Health Care Homes Help — Data Entry Results Screen
Tier e Results
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Overview
Aggregated Diagnostic Groups (ADG)
Complexity Level Modifier
Expanded Diagnostic Cluster (EDC)
Language
Mental Illness
MHCP Found
MTMS (Medication Therapy Management Services)
NPI
P4P (Pay-for-performance)
Resource Utilization Band (RUB)
Tier Level
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Overview
The HCH Data Entry Results is a guide for the health care home team at your clinic. Review every recipient’s/patient’s preliminary
tier assignment to confirm that the patient complexity was accurately assessed.
Aggregated Diagnostic Groups (ADG)
ADGs are groups of ICD diagnosis codes that are homogenous with respect to clinical criteria and expected need for healthcare
services. The ADG categories reflect the entire spectrum of care, with certain ADGs indicating preventive care, while others
assigned when specialty care is more likely. Recipients/Patients with only one diagnosis over a time period are assigned only one
ADG, while a recipient/patient with multiple diagnoses can be assigned to one or more ADGs. To be included in HCH Tiers 1-4, a
patient must be included in at least one ADG group that indicates that their condition is chronic, severe, and requires a care team
to coordinate services in order to attain or maintain the recipient’s/patient’s stability or to reach their optimal goals. Time-limited
ADGs (ADG 3 and ADG 4) do not meet HCH Tier eligibility criteria. ADGs are generated by the MHCP risk adjustment software,
the ACG System.,.
Complexity Level Modifier
The Health Care Home modifier defined by MHCP as indicating the Tier level. One Complexity Level Modifier is required when
billing the S0280 or S0281 procedure code. See the Tier Level description for more information.
Expanded Diagnostic Cluster (EDC)
EDC’s are broad groupings of diagnosis codes that remove differences in coding behavior between practitioners. ICD codes within
an EDC share similar clinical characteristics and evoke similar types of diagnostic and therapeutic responses. The main criterion
used for the ICD-to-EDC assignment is diagnostic similarity. EDC groups are generated by mapping ICD codes that refer to the
same disease or condition to a single EDC. EDCs that are associated with the same organ system are rolled up into condition
groups that are summed and mapped to a HCH tier level. EDC condition groups that do not indicate a need for sustained care
coordination do not meet HCH tier eligibility criteria. These include: ADM (administrative). GSU (general surgery), GSI (general
signs and symptoms), NEW (neonatal), and REC (reconstructive) classes. EDCs are generated by the MHCP risk adjustment
software, the ACG® System.
Refer to the EDC Code and Description list for a complete description.
Language
Indicator field for provider use. Mark 'Y' if recipient/patient needs to communicate about their health care in a non-English primary
language. This means that the recipient’s/patient’s English skill levels are not sufficient to discuss and create complicated care
plans, complex care choices and options, etc. This also includes those recipient’s/patients who are hearing impaired and require a
sign language interpreter. Please consider whether the language barrier is significant enough to prevent a discussion with a
recipient’s/patient’s care team for care coordination services for patients with severe chronic conditions. If so, the U3 modifier
should be used when billing the S0280 or S0281 procedure code. This extra designation for non-English speaking
recipients/patients is in addition to any billing that is done for interpreter services for interpretation. This designation is for the extra
work of care coordination.
Mental Illness
A “Y” indicates the recipient’s/patient’s conditions indicate a “Serious and Persistent Mental Illness”. These “Serious and
Persistent Mental Illness” are defined in Minnesota Statute 245.462, subdivision 20. The health care home team should review the
recipient’s/patient’s record to confirm whether the diagnosis is associated with some level of functional impairment resulting in a
more intense need for care coordination. If so and the patient is a MHCP recipient, the U4 modifier should be used when billing
the S0280 or S0281 procedure code. This designation is in addition to the condition count for the condition group associated with
the mental health diagnoses. ‘U4’ means that a diagnosis of schizophrenia, bipolar disorder, major depression or borderline
personality disorder was entered for this recipient/patient. The U4 modifier may also be used when the caregiver of a dependent
recipient has these diagnoses. If so and the patient is not a MHCP recipient, contact the payer for more billing information.
MHCP Found
A “Y” value indicates the recipient’s major program is eligible for health care home services.
MTMS (Medication Therapy Management Services)
A “Y” means that the recipient/patient is potentially eligible for the MHCP MTMS program, based on the number of chronic
diagnoses that had been entered. If the patient is a MHCP recipient, see the MHCP Provider Manual – Medication Therapy
Management Services chapter for additional eligibility requirements. If the patient is not a MHCP recipient, contact the payer for
potential eligibility on a similar program.
NPI
NPIs are the standard unique health identifier to use in submitting and processing health care claims and other transactions.
P4P (Pay-for-performance)
MHCP fee-for-service (FFS) recipients of the Medical Assistance (MA), General Assistance Medical Care (GAMC) and
MinnesotaCare programs are eligible for the MHCP Pay-for-Performance program if the provider renders optimal chronic disease
care and the patient meets the following criteria:
1. Be 18-75 years of age
2. Have a diagnosis in one or both of the following categories:
 Diabetes
 Cardiovascular disease
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A "C" means that cardiovascular diagnoses covered by the MHCP Pay-for-Performance program were entered for the
recipient/patient. A "D" means that diabetes diagnoses covered by the MHCP Pay-for-Performance program were entered for the
recipient/patient. A “B” means that the diagnoses covered under both Pay-for-Performance programs were entered for the
recipient/patient. If the patient is a MHCP recipient, MHCP fee-for-service (FFS0 providers who render optimal chronic disease
care to their qualifying MHCP FFS recipients are eligible for $250 results awards twice in 12 months. See MHCP Industry
Initiatives – Pay-for-performance for additional eligibility requirements. If the patient is not a MHCP recipient, contact the payer for
potential eligibility on a similar program.
Resource Utilization Band (RUB)
RUBs are groups of ACGs that have similar resource use. RUBs can be used as an indicator of severity/co-morbidity. 0 = no or
only invalid diagnoses, 1 = healthy health care users, 2 = low morbidity, 3 = moderate morbidity, 4 = high morbidity, 5 = very high
morbidity. RUBs are generated by the MHCP risk adjustment software, the ACG System.
Tier Level
The preliminary Health Care Home tier level calculated by the Tier e-Tool based on the diagnoses and medications entered for the
recipient/patient.
The accuracy of the Tier e-Tool tier assignment depends on a complete list of ICD codes being submitted for each
recipient/patient. The chronic disease diagnoses are grouped in condition groups based on organ system. The Tier e-Tool
generates a count of chronic condition groups for each recipient/patient. The Tier e-tool converts the count of chronic condition
groups into a preliminary HCH tier using the table shown below.
Number
of
Condition
Groups
0
1–3
4–6
7–9
10 or
more
HCH
Tier
Complexity
Tier Level
0
1
2
3
4
None
U1
TF
U2
TG