Download Arkansas Health Care Payment Improvement Initiative Perinatal

Arkansas Health Care Payment Improvement Initiative
Perinatal Algorithm Summary
Perinatal Algorithm Summary v1.3
Triggers
PAP
assignment
Exclusions
Episode time
window
Claims
included
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An episode is triggered when a patient shows a claim with a delivery CPT procedure code. The patient’s claims will also be processed by the
OptumInsights ETG software, where they must me assigned an Episode Treatment Group (ETG) for pregnancy, with delivery. For specific DRG,
ICD-9-CM, and CPT/HCPCS procedure codes, please see dataset.
The Principal Accountable Provider (PAP) for an episode is physician enrolled in an Arkansas Blue Plan provider network that performs the
delivery procedure. This provider must also perform the majority of the prenatal care for the patient identified by claims with the appropriate
global OB bundle procedure, prenatal care bundle procedure, or office visit procedures. If office visits are used to determine prenatal care,
there must be claims with office visit procedures for at least 60 days prior to delivery in order for the office visits to qualify as prenatal care.
Episodes meeting one or more of the following criteria will be excluded:
A. The patient has claims or enrollment records that indicate coordination of benefits with another payer not associated with the Arkansas
Blue Plans within the duration of the episode
B. The patient does not have continuous coverage with at least one Arkansas Blue Plan for at least six months prior to delivery
C. The overall episode cost for the patient exceeds the outlier criteria. Currently, the outlier threshold is set at three standard deviations
above the average episode cost for all patients otherwise included in the reporting period for all PAPs
D. The patient has claims with CPT procedure codes indicating both cesarean and vaginal deliveries were performed
E. The patient shows multiple claims with delivery procedures with conflicting service dates preventing a systematic assignment of a delivery
date to the episode
F. The patient has claims indicating one of the following comorbidities within one year of the episode: 1) non-live birth, 2) cystic fibrosis, 3)
sickle cell anemia, 4) end stage renal disease, 5) sever preeclampsia, 6) placenta previa, 7) early threatened labor, 8) type I diabetes, 9)
cancer, 10) twins, 11) gestation over three, 12) congenital cardiovascular disorders, 13) suspected damage to the fetus from viral disease,
14) major puerperal infection, 15) puerpural endometritis, 16) puerpural sepsis, 17) puerpural septic thrombophlebitis, 18) other major
puerperal infection, 19) varicose viens of legs, 20) varicose veins of vulva and perineum, 21) superficial thromophlebitis, 22) deep
phlebothromobosis, 23) other phlebitis and thrombosis, 24) obstetrical air embolism, 25) amniotic fluid embolism, 26) obstetrical bloodclot embolism, 27) obstetrical pyemic and septic embolism, 28) other obstetrical pulmonary embolism, 29) cerebrovascular disorders in
the puerperium
G. Patient is an Exchange member
H. Patient is an Access Only member
Episodes begin on the day of the first service assigned the ETG for pregnancy, with delivery and conclude 60 days after the delivery. This
period typically extends for up to ten months prior to delivery through two months after delivery. Comorbidities are assessed within the
episode. Quality measures are assessed up to 270 days prior to delivery.
The episode will include all claims identified by the ETG for pregnancy with delivery prior to the delivery date through 60 days after delivery.
This includes all pregnancy-related medical assistance. Medical assistance related to neonatal care is not included.
Perinatal Algorithm Summary v1.3
Quality
measures
Utilization
measures
Adjustments
Trigger codes
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Quality measures “to pass” (payment related):
A. HIV screening rate within 270 days prior to delivery. A CPT procedure indicating the screening was performed or a diagnosis of HIV within
270 days prior to delivery qualifies as the screening. Must meet a minimum threshold of 80% of episodes.
B. Chlamydia screening rate within 270 days prior to delivery. A CPT procedure indicating the screening was performed within 270 days prior
to delivery qualifies as the screening. Must meet a minimum threshold of 80% of episodes.
C. Group B streptococcus screening rate within 84 days prior to delivery. A CPT procedure indicating the screening was performed within 84
days prior to delivery qualifies as the screening. Must meet a minimum threshold of 80% of episodes.
Quality measures “to track” (not payment related):
A. Hepatitis B screening rate within 270 days prior to delivery. A CPT procedure indicating the screening was performed within 270 days prior
to delivery qualifies as the screening.
B. UTI or asymptomatic bacteriuria screening rate within 270 days prior to delivery. A CPT procedure indicating the screening was performed
within 270 days prior to delivery qualifies as the screening.
