It’s all about Coding,
Caring, and Collaborating
Updated February 2013
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Appropriate and Complete
Coding
2
Why complete documentation/coding is
important to you…
•
•
•
•
Ensures appropriate benefit application and payment
Patients receive the best care management
Demonstrates a composite of the patient’s health
Complete documentation of diagnoses and corresponding coding
reduces on-site reviews
• Assists your practice/facility to manage increased detail needed for:
– complying with insurance companies quality measures
– government programs
– incentive programs such as the Physician Group Incentive Program and
the MA PPO Performance Recognition Program
3
Issues Related to Reporting
Diagnoses
• Too few diagnoses are reported
• Reported diagnoses lack specificity
– An example: patients with diabetes lack description of
complicating factors such as kidney failure, nerve damage, etc…
• Many diagnoses are over-reported, resulting in lower revenue
– Believed to be due to coding to “rule out” conditions that are not
present
4
Documenting Conditions
and Coding Specificity
• Documenting conditions and submitting complete diagnoses
– this means coding to specificity by following national coding
guidelines and to accurately describe a patient’s condition through
the coding nomenclature
• Important items for the medical record
– Document all of the patient’s existing health conditions.
– All chronic conditions must be documented and reported at least
once per year
– Follow national coding guidelines
– Include all required signatures, including credentials and signature
date
– Documentation in the medical record must be specific about
diagnoses
5
Best Guideline to Follow is CMS
• The federal Centers for Medicare & Medicaid Services Internet Only
Manual (Publication 100-04, Chapter 23, Section 10.A) provides
information on the appropriate diagnosis codes to include on your
claim. Here is the pertinent language from that section:
• “Rules for reporting diagnosis codes on the claim are:
• Use the ICD-9-CM code that describes the patient’s diagnosis,
symptom, complaint, condition, or problem. Do not code suspected
diagnosis.
6
Best Guideline to Follow is CMS
• Use the ICD-9-CM code that is chiefly responsible for the item or
service provided.
• Use the fourth and fifth digits where applicable.
• Code a chronic condition as often as applicable to the patient’s
treatment.
• Code all documented conditions that coexist at the time of the visit
that require or affect patient care or treatment. (Do not code
conditions that no longer exist.)”
7
CMS 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
• 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.
8
The Annual Wellness Visit
•At this visit the physician generally reviews and completes a full
examination of all body systems and reviews all medications the patient
is currently taking
•If modifications need to be made to the current prescriptions, the note
must state (as an example) “CHF stable on meds”, “condition worsening
and (specific name) medication adjusted, “HTN improving” including any
changes made to treatment plan.
•If any tests are ordered they need to be incorporated into the treatment
plan.
•Listing diagnoses, medications and tests in the medical record does not
meet documentation requirements.
9
The Annual Wellness Visit
•Chronic diseases treated on an ongoing basis may be coded and
reported as many times as the patient receives treatment and care for
the condition(s)
•The Affordable Care Act (ACA) provides for an Annual Wellness Visit
(AWV), Including Personalized Prevention Plan Services (PPPS) for
Medicare beneficiaries as of January 1, 2011.
Reference: MLN Matters® Number: MM7079
10
The Office Visit
The Office Visit documentation standards
History…
• Chief Complaint: A concise statement in the patient’s own words
describing the symptom, problem, reason for the office visit.
• History of Present Illness: A chronological description of the
patient’s condition from the first sign to the present
• Review of Systems: An inventory of body systems from asking the
patient questions in order to identify what the patient is
experiencing
• Past, Family, Social History: Notating any medical events,
diseases and hereditary conditions that may affect the patient
11
The Office Visit
Examination
• Problem focused
• Expanded problem focused
• Detailed
• Comprehensive
Medical Decision Making
• Refers to the complexity of establishing a diagnosis and/or
selecting a management option
12
The Office Visit
What is the reason for the office visit?
• The office visit note should consistently demonstrate the nature of the
presenting problem(s).
