Download HICM November 2014

High Intensity Care Management
November 4, 2014
Webinar
Additional 2014 Clinical Model
Elements
The following elements of the clinical model cannot be tracked/measured via the
claims system, but are identified as important goals within the clinical model.
Physician Organizations should track these metrics. Metrics will be discussed at
joint meetings, in addition, Physician Organizations may be asked to submit data to
BCBSM.
Clinical Model Goal
Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach
patient via telephonic or in-person verbal contact)
Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted
Members patients, and for 100% of Accepted Members within 6 months
Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness
visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of
patients within 6 months
Quarterly review/update of care plan for engaged patients
Hospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient
needs
SNF to home transition initial contact within 24-48 hours of discharge for engaged patients
SNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients
SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency
of phone calls dependent upon patient needs
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10-1-14
HICM Common Clinical Model Components
4-1-15
Subset of
Core
Model
Core
Model
Comprehensive
Clinical Model
1.24/7 phone access to clinical decision-maker with electronic access to pt record
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2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses
capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for
homebound) – top priority for July 1, 2014 start
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3. In-home health care assessment by PCP, NP, or PA for homebound
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4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including
in-home assessments
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5. Patient-specific comprehensive care plan (updated at least quarterly)
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6. Care management team includes pharmacist and nutritionist
7. Access to in-home PT and OT
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8. Care transitions management – Hospitals
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9. Care transitions management – SNFs
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10. Access to palliative care team
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11. Access to hospice
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12. Transportation for non-emergent medical visits and Rx
2016
13. Remote patient monitoring (weight, BP, glucose)
2016
14. Standardized staff training
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15. Review of all patients on monthly patient lists, common outreach script (2nd
outreach by PCP as needed); POs maintain disposition information on all patients on
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Medicare Advantage STAR
Recognition Program
Medicare STAR Ratings

The CMS star rating program is a pay-for-performance
program for Medicare Advantage plans

Plans will now receive revenue based on outcomes and the
quality of their performance

The higher the quality ranking, the higher the payments and
the more competitive the plan is in the marketplace

This is an attempt by CMS to create a new paradigm to bend
the cost curve
What’s Measured

STAR ratings measure a Plan’s performance in
delivering quality outcomes

STAR ratings are based on 53 key quality measures
(36 related to Medicare and 17 related to
prescription drug coverage) across the five
following domains (subset of HEDIS measures)
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What do CMS STARS Rating Measure





Staying Healthy: screenings, tests, and vaccines
Managing chronic (long term) conditions
Ratings of health plan responsiveness and care
Member complaints, problem getting services, and
choosing to leave the plan
Health plan customer service
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What’s It Look Like
Clinical quality and
outcomes
HEDIS
Member perceptions of
Plan, providers and care
CAHPS
Plan administrative
performance and
compliance
Member
assessment of their
health
(Health Outcomes
Survey)
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2014 Provider Outreach Activities

Diagnosis coding education where DDDS is not
part of practice

HEDIS/STARS for all targeted providers

Activities include:
• Address and close HEDIS/STARS treatment
opportunity gaps
• Address and close Enterprise and BCNA risk
adjustment diagnosis gaps
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2014 Provider Outreach Activities

Activities include:
• Support HEB education and sign-up
• Support provider staff on scheduling member
appointments
• Provide education to providers
• Provide reference tools and materials to providers
• Retrieve medical records related to treatment
opportunity gaps if necessary
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2014 Provider Outreach Activities