C. Gestational diabetes screening rate within 270 days prior to delivery. A CPT procedure indicating the screening was performed or a
diagnosis of gestational diabetes within 270 days prior to delivery qualifies as the screening.
Utilization measures “to track” (not payment related):
A. Percentage of episodes with a cesarean delivery
The total reimbursements attributed to the PAP will be adjusted based on the presence complications that resulted in variations in treatment
using a multiplier determined by regression. Over time, risk factors may be added or subtracted based on new research and/or empirical
evidence.
Claims with following CPT procedure codes indicating a vaginal delivery are considered when triggering an episode:
Procedure codes: 59400, 59409, 59410, 59610, 59612, 59614
Claims with following CPT procedure codes indicating a cesarean delivery are considered when triggering an episode:
Procedure codes: 59510, 59514, 59515, 59618, 59620, 59622
The prenatal care requirement for the PAP is determined by the claims with the following CPT procedure codes:
Procedure codes: 59400, 59425, 59426, 59510, 59610, 59618, 99211, 99212, 99213, 99214, 99215, T1015
Exclusion
codes
An inpatient facility claim with one of the following DRG codes must be present in order to trigger an episode:
MS-DRG: 765, 766, 767, 768, 774, 775
Patients who have co-morbid condition(s) matching the following ICD-9-CM codes will be excluded:
ICD-9-CM codes: 140-208.99, 209.0-209.39, 209.7-209.79, 228-228.99, 230-239.99, 250.xx, 277.0x, 282.6x, 585.5, 585.6, 641.0x, 641.1x, or
641.2x, 642.5x, 644.0x, 644.1x, 648.5x, 651.0, 651.00, 651.01, 651.03, 651.1x-651.23, 651.3, 651.30, 651.31, 651.33, 651.4x-651.93, 655.3x,
670.0x, 670.1x, 670.2x, 670.3x, 670.8x, 671.0x, 671.1x, 671.2x, 671.3x, 671.4x, 671.5x, 673.0x, 673.1x, 673.2x, 673.3x, 673.8x, 674.0x, V27.1,
V27.4, V31.xx, V32.xx, V33.xx, V34.xx, V35.xx, V36.xx, or V37.xx, V45.1, V42.0, V56.xx, 656.4, 656.40, 656.41, 656.43, V27.3, V27.6, V27.7,
758.2, 779.9
Perinatal Algorithm Summary v1.3
Claims
included codes
Quality codes
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The episode will include all claims classified with an ETG of pregnancy, with delivery, until 60 days after delivery.
Claims with service dates within 270 days prior to delivery with the following CPT procedure or ICD-9-CM diagnosis codes will qualify the
episode for HIV screening:
ICD-9 codes: 042
Procedure codes: 80055, 84181, 84182, 86701, 86702, 86703, 87300, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87539
Claims with service dates within 270 days prior to delivery with the following CPT procedure codes will qualify the episode for chlamydia
screening:
Procedure codes: 3511F, 87110, 87270, 87320, 87451, 87490, 87491, 87492, 87797, 87798, 87799, 87800, 87801, 87810
Claims with service dates within 84 days prior to delivery with the following CPT procedure codes will qualify the episode for group B
streptococcus screening:
Procedure codes: 86403, 87070, 87071, 87075, 87077, 87081, 87147, 87149, 87449, 87653, 87797, 87798, 87800, 87801, 87802
Claims with service dates within 270 days prior to delivery with the following CPT procedure or ICD-9-CM diagnosis codes will qualify the
episode for gestational diabetes screening:
ICD-9 codes: 250.xx
Procedure codes: 82947, 82950, 82951, 82952
Claims with service dates within 270 days prior to delivery with the following CPT procedure codes will qualify the episode for UTI or
asymptomatic bacteriuria screening:
Procedure codes: 81000, 81001, 81002, 81003, 81005, 81007, 81015, 87077, 87081, 87086, 87088, 87149, 87152, P7001
Utilization
codes
Claims with service dates within 270 days prior to delivery with the following CPT procedure codes will qualify the episode for hepatitis B
screening:
Procedure codes: 80055, 80074, 86704, 86705, 86706, 86707, 87340, 87341, 87350, 87515, 87516, 87517
Claims with following CPT procedure codes indicating a cesarean delivery are considered when calculating the cesarean section rate:
Procedure codes: 59510, 59514, 59515, 59618, 59620, 59622