• The assessment, plan and diagnoses need to be complete and
consistent with the reason for the visit.
• Documentation must support the ICD-9 diagnoses that are reported
including a plan for each diagnosis.
• Document all conditions evaluated during each visit and code to the
highest level of specificity.
13
The Office Visit
• Any conditions that are present at the time of the visit that may affect
the patient care, treatment or management must be documented and
coded as an active condition, even if it is under control.
• Documentation does not need to be lengthy, just concise and clear;
see example below:
– For Atrial flutter: ICD-9 427.32
– Document: “Controlled by medication” rather than a history code for
‘unspecified circulatory disease.’
14
The Office Visit
• Keep in mind that a diagnosis can only be coded when it is
EXPLICITY described in the progress note
• Evidence must be documented in the medical record to support each
diagnosis.
• In the outpatient setting, use caution with terms like ‘rule out,’
‘consistent with’ or probable’ as they cannot be coded as the patient
actually having that condition/disease.
• “History of” is only appropriate in the assessment if the patient has
been cured.
15
The Office Visit
• Circling a code on an encounter form or listing a diagnosis on a
medical record problem list does not meet documentation
requirements. The diagnosis must be present in the note.
• Listing medications and scripts in a medical record does not meet
medical documentation requirements to substantiate that an
evaluation for a condition was performed.
• Listing a sequence of signs and symptoms and laboratory results
cannot substitute for a diagnosis.
16
How Coding Affects PGIP
• Analyzing data for all products to determine a true picture of
population’s health and disease management
• We risk score utilization metrics to risk adjust the population for each
physician organization
• The Professional Diagnosis Report – sent to PO to increase the
awareness of variations among the practices and POs
• Objective is to educate on the importance of submitting complete and
accurate coding
• Scores are compared against other physician organizations
17
How Coding Affects PGIP
• Affects PGIP incentive payments
• PGIP is expanding number of incentives based on risk adjustment
measures
• BCBSM includes risk adjustment in most measures to assure that
providers with more complete and accurate reporting of patient’s
conditions are financially rewarded.
• Outcomes will demonstrate improvement or lack of improvement in
coding
• Providers that report diagnosis with a greater level of granularity will
position themselves at a greater advantage in the PGIP program.
18
How coding affects PGIP
•
Coding at the highest level of Granularity.
 3 digit- category 250 (Diabetes Mellitus)
 4 digit- subcategory 250.4 (diabetes with renal
manifestations)
 5 digit- sub-classification 250.40 (diabetes with renal
manifestations not stated as controlled)
19
Tip Card: It All Begins with Correct
Documentation
20
Tip Card: It All Begins with Correct
Documentation
21
Tip Card: Criteria for Medical Record
22
Tip Card: Vascular Diseases
23
Tip Card: Cardiac Diseases
24
Tip Card: Respiratory Diseases
25
Tip Card: Breast, Prostate, Colorectal,
Cancers
26
Tip Card: Rheumatoid Arthritis & ICTD
27
Tip Card: Neurological Diseases
28
Tip Card: Diabetes and Neuropathy
29
Tip Card: Diabetes & Peripheral Vascular
Disease
30
Tip Card: Diabetes & Peripheral Vascular
Disease
31
Tip Card: Diabetes & Kidney Disease
32
Tip Card: Chronic Kidney Disease
33
Tip Card: Cerebral Hemorrhage/Ischemic Stroke
34
Tip Card: Cardio-Respiratory Failure and Shock
35
Tip Card: Chronic Ulcer of Skin (except
Decubitus)
36
Tip Card: Major Depressive, Bipolar & PD
37
Tip Card: Medical Complications
38
Resources – links for ICD-9-CM and
ICD-10-CM guidelines
• Link for the current ICD-9 coding guidelines
http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf
• Link for the current version of ICD-10-CM coding guidelines.
