75 for codes 99381 – 99385 and $62 for codes 99391 – 99395. Providers must provide all components of the EPSDT program to submit for the enhanced reimbursement. Providers must report on the claim form all screens and immunizations administered during the HealthWatch/EPSDT visits. P0608 3 EPSDT – MCE Billing Vaccines The MCE’s follow HP guidelines and reimburse Vaccines for Children (VFC) services for the administration fee. The VFC fee is a maximum of $8.00 or lower of the submitted charge from the provider. For appropriate claims submission for $8.00 reimbursement, V20.2 is submitted as the primary diagnosis code. A list of covered VFC available vaccines, visit the EPSDT HealthWatch Provider Manual at the IHCP Web site under Section 3, General VFC Billing Information. HEDIS guidelines and the Periodicity and Screening Schedule provide guidelines, and recommended timelines for immunizations for members. Providers should utilize CHIRP to record, manage, and tally immunizations for their office. P0608 4 EPSDT – MCE Billing If a patient is evaluated and treated for a problem during the same visit as an EPSDT annual exam or well – child service, the problem oriented exam can be billed separately accompanied by the 25 modifier (separate significantly identifiable E&M service). The problem must require additional moderate level evaluation to qualify as a separate service on the same date. FQHC’s and RHC’s – Providers should NOT use the T1015 encounter code in addition to the CPT or HCPCS codes when billing MCEs. These providers should bill the appropriate EPSDT services provided to the member. P0608 5 EPSDT – Missed Appointments If a member misses a well – child appointment, the office should reach out to the member and reschedule the visit. The provider office can also reach out to the MCE for additional member education. Provider offices should take every opportunity to educate a member, provide preventive care, and immunizations per the screening schedule as early detection and treatment help prevent diseases in members. P0608 6 HEDIS Measures Each MCE will help providers focus on the EPSDT program in conjunction with the HEDIS well – child measures for the following performance measures: Well – Child Visits 0 – 15 Months Frequency of Visits Health and Developmental history, physical and mental Health Education and Anticipatory Guidance Well – Child Visits 3 – 6 Years Annual well – child visit Health and Developmental history, physical and mental Health Education and Anticipatory Guidance Well – Child Visits 12 – 21 Years Annual well – child visit Health and Developmental history, physical and mental Health Education and Anticipatory Guidance *Please see 2010 HEDIS Performance Measure poster for additional details on MDwise well – child and additional performance measures. P0608 7 EPSDT – Lead Screening Lead poisoning is preventable. Children from 9months to 6 years are at greatest risk for elevated blood levels. Ensure lead screenings are a part of a well – child exam. If children are identified with elevated lead levels, ensure they have recommended follow – up treatment. Codes for billing lead screenings are the following: 83655 – U1 83655 – U2 83655 P0608 8 EPSDT – Documentation It is imperative when member receives all components of the EPSDT program, that the services are documented and incorporated into the members medical chart. A provider should document the family and medical history: Reason for visit Initial observation Perinatal history Nutritional status Developmental history Medical history Body system review Family health history Referrals must be documented and recorded in the member’s medical chart. Anticipatory guidance provided during the EPSDT visit and/or the well – child visit must be documented in the member’s medical chart. P0608 9 EPSDT – Documentation A provider should perform the following during an EPSDT exam: Measurements Height Weight Weight for height/BMI Head circumference Blood pressure General physical examination of the systems Screenings for referrals *Please refer to the EPSDT Health Watch Manual for testing and referral charts. P0608 10 Well – Child Services If all components of the EPSDT program are not provided to the member, but the following components are documented and provided, the provider can submit for well – child services and not EPSDT services and not receive enhanced reimbursement: Annual well – child visit