Activities include:
• Retrieve medical records for BCNA risk adjustment
diagnosis gaps, BCNA only
• Complete focus-driven activities as specified
• Report on outreach activities completed by practice
unit/providers
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Provider Recognition Program
MA PPO 2013
MA PPO 2014
BCNA 2013
BCNA 2014
Base PRP
Quality Preventative
Breast Cancer screening
Breast Cancer screening
Breast Cancer screening
Breast Cancer screening
Colorectal cancer screening
Colorectal cancer screening
Colorectal cancer screening
Colorectal cancer screening
Quality Disease Management
Diabetes Retinal Eye Exam
Diabetes Retinal Eye Exam
Diabetes Retinal Eye Exam
Diabetes Retinal Eye Exam
Diabetes HbA1C level <=9%
Diabetes HbA1C level <=9%
Diabetes HbA1C level <=9%
Diabetes HbA1C level <=9%
Diabetes monitoring for nephropathy
Diabetes monitoring for nephropathy
Diabetes monitoring for nephropathy
Diabetes monitoring for nephropathy
Diabetes LDL-C testing
Diabetes LDL-C testing
Diabetes LDL-C testing
Diabetes LDL-C testing
Diabetes LDL-C level < 100 mg/dl
Diabetes LDL-C level < 100 mg/dl
Diabetes LDL-C level < 100 mg/dl
Diabetes LDL-C level < 100 mg/dl
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C level <100 mg/dl
Cardiovascular disease LDL-C level <100 mg/dl
Quality Payout
0%-69% = $0.00 PMPM
0%-71% = $0.00 PMPM
0%-69% = $0.00 PMPM
0%-71% = $0.00 PMPM
70%-74% = $2.00 PMPM
72%-74% = $2.00 PMPM
70%-74% = $2.00 PMPM
72%-74% = $2.00 PMPM
75%-79% = $3.50 PMPM
75%-79% = $3.50 PMPM
75%-79% = $3.50 PMPM
75%-79% = $3.50 PMPM
>=80% = $5.00 PMPM
>=80% = $5.00 PMPM
>=80% = $5.00 PMPM
>=80% = $5.00 PMPM
Payable to Practice Group based on overall score
Payable to Provider for each eligible service
Payable to Practice Group based on overall score
Payable to Provider for each eligible service
Adult BMI $200 to practice group--score 67% or greater
Annual Monitoring for persistent meds $200 to practice group -score 94% or >
Adult BMI $10 each eligible service--score 80% or greater
Adult BMI $200 to practice group--score 67% or greater
Annual Monitoring for persistent meds $200 to practice group -score 94% or >
Adult BMI $10 each eligible service--score 80% or greater
Bonus PRP
Diabetes treatment with ACE/ARB for hypertension $200 to prac grp-- Diabetes treatment with ACE/ARB for hypertension $20--score 87% Diabetes treatment with ACE/ARB for hypertension $200 to prac grp- Diabetes treatment with ACE/ARB for hypertension $20--score
score 87% or>
or>
-score 87% or>
87% or>
Glaucoma testing $125-$300 depending on prac grp score:
Glaucoma testing $20-$40 depending on provider score:
Glaucoma testing $125-$300 depending on prac grp score:
Glaucoma testing $20-$40 depending on provider score:
score 70%-74% payment $125
score 70%-74% payment $20 each eligible service
score 70%-74% payment $125
score 70%-74% payment $20 each eligible service
score 75%-100% payment $300
score 75%-100% payment $40 each eligible service
score 75%-100% payment $300
score 75%-100% payment $40 each eligible service
High Risk Medications $450 depending on prac grp score--score 5%
or<
High Risk Medications $20 each eligible service --score 10% or<
High Risk Medications $450 depending on prac grp score--score 5%
or<
High Risk Medications $20 each eligible service --score 10% or<
Pay As You Go
Same measures as Base PRP but payable for one service per each eligible member per year
Breast Cancer screening
$ 10 Breast Cancer screening
$ 10 Breast Cancer screening
$
10 Breast Cancer screening
$
10
Colorectal cancer screening
$ 10 Colorectal cancer screening
$ 10 Colorectal cancer screening
$