(Diagnosis only)
http://www.cdc.gov/nchs/icd/icd10cm.htm
39
Resources related to the implementation
of ICD-10-CM
•
40
Resources for information
– AHIMA's ICD-10 Resource Page
http://www.ahima.org/icd10/
– CMS
http://www.cms.gov/ICD10/
– World Health Organization website
http://www.who.int/classifications/icd/en/
– Implementation of ICD10:
http://www.who.int/classifications/icd/implementation/en/index.html
– The Updating Process:
http://www.who.int/classifications/icd/updates/en/index.html
– Federal Register: August 22, 2008 (Volume 73, Number 164)][Proposed
Rules] [Page 49795-49832]
www.access.gpo.gov/su_docs/fedreg/a080822c.html
– The final rule, published in the January 16, 2009 issue of the Federal
Register can be found at http://edocket.access.gpo.gov/2009/pdf/E9743.pdf
MEDICARE ADVANTAGE
CMS Risk Adjustment
41
What is Risk Adjustment?
CMS risk adjustment takes data from a large pool of Medicare
beneficiaries to estimate average costs in order to adjust payments
relative to the average Medicare beneficiary.
• Risk adjustment is used to determine the amount of money CMS pays
to Medicare Advantage health plans
• Medicare Beneficiaries with lower-than-average predicted costs have
their payments decreased to their plan
• Medicare Beneficiaries with higher-than-average predicted costs have
their payments increased to their plan
42
Why Care About Risk Adjustment?
• Compliance with CMS diagnostic submission requirements
• Improve Care Management services for members
• Receive proper reimbursement from CMS to keep premiums as low as
possible for our members and improve the health of the Michigan
economy
• The projection of CMS funding directly impacts member premiums
• A 1 percent improvement in risk scores can lower member premiums
by roughly 10 percent.
43
CMS Risk Adjustment –
Physician Records
• The diagnosis code has to be the 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 physician.
• 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.
• CMS conducts national Risk Adjustment Validation Audits (RADV) and
national samplings (industry-wide 30-40% error rate).
44
Address and Code Chronic Conditions
Annually
45
Acceptable Document Sources
• The following documents are considered acceptable documents
for abstraction:
• Discharge summaries
• Admission summaries
• History and physicals
• Consultations
• Surgical, procedure and/or pathology reports
• Physician’s progress notes
• Interventional or therapeutic imaging reports
• Emergency room records
46
Unacceptable Document
Sources
– The following documents are considered unacceptable documents for
abstraction:
• Documentation not from a face-to-face encounter (phone calls, etc.)
• Home health care records
• Durable medical equipment (DME) providers
• Pharmacies/prescriptions
• Ambulance records
• Orthotics and/or prosthetic provider records
• Laboratory services
• Diagnostic radiology reports
47
Unacceptable Document
Sources
• Non-acceptable provider type source documents
• Superbills
• Diagnosis attestation statements without evidence of a face-to-face
encounter
• Undated problem lists
• Physician orders
48
Acceptable Facility and Provider Types
• CMS has guidelines that identify acceptable physician specialties
as well as acceptable document sources.
• If documentation is not from an acceptable provider type, or from an
acceptable document source, it is not considered acceptable
according to CMS and may NOT be used to abstract diagnoses for
risk adjustment purposes.
49
Acceptable Physician Specialties
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…
50
Acceptable Physician Specialties
Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear Medicine
Nurse Practitioner
Obstetrics/Gynecology
Occupational Therapist
Oncology (Medical and Surgical)
Ophthalmology
Optometry (Optometrist)
Oral Surgery (Dentists Only)
Osteopathic Manipulative Therapy
Otolaryngology
Pain Management
Pathology
Pediatrics
Peripheral Vascular Disease
Physical Medicine and Rehabilitation
Physical Therapist
Physician Assistant
Plastic and Reconstructive Surgery
Podiatry
Preventive Medicine
Psychologist
Pulmonary Disease
Radiation Oncology
Rheumatology
Thoracic Surgery
Unknown Physician Specialty
Urology
Vascular Surgery
51
Acceptable Physician Signatures
Purpose of the provider 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 requirements
In order for a provider signature to be considered acceptable, three specific
provider signature elements must be present:
• Full, legible name or initials
• Acceptable provider credentials
• Either a handwritten signature or electronic authentication
Note: Signature stamps have not been acceptable as of 09/03/2007.