Health and Developmental history, physical and mental Health Education and Anticipatory Guidance The provider should submit the claim with the appropriate E&M procedure code and the V20.2 diagnosis code. The services will count towards the provider’s quality measures to receive credit for the services provided and increase the measure. P0608 11 Billing Scenarios If a member presents for an EPSDT exam and all components were provided and documented, submit a claim following these guidelines: CPT ICD – 9 Code 99391 – 99395 or 99381 – 99385 V20.2 P0608 12 Billing Scenarios If a member presents for an EPSDT exam and all components were provided and documented, and VFC immunizations were also provided, submit a claim following these guidelines: CPT Code ICD – 9 Code 99391 – 99395 with the 25 modifier or 99381 – 99385 V20.2 90707 V06.4 90716 V05.4 90721 V06.8 P0608 13 Billing Scenarios If a member presents for an EPSDT exam and all components were provided and documented, and a member complains of ear pain so they are being seen for a sick visit, submit a claim following these guidelines: CPT Code ICD – 9 Code 99391 – 99395 or 99381 – 99385 V20.2 99201 – 99205 with the 25 modifier or 99212 – 99215 with the 25 modifier Appropriate diagnosis code for the visit. P0608 14 Additional EPSDT Tips By ensuring appropriate coding of the services that are provided, it will demonstrate that the care being provided also meets quality measures. Reimbursement can be maximized by correct coding. Remember to submit charges if the member has third party liability (TPL). Well child services can be billed for reimbursement when they do not include all components of an EPSDT visit. A comprehensive prenatal visit meets all of the requirements for a preventive care visit and can be billed in conjunction with the V20.2 to count towards the HEDIS measure. By increasing EPSDT services, performance measures in the well – child targeted measures will rise. Complete the Notification of Pregnancy (NOP) to ensure the MCE’s are aware of new member’s becoming pregnant and to ensure they receive the required prenatal services. P0608 15 Periodicity and Screening Schedule P0608 16 Hoosier Healthwise Managed Health Services (MHS) Interventions MHS HEDIS Reporting and Material – MHS Team (Provider Relations and Quality Improvement) mail quarterly scorecard information to PMP network, providing snapshot of current metrics and listing of members identified as not receiving service to date to aid in patient outreach. MHS Education Sessions – MHS is holding workshops & individual sessions throughout the State to assist our provider network in education regarding what is needed to achieve goals. Billing/Claims assistance – MHS team providing one on one education sessions with office to provide instruction on appropriate EPSDT and HEDIS billing procedures. Educational Material – MHS has developed and issued education material such as HEDIS Quick Reference Guide and Healthwatch (EPSDT) chart tool. Connections Representatives – A team dedicated to providing one-on-one education for members with compliance issues (i.e. missed appointments, ER utilization, etc.) In addition, the Quality Outreach Team provides telephone follow-up on EPSDT/Well Child mailings assisting members with obtaining appointments and arranging transportation if needed. P0608 17 Hoosier Healthwise Managed Health Services (MHS) Interventions P0608 18 Hoosier Healthwise Managed Health Services (MHS) Interventions P0608 19 Members Needing Service P0608 20 Service Needing Members P0608 21 P0608 22 Hoosier Healthwise Anthem Interventions Anthem Education – Anthem’s NERs, Outreach, Health Promotions staff assist in educating providers on a one on one basis related to HEDIS, EPSDT guidelines, and documentation standards. Educational Materials –Anthem’s educational materials consist of the HEDIS Measure Physician Documentation Guidelines and Administrative Codes brochure to assist physicians in identifying the criteria/requirements for services and the elements of documentation needed for each visit. Anthem provides age appropriate forms to providers promoting anticipatory guidelines, growth and development, and physical and mental health exams. Anthem provides P4P brochures to providers as a baseline regarding measures scored per HEDIS, as well as individual provider scores implementing continuous plans for improvement. P0608 23 Hoosier Healthwise