10 Colorectal cancer screening
$
10
Diabetes Retinal Eye Exam
$ 10 Diabetes Retinal Eye Exam
$ 20 Diabetes Retinal Eye Exam
$
10 Diabetes Retinal Eye Exam
$
20
Diabetes HbA1C level <=9%
$ 10 Diabetes HbA1C level <=9%
$ 20 Diabetes HbA1C level <=9%
$
10 Diabetes HbA1C level <=9%
$
20
Diabetes monitoring for nephropathy
$ 10 Diabetes monitoring for nephropathy
$ 20 Diabetes monitoring for nephropathy
$
10 Diabetes monitoring for nephropathy
$
20
Diabetes LDL-C level < 100 mg/dl
$ 10 Diabetes LDL-C level < 100 mg/dl
$ 20 Diabetes LDL-C level < 100 mg/dl
$
10 Diabetes LDL-C level < 100 mg/dl
$
20
Diabetes LDL-C testing
$ 10 Diabetes LDL-C testing
$ 10 Diabetes LDL-C testing
$
10 Diabetes LDL-C testing
$
10
Cardiovascular disease LDL-C testing
$ 10 Cardiovascular disease LDL-C testing
$ 10 Cardiovascular disease LDL-C testing
$
10 Cardiovascular disease LDL-C testing
$
10
$
10
Cardiovascular disease LDL-C level <100 mg/dl
$ 10
Cardiovascular disease LDL-C level <100 mg/dl
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Claims Coding Reference
Measure
Codes
Adults’ Access to Preventive/
Ambulatory Health Services
(AAP)
CPT® codes to identify preventive/ ambulatory health services:
Office or other outpatient services: 99201-99205, 99211-99215,
99241-99245
Home services: 99341-99345, 99347-99350
Nursing facility care: 99304- 99310, 99315, 99316, 99318
Domiciliary, rest home or custodial care services: 99324-99328,
99334-99337
Preventive medicine: 99381- 99387, 99391-99397, 99401- 99404,
99411, 99412, 99420, 99429
HCPCS: G0402, G0438, G0439, S0620, S0621
Ophthalmology and optometry: 92002, 92004, 92012, 92014
General medical examination:
ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Adult Body Mass Index (ABA)
Assessment
CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 9934799350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420,
99429, 99455, 99456
HCPCS: G0402, G0438, G0439
ICD-9-CM Codes to identify BMI: V85.0-V85.5
Exclusions: Members with a diagnosis of pregnancy in the measurement
year or the year prior to the measurement year.
ICD-9-CM: 630-679, V22, V23, V28
Breast Cancer Screening (BCS)
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Claims Coding Reference
Measure
Codes
Annual Monitoring for Patients
on Persistent Medications
(MPM)
Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics:
Drug serum concentration for serum potassium:
CPT®: 80051, 84132
Drug serum concentration for serum creatinine:
CPT®: 82565, 82575
Drug serum concentration for blood urea nitrogen:
CPT®: 84250, 84525
*Drug serum concentration for Digoxin:
CPT®: 80162
Monitoring for Anticonvulsants:
Drug serum concentration for phenobarbital:
CPT®: 80184
Drug serum concentration for carbamazepine:
CPT®: 80156, 80157
Drug serum concentration for phenytoin:
CPT®: 80185, 80186
Drug serum concentration for valproic acid and divalproex
sodium:
CPT®: 80164
Lab panel codes:
CPT®: 80047, 80048, 80050, 80053, 80069
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Claims Coding Reference
Measure
Codes
Breast Cancer Screening
(BCS)
CPT®: 77055-77057
HCPCS: G0202, G0204, G0206
ICD-9-PCS: 87.36, 87.37
Exclusions: Members with a bilateral mastectomy. Any of the following
meet criteria for bilateral mastectomy:
Bilateral mastectomy
ICD-9: 85.42, 85.44, 85.46, 85.48
Unilateral mastectomy
CPT®: 19180, 19200, 19220, 19240, 19303-19307
ICD-9-PCS: 85.41, 85.43, 85.45, 85.47
Two unilateral mastectomies
*50 and 09950 modifier codes indicate the procedure was bilateral and
performed during the same operative session.
Cholesterol Management for
Patients with Cardiovascular
Conditions (CMC)