52
Acceptable Authentication (Electronic)
Approved
by
Acceptable
PhysicianDigital signed
Signatures
Authenticated
by
Acceptable
Signature on file
Digitally reviewed and
Signed, but not
Authentication
(Electronic)
(Not allapproved
meticulously
reviewed
inclusive)
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
53
Unacceptable Authentication (Electronic)
Added
by/Addended by
Acceptable
Physician
Signatures
Author
Initiated by
Rendered by
Interpreted by
Signed out by proxy
Unacceptable Authentication
Table (Electronic)
(Not
Last generated by
Status preliminary
all Inclusive)
Created by
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
54
Risk Adjustment Case Study
• 85 year old white female, symptoms of UTI.
• Patient is tired, less energy and poor appetite and had a heart attack
(MI) one year ago. Patient 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.
• 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 3.
• Plan: Glucophase 500 mg b.i.d. for DM. Cipro for UTI. Ensure
supplements for malnutrition. RTC in three months. Referral to
nephrologist for CKD3.
55
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
0.162
599.0
0.0
Demographic
Score
0.637
Total RAF
Score
Total Payment
$750 (Illustrative
Purposes) x RAF Score
0.799
- 0.0829**
0.716
$537.06
Scenario 2 – What can be coded and reported by the physician
Diabetes Mellitus
w/Renal
Manifestations
UTI
250.40
0.508
0.637
3.291
- 0.342**
2.949
$2,212.10
599.0
0.0
Diabetic
Nephropathy
583.81
Trumped by
CKD Stage 3
CKD Stage 3
585.3
0.368
Mild Degree
Malnutrition
263.1
0.856
Payment = Plan’s Base Payment x Total RAF Score
412
0.244
V49.75
0.678
Data provided reflects 2012 payment year for 2011 dates of service.
**Includes CMS normalization and coding intensity factors that
reduce RAF scores.
Old MI
BKA Status
Missing Digits and Undercoding
on Claims
Issues:
• Incomplete or lack of specificity
• With ICD-10 CMS will likely modify the model
to be more refined exacerbating the problem
Real examples of potential lost revenue due to lack of specificity in claims and records:
Missing Digit
Claims
ICD-9
Description
250.00
Diabetes without complications
Actual
HCC
19
Revenue
$1,307
493.00
Total Revenue
$1,307
ICD-9
Description
HCC
250.60
Diabetes with neurologic or
other specified manifestation
16
$3,291
493.20
COPD
108
$3,218
Total Revenue
Revenue
$6,509
Under Coded Claim
Claim
ICD-9
Description
250.00
Diabetes without complications
Total Revenue
57
Documentation
HCC
19
Revenue
ICD-9
Description
$1,307
250.60
Diabetes with neurologic or
other specified manifestation
16
$3,291
357.20
Polyneuropathy
71
$2,637
$1,307
Total Revenue
HCC
Revenue
$5,928
RADV-Purpose
Section 1853(a)(3) of the Social Security Act requires CMS to risk
adjust payments to MA plans
• CMS wants to ensure risk-adjusted payment integrity and accuracy
for MA plans. RADV audits allow CMS to comply with the Improper
Payments Elimination and Recovery Act of 2010 (IPERA)
– Risk adjust Part C payments
– Validate payments (based on diagnosis codes)
– Report the payment error
58
Common Medical Record Errors found on
Risk Adjustment Data Validation audits
• Incomplete medical record
• Missing and/or illegible physician/practitioner signature and/or credential
• Coding discrepancy
• Missing record
• Other
– Incorrect beneficiary
– Name on record and name on cover sheet did not match
– Date of service (DOS) outside of data collection period
– Invalid provider type (i.e., SNF, DME, freestanding ambulatory surgical
centers, pharmacy, etc.)