Anthem Interventions Anthem Reports – Anthem provides Gap in Care reports to physicians as an outreach effort to assist with getting members in for preventive care. Outreach – Anthem’s Outreach Specialists provide one on one education, telephone and home visits to members per provider request or those needing assistance with getting in to see their PMPs, transportation services, missed appointments, ER usage, etc. Anthem Outreach Specialists have clinic days arranged to target and educate members in need of preventative care. Anthem Webinars – Anthem provides educational webinars to assist providers in gaining knowledge of the required measures, billing guidelines, and documentation needed to increase their HEDIS scores. P0608 24 Anthem - Age Appropriate Documentation Form for Well Visits 3-6 Years Areas covered with the form: • Nursing Intake • Interval History • Growth – Development • Parental/Patient Concerns Name:_______________________________________________ DOB: _________________________ Actual Age: ___________ Language Spoken____________ Interpreter Name ____________ Date: ______________________________ 4 - 5 YEARS NURSING INTAKE Height: Weight: BMI: BMI%: BP: Temp.: Pulse: Resp.: Allergies: Growth Charts Completed: [ ] Abuse: Witness or Victim: Notes: Alternate health care provider: MA Signature Fatigue, nightmares, enuresis, wt. loss or gain: INTERVAL HISTORY Diet: Has WIC: Yes / No Stools: Illnesses: Sleep Pattern: Seeing dentist: Yes / No Accidents: Family history: HTN, heart disease, high cholesterol, DM, asthma Meds./Vits.: Exposure to tobacco smoke: TB Risk: Yes / No GROWTH-DEVELOPMENT: Physical activity:__________________________ [ ] Hops on one foot [ ] Plays with several children [ ] Counts 4 pennies [ ] Recognizes 3-4 colors [ ] Copies a square [ ] Knows opposites [ ] Catches, throws a ball [ ] Knows name, address, phone no. PARENTAL/PATIENT CONCERNS: PHYSICAL EXAMINATION • Physical Examination • Assessment • Plan • Orders • Anticipatory Guidance General Appearance [ [ Head [ Eyes [ [ [ Ears [ [ Nose [ Mouth & pharynx [ Neck [ ASSESSMENT: ] ] ] ] ] ] ] ] ] ] ] Well nourished and developed No abuse/neglect evident Symmetrical Conjunctivae, sclerae, pupils normal Red reflexes present Appears to see [ ] No strabismus Canals clear, TMs normal Appears to hear Passages patent Normal color, no lesions, no cavities Supple, no masses palpated Teeth [ ] Grossly normal, no cavities Heart Lungs Abdomen Genitalia: Male [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] No murmurs, regular rhythm Breath sounds normal bilaterally Soft, no masses, liver & spleen normal Normal appearance, circ./uncirc. Testes in scrotum No lesions, nl external appearances Good abduction Present and equal No deformities, full ROM Clear, no significant lesions Alert, moves extremities well Female Hips Femoral pulses Extremities Skin Neurologic PLAN: ORDERS: [ ]Vaccine reactions, risks and follow-up explained / VIS sheet given [ ] DTAP [ ] UA at 5 years [ ] MCV4 (high risk) [ ] IPV [ ] Vision screening Yearly [ ] PPD [ ] Hep B (if not previously done) [ ] Audiometry at 4 and 5 years [ ] MMR [ ] Lead Blood Test (if not in chart) [ ] Varicella (second dose) [ ] WIC Referral given [ ] Hep A (if not previously done) [ ] Dental Referral given [ ] HCT (if high risk) [ ] Rx for fluoride drops/chewable tabs .50/1.0 QD till age 14 [ ] Influenza vaccine (check recommendations) [ ] Immunization Registry entry [ ] Fluoride varnish application [ ] Lipid Profile (if high risk) ANTICIPATORY GUIDANCE: Circle if discussed Diet: Regular balanced meals with snacks, caloric balance, sweets, Fe, Na, meal socialization, school lunch program Injury & Violence prevention: Street dangers, knives, falls, drowning, caution with strangers, smoke detector, hot water temp., Window guards, pool fence, bike helmet, poison center phone, storage of drugs, toxic chemicals, matches, and guns, burns, lead poisoning prevention Education on Fluoride varnish treatment. Guidance: Knows name, address, phone no., plays with other children, imitates adults, honest & simple answers regarding sex, dressing self, B&B problems, school plans, TV programs, play supervision, regular exercise, UV skin protection, dentist Q 1 yr, tooth care, parent smoking, strangers, school readiness , seat belt use, childcare plan, emergency care plan, physical activity, sun screen [ ] Refer to appropriate agency. Next appointment [ ] 1 