CPT®: 80061, 83700, 83701, 83704, 83721 Plus
CPT® II: 3048F, 3049F, 3050F
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Claims Coding Reference
Measure
Codes
Claims Coding FOBT
Reference
Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013:

Colorectal
Cancer
Screening (COL)
 CPT®: 82270, 82274
 HCPCS: G0328
Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013:
 CPT®: 45330-45335, 45337-45342, 45345
 HCPCS: G0104
 ICD-9-PCS: 45.24
Colonoscopy between 1/1/2004 and 12/31/2013:
 CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392
 HCPCS: G0105, G0121
 ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, 45.43
AND/OR
Chart documentation of previously performed colorectal cancer screening
tests.
Exclusions: Members with a history of either of the following:
 Colorectal cancer
 HCPCS: G0213-G0215, G0231
 ICD-9-CM: 153, 153.0-153.9, 154.0, 154.1, 197.5, V10.05
 Total colectomy
 CPT®: 44150-44158, 44210-44212
 ICD-9-PCS: 44.80-45.83
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HEDIS Coding Reference
Measure
Codes
HEDIS Claims Coding
Reference
CPT®: 67028,
67030, 67031, 67036, 67039-67043, 67101, 67105,

Comprehensive
Diabetes Care
(CDC) – Eye Exam
67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208,
67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012,
92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250,
92260, 99203-99205, 99213-99215, 99242-99245
CPT® II codes: 2022F, 2024F, 2026F, 3072F
HCPCS codes: S0620, S0621, S0625, S3000
Exclusions:
Identify members who do not have a diagnosis of diabetes, in any setting,
during the measurement year or year prior to the measurement year and
who meet either of the following criteria:
A diagnosis of polycystic ovaries, in any setting, any time during the
member’s history through December 31 of the measurement year.
ICD-9-CM: 256.4
A diagnosis of gestational diabetes or steroid-induced diabetes, in any
setting, during the measurement year or the year prior to the
measurement year.
ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
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HEDIS Claims Coding Reference
Measure
Comprehensive
Diabetes Care (CDC)
– HbA1c
Comprehensive
Diabetes Care (CDC)
– LDL-C
Codes
CPT®: 83036, 83037 PLUS
CPT® II: 3044F, 3045F, 3046F
Exclusions:
Identify members who do not have a diagnosis of diabetes, in any setting, during the
measurement year or year prior to the measurement year and who meet either of the
following criteria:
A diagnosis of polycystic ovaries, in any setting, any time during the member’s history
through December 31 of the measurement year.
ICD-9-CM: 256.4
A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the
measurement year or the year prior to the measurement year.
ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
CPT®: 80061, 83700, 83701, 83704, 83721 PLUS
CPT® II: 3048F, 3049F, 3050F
Exclusions:
Identify members who do not have a diagnosis of diabetes, in any setting, during the
measurement year or year prior to the measurement year and who meet either of the
following criteria:
A diagnosis of polycystic ovaries, in any setting, any time during the member’s history
through December 31 of the measurement year.
ICD-9-CM: 256.4
A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the
measurement year or the year prior to the measurement year.
ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
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HEDIS Claims Coding Reference
Measure
Comprehensive
Diabetes Care
(CDC) –
Nephropathy
Screening
Codes
CPT®: 82042, 82043, 82044, 84156 PLUS
CPT® II: 3060F, 3061F, 3066F, 4010F
ICD-9-CM: 250, 403-405, 580-588, 753, 791
Exclusions:
Identify members who do not have a diagnosis of diabetes, in any setting, during the
measurement year or year prior to the measurement year and who meet either of the
following criteria:
A diagnosis of polycystic ovaries, in any setting, any time during the member’s history
through December 31 of the measurement year.
ICD-9-CM: 256.4
A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the
measurement year or the year prior to the measurement year.
ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
Disease-Modifying ICD-9-CM codes to identify rheumatoid arthritis:
Anti-Rheumatic
714.0, 714.1, 714.2, 714.81
Drug Therapy for HCPCS codes to identify pharmacy claims for DMARD in the measurement
Rheumatoid
year:
Arthritis (ART)
J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518,
J9250, J9260, J9310
Use of Spirometry COPD:
Testing in the
Chronic bronchitis: 491
Assessment and
Emphysema: 492
Diagnosis of
COPD: 493.2, 496
COPD (SPR)
CPT® codes to identify spirometry testing:
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94010, 94014-94016, 94060, 94070, 94375, 94620
HEDIS Claims Coding Reference
Measure
Codes
Osteoporosis Management in
Women Who Had a Fracture
(OMW)
Codes to identify bone mineral density test:
CPT®: 76977, 77078-77083, 78350, 78351
HCPCS: G0130
ICD-9-CM: 88.98
AND/OR pharmacy claims for osteoporosis drug therapy:
HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488
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Open Discussion
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