59
References
• CY 2011 CMS Risk Adjustment Data Validation Overview
http://www.cms.gov/Medicare/Medicare-Advantage/PlanPayment/Downloads/RADVIndustryTrainingSlides.pdf
• National Kidney Foundation of Michigan: http://nkfm.org/
• Official ICD-9-CM Guidelines for Coding and Reporting Effective October 1,
2011: http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf
• Optum 2013 ICD-9-CM Expert for Hospitals and Payers -Volumes 1,2,& 3,
6th Edition.
60
CMS Stars Overview
61
Overview
• The CMS Stars program has a three-part goal: members receiving
better care; healthier people and communities, and affordable care.
• The program focuses on improving:
– Member health
– Health care delivery
– Quality of service
• CMS measures plans in three areas: health plan operations, clinical
outcomes, and member satisfaction
• CMS provides a rating system for patients on the overall plan and
supporting network.
62
Overview
(Continued)
• Plans that fail to obtain an overall rating of at least four stars could
have their contract cancelled by CMS
• We are approaching this with multiple interventions
– Disease management
– Provider Delivered Care Management Program
– Primary care provider and patient/member communication
– Home visits for members without primary care provider
relationship
63
Measures Fall into Four Categories
HEDIS
(Health
Effectiveness
Data and
Information
Set)
CMS
administrative
measures
CAHPS
(Consumer
Assessment of
Healthcare
Providers and
Systems)
64
Health
Outcomes
Survey
Treatment Opportunities
65
Treatment Opportunities
• Shift in health care to paying for quality
• Treatment Opportunities
– Detail data at physician and patient level
– Treatment opportunity listings are sent to physician organizations
for distribution to their physician membership
– Consultants/provider rep role in assisting with closing treatment
opportunities
– Quality indicators
• 26 measures
• 16 measures in MA Performance Recognition Program
– To receive credit for closing PRP indicators, supplemental data for
services rendered must be billed on a claim, documented in the
medical record and some services entered into Health e-BlueSM
66
26 Treatment Opportunities
• Adult BMI assessment (H)
• Annual monitoring for patients
on persistent medications:
– ACE inhibitors or ARBS (H)
– Digoxin (H)
– Diuretics (H)
– Anticonvulsants
• Carbemazepine (H)
• Phobarbital (H)
• Phenytoin (H)
• Valporic Acid (H)
• Breast cancer screening (C, H)
• Cholesterol management for
patients with cardiovascular
conditions (LDL-C Screening) (C, H)
• Colorectal cancer screening (C, H)
• Comprehensive diabetes care
–
–
–
–
–
–
HbA1c testing (H)
Eye exam (retinal) (C, H)
LDL-C testing (C, H)
LDL level <100 (H)
Monitor nephropathy (C, H)
Medications for high blood pressure
recommended for diabetes (C)
C = Claims; H = HEB
67
26 Treatment Opportunities (continued)
• Controlling high blood pressure
(actual BP values) (MR)
• Disease modifying antirheumatic drug therapy in
rheumatoid arthritis
– RA management (C,H)
• Glaucoma screening in older
adults (C, H)
• Osteoporosis management in
women with a fracture (C,H)
• Prescriptions for drugs with
high risk of side effects (inverse
measure) (C)
• Prescriptions for drugs with
high risk of side effects when
there may be safer drug
choices (inverse measure) (C)
• Cholesterol (statins) (C)
• Oral diabetes medications (C)
• Hypertension (C)
C = Claims; H = HEB; MR = Medical Record
68
Performance Recognition Program
69
Performance Recognition Program Philosophy
Program objectives:
• Increase HEDIS® scores and Stars ratings for Blues Medicare
Advantage members
• Reward physicians for providing quality care to members
Program components:
• BCBSM and BCN measure the same services in the same way
• Three components of the program:
– Base PRP
– Pay As You Go
– PRP Bonus
70
Provider Types Included
PCP-type provider relationships
•
•
•
•
•
•
•
•
•
71
Adult medicine
Family practice
Family medicine
Geriatric medicine
General practice
Health clinic practice
Internal medicine*
Nurse practitioner
Physician assistant
Six *subspecialties within internal
medicine (if patients attributed)
• Cardiovascular disease
• Endocrinology, diabetes, &
metabolism
• Hematology
• Infectious disease
• Nephrology
• Rheumatology
Base PRP Highlights
• Quality composite target based on preventive screenings and disease
management measures with a focus on HEDIS® measures
• Possible payment ranges from $2 to $5 per member per month depending
on the PCPs composite score
• PCP must have signed and be in full compliance with the BCBSM MA
PPO Provider Agreement
• Must be affiliated with the BCBSM MA PPO for the entire 2013 calendar
year as well as at time of payment (unless the PCP is recently retired)
• PCP or office is required to be registered with HEB and actively use the
program.