year or________________ Signature ____________________________ Date ____________________ P0608 25 Anthem - Age Appropriate Documentation Form for Adolescent 12-21 Years Name:_______________________________________________ DOB: _________________________ Actual Age: ___________ Language Spoken____________ Interpreter Name ____________ Date: ______________________________ 13 - 14 - 15 - 16 YEARS NURSING INTAKE Height: Weight: BMI: BMI%: BP: Temp: Pulse: Resp.: Allergies: Growth Charts Completed: [ ] Abuse: Witness or victim: Notes: Alternate health care provider: MA Signature Meds/Vits.: LMP: INTERVAL HISTORY ( indicate alone or with parent) Diet: Weight loss/gain: Menarche: Appetite: Physical Activity: TB risk: Yes / No Exposure to tobacco smoke: Accidents: Seeing dentist: Yes / No Tobacco/alcohol/drug use: Family history: HTN, heart disease, high cholestero1, DM, asthma Sexual activity: Illnesses, stomach, headache, fatigue, depression: GROWTH/SCHOOL PROGRESS: Physical activity:___________________________Risk questions should be asked for all ages. Achievement, sports, peer relationships, attendance, hobbies, school vision or hearing problem, attendance, after high school plans : PARENTAL/PATIENT CONCERNS: PHYSICAL EXAMINATION General Appearance [ ] Well nourished and developed [ ] No abuse/neglect evident Head [ ] No lesions Eyes [ ] PERRL, conjunctivae & sclerae clear [ ] Vision grossly normal Ears [ ] Canals Clear, TMs normal [ ] Hearing grossly normal Nose [ ] Passages clear, MM pink, no lesions Teeth [ ] Grossly normal Neck [ ] Supple, no masses, thyroid not enlarged Chest [ ] Symmetrical Heart [ ] No organic murmurs, regular rhythm ASSESSMENT: [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] [ ] Pap done [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] No masses, Tanner stage I II III IV V Clear to auscultation bilaterally Soft, no masses, liver & spleen normal Grossly nl, Tanner stage I II III IV V Circ./uncirc. [ ] Testes in scrotum No lesions, nl external appearances Normal No deformities, full ROM Not enlarged No scoliosis Clear, no significant lesions Alert, no gross sensory or motor deficit [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] Immunization registry entry Vision screening (objective at 15 yrs) Audiometry (objective at 15 yrs) Dental Referral given [ ] HPV ( if not up to date) [ ] UA(yearly) [ ] PPD [ ] Lipid profile (if high risk) Rx for fluoride .50/1.0 mg QD till age 14. Rx. For Folic Acid .4 mg qd. (if female) Pap, GC, Chlamydia, VDRL (if sexually active) Counsel re HIV (test if at risk) ANTICIPATORY GUIDANCE: Circle if discussed Diet: Fat (esp. sat. & chol.), Na, Fe, Ca, caloric balance, appropriate weight, junk food, eating disorders, physical activity. Accident prevention: Safety helmet, risk-taking behavior, DUI, guns, violent behavior, motor vehicle safety, work safety. Guidance: Smoking, alcohol, marijuana, cocaine, IV and other drugs, depression, suicidal ideation, puberty progress, sun screen, sex education (partner selection, condoms, contraception, AIDS risk factors), goals in life, family interaction, exercise, physical activity, seat belt use , self breast exam , testicular self exam, personal development : physical, growth, sexuality, independence [ ] Refer to appropriate agency. [ ] Refer to Drug/ ETOH rehab, stop smoking class, OB/Gyn service, mental health services or other________________________ Next appointment: [X] 1 year or • Interval History • Parental/Patient Concerns • Physical Examination • Assessment [ ]Vaccine reactions, risks and follow-up explained /VIS sheets given. Hep B (if not given previously) MMR (if not up to date) Varicella, (if not up to date or history date documented) Hep A (if not given previously) HCT (once between 11 to 21 years) MCV4 @ 15 years (if not up to date) Influenza vaccine (check recommendations) Td/Tdap (if not up to date) • Nursing Intake • Growth – Development Female Breast (female) Lungs Abdomen Genitalia Male Female Femoral pulses Extremities Lymph nodes Back Skin Neurologic PLAN: ORDERS: Areas covered with the form: MD Signature: • Plan • Orders • Anticipatory Guidance Date_________________ P0608 26 Clinical Quality Compliance Administrators for Anthem Acquanetta McKinney, CQA RN BSN acquanetta.mckinney@anthem.com (219) 796-9543 Tamela Queen, CQA RN PLNC tamela.queen@anthem.com (812) 469-7540 P0608 27 Hoosier Healthwise MDwise Interventions MDwise Member