72
Base PRP Measures
•
•
•
•
•
•
•
•
73
Breast cancer screening
Cholesterol management for patients with cardiovascular
disease – LDL-C testing
Colorectal cancer screening
Comprehensive diabetes care – A1C control <9%
Comprehensive diabetes care – LDL-C testing
Comprehensive diabetes care – LDL-C level <100 mg/dL
Comprehensive diabetes care – monitoring for nephropathy
Comprehensive diabetes care – retinal eye exam
Base PRP Highlights
• Paid annually to individual PCP; payment will be in Spring 2014
• Payout is tiered and depends on the PCP’s composite target rate
74
Quality Composite
Score
PMPM
( Per member per month)
70 % - 74%
$2.00
75 % - 79%
$3.50
>= 80%
$5.00
Pay As You Go Highlights
• Focus on HEDIS® oriented measures
• Payments made for services that have been completed
during 2013
• Payments will be made in: Fall 2013 and Spring 2014
• Payment per service will be paid once per eligible
member: $10
• Provider must be participating with BCBSM at time of
payment to earn payment.
• All components of each quality measure must be
completed to earn a payment.
• Measures: same measures as Base PRP
• Paid to individual PCP
75
PRP Bonus Highlights
• Focus on measures not part of the Base PRP/Pay As You Go
• Paid once a year for a specific time period : Spring 2014
• Measurement Timeframe: January 1, 2013 through
December 31, 2013
• Payment is made at the group level. If PCP does not belong to a
practice group, then payment is made at the individual level.
• Based on five measures
76
PRP Bonus Highlights
• Five measures:
• Adult BMI (potential reward = $200 overall practice group score)
- Members 18 to 74 years of age who had an outpatient visit
and whose body mass index was documented during the
measurement year or the year prior to the measurement year.
- Continuous Enrollment: The measurement year and the year
prior to the measurement year.
77
PRP Bonus Highlights
•
78
Annual monitoring for patients on persistent medications –
(potential reward = $200 overall practice group score)
- 18 years of age and older as of December 31 of the
measurement year.
- Continuous Enrollment: The measurement year
- The percentage of members 18 years of age and older who
received at least 180 treatment days of ambulatory medication
therapy for a selected therapeutic agent during the
measurement year and at least one therapeutic monitoring
event for the therapeutic agent in the measurement year.