Advocates - MDwise Member Advocates provide one – on – one education and telephone outreach with members with special needs or compliance issues (e.g. missed appointments, PMP conflicts, ER utilization, etc.) or those who are not accessing their PMP. Billing guidelines – To help prevent coding problems, providers are encouraged to refer to the MDwise educational materials and the Indiana Medicaid supplemental manual on EPSDT @Indiana Medicaid Website: http://www.indianamedicaid.com/ihcp/Manuals/Other/EPSDT_He althwatch.pdf P0608 28 Hoosier Healthwise MDwise Interventions MDwise Education – MDwise along with its Network Improvement team, and Delivery Systems (Reps and Quality Management staff) will work one on one with providers to educate on EPSDT and HEDIS to ensure specific goals are met. Created to take improvement efforts to a higher level Educating providers on HEDIS and ROQ standards. Providing providers information about their quality performance Diagnose office practices that may result in missed opportunities to provide care or cause services to not be billed correctly Creating and distributing reference/educational materials and tools Educational Materials – MDwise has developed education materials such as the HEDIS poster, the well – child campaign and flyers for providers and office staff to help promote early detection and treatment. Reports – MDwise Delivery Systems will provide it’s PMP’s reports that will identify members who are delayed in their check ups. P0608 29 Converting Acute Visits to Well Visits P0608 30 Hoosier Healthwise MDwise Reports Measure Eligible Members Current Current % 90th Numerator Meets Percentile Vol. Mbrs. Potential % Vol. Needed Missed Opp. Meets for 90th % of Opportunity Needed W34 2,996 1,380 46.1% 79% 1254 87.9% 987 79% AWC 3,239 747 23.1% 57% 1308 63.4% 1099 84% Note: Data is based on dates of service 1/1/09-12/31/09 with claims paid through 11/30/09 captured. P0608 31 Hoosier Healthwise MDwise Reports DS Practice 0 0 % Meet Criteria 100.0% Meet Criteria LDL-C Screening F/U Care for Children Prescribed ADHD Meds Initial Phase Follow-up After Hospitalization for Mental Il Follow-up Within 7 Days of Discharge 0 0 0 0 0 Timeliness of Prenatal Care Meet Criteria 0 0 100.0% 0 0 100.0% 0 0 0 100.0% 0 0 0 100.0% Timeliness of Postpartum Care 0 0 Frequency of Prenatal Care >81% Well-Child Visits in First 15 Mths of Life Six or More Visits 0 0 Well-Child Visits - Ages 3-6 0 Adolescent Well-Care Visits 0 0 0 #DIV/0! 0 0 #DIV/0! 0 0 0 #DIV/0! 0 0 0 #DIV/0! 100.0% 0 0 0 100.0% 0 0 100.0% 0 0 100.0% 0 0 100.0% 0 Denom inator Meet Criteria 0 0 LDL-C Screening F/U Care for Children Prescribed ADHD Meds Initial Phase Follow-up After Hospitalization for Mental Il Follow-up Within 7 Days of Discharge 0 0 0 0 0 Timeliness of Prenatal Care Meet Criteria Denom inator Meet Criteria Doc3 0 0 % Meet Criteria 0% 0% 0 0 0% 0 0 0 0% 0 0 0 0% #DIV/0! 0 0 0 #DIV/0! 0 0 #DIV/0! 0 0 #DIV/0! 0 0 #DIV/0! 0 Practice % Meet Criteria 100.0% Denom inator 0 0 0% 0 0 0% 0 0 0 0% 0 0 0 0% 0% 0 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 Doc5 % Meet Criteria Meet Criteria Meet Criteria Doc4 % Meet Criteria 0% Denom inator 0 0 % Meet Criteria 0% 0% 0 0 0% 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0 0% 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0 % Meet Criteria 0% Doc6 0 0 % Meet Criteria 0% 100.0% 0 0 100.0% 0 0 0 100.0% 0 0 0 100.0% Timeliness of Postpartum Care 0 0 Frequency of Prenatal Care >81% Well-Child Visits in First 15 Mths of Life Six or More Visits 0 0 0 Well-Child Visits - Ages 3-6 Adolescent Well-Care Visits Measure Cervical Cancer Screening Denom inator Meet Criteria Doc2 % Meet Criteria 0% DS Denom inator Doc1 % Meet Criteria #DIV/0! Measure Cervical Cancer Screening Denom inator Denom inator Denom inator Doc7 0 0 % Meet Criteria 0% Denom inator 0% 0 0 0% 0 0 0 0% 0 0 0 0% 100.0% 0 0 100.0% 0 0 0 100.0% 0 0 0 100.0% 0 0 100.0% Meet Criteria Doc8 0 0 % Meet Criteria 0% 0% 0 0 0% 0 0 0% 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0% 0 0 0% 0 0 0% 0 0 0% 0% 0 0 0% 0 0 0% 0 0 0% 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% 0 0 0% P0608 Meet Criteria Meet Criteria Denom inator Meet Criteria Denom inator 32 Hoosier Healthwise MDwise Reports 120% 100% OMPP Target 80% DS Totals 60% Practice Totals 40% 20% 0% CCS CDC ADD FUH P0608 PPC PPC FPC W15 W34 AWC 33 Questions? Thank You for attending! P0608 34