PRP Bonus Highlights
• Annual monitoring for patients on persistent medications (continued)
 Annual monitoring for members on angiotensin converting
enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
 Annual monitoring for members on digoxin
 Annual monitoring for members on diuretics
• Monitoring for ACE/ARBs, digoxin, diuretics including lab tests:
 Lab panel, serum potassium, serum creatinine, blood urea
nitrogen (BUN)
79
PRP Bonus Highlights
Annual monitoring for patients on persistent medications
(continued)
• Annual monitoring for members on anticonvulsants
• Monitoring for anticonvulsants
– Phenobarbital
– Phenytoin (Dilantin)
– Valproic acid (Depakote)
– Carbamazepine (Tegretol)
80
PRP Bonus Highlights
• Diabetes treatment (ACE/ARB for hypertension) (potential reward
= $200 overall practice group score)
- The percentage of Medicare members 18 years of age and
older dispensed a medication for diabetes and for
hypertension who were receiving an ACEI or ARB medication
which are recommended for people with diabetes.
• Glaucoma testing (potential reward = $125-$300 overall practice
group score)
- Glaucoma test performed by an eye care professional
- Medicare members 67 years and older as of December 31 of
the measurement year.
- Continuous Enrollment: The measurement year and the year
prior to the measurement year.
81
PRP Bonus Highlights
• Use of high risk medication in the elderly (potential
reward = $450 overall practice group score)
- Members 65 of age or older as of December 31st of the
measurement year
- Continuous Enrollment: The measurement year
- Rate being scored and reported:
- At least one prescription dispensed for any high risk medication
during the measurement year
- A lower rate represents better performance
- Medications that are considered to be high risk for the elderly
include medications such as narcotics, amphetamines,
barbiturates
82
Prescriptions for drugs with high risk sideeffects
Details on medications in this measure reference: NCQA.org
DAE-A
•
•
•
•
•
•
•
Anti-anxiety
Anti-emetics
Analgesics
Anti-psychotic
Amphetamines
Barbiturates
Long-acting
benzodiazepines
• Calcium channel blockers
• Gastrointestinal
antispasmodics
83
•
•
•
•
•
•
•
Belladonna alkaloids
Skeletal muscle relaxants
Oral estrogens
Oral hypoglycemics
Narcotics
Vasodilators
Others (including androgens
and anabolic steroids,
thyroid drugs, urinary antiinfectives)
Blues Medicare Advantage Performance
Recognition Program
Measure
Breast Cancer Screening
Cholesterol Screening for Patients with Diabetes
Cholesterol Screening for Patients with Heart Disease
Colorectal Cancer Screening
Diabetes Care – Blood Sugar Controlled
Diabetes Care – Cholesterol Controlled
Diabetes Care – Eye Exam
Diabetes Care – Kidney Disease Monitoring
Annual Monitoring For Patients on Persistent Medications
Diabetes Treatment (ACE/ARB for Hypertension)
Glaucoma Testing
High Risk Medication
Adult BMI Assessment
84
Final
Measure
Yes
Yes
Yes
yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Measure
Type
BASE/PAYG
BASE/PAYG
BASE/PAYG
BASE/PAYG
BASE/PAYG
BASE/PAYG
BASE/PAYG
BASE/PAYG
BONUS
BONUS
BONUS
BONUS
BONUS
Summary of BCN Advantage HMO-POSSM and BCBSM Medicare Plus Blue
PPOSM 2013 Performance Recognition Program
2013 Base PRP Measures
Quality – Preventive measures
•
•
Cancer screening
Colorectal cancer screening
Diabetes retinal eye exam
Diabetes HbA1C level < 9
Diabetes monitoring for nephropathy
Diabetes LDL-C level < 100
Diabetes LDL-C testing
Cardiovascular disease LDL-C testing
Quality Payout –
85
•
•
•
•
•
•
Quality – Disease management
•
•
•
•
•
•
2013 Bonus Incentives
Quality composite score PMPM
70%-74%
$2.00
75%-79%
$3.50
>= 80%
$5.00
•
•
•
Annual monitoring for patients on
persistent medications
Diabetes treatment (ACE/ARB for
hypertension)
Glaucoma testing
High risk medications
Adult BMI
2013 Pay As You Go Incentives
•
All of the base PRP measures
Scoring and Payout
•
•
Fall 2013 and Spring 2014
Payment PAYG $10