Att. #4. Adapting the Electronic Health Record for Partnership Health Plan Best Practices June, 2013

Size: px

Start display at page:

Download "Att. #4. Adapting the Electronic Health Record for Partnership Health Plan Best Practices June, 2013"

Clementine Barber
5 years ago
Views:

Adapting the Electronic Health Record for Partnership Health Plan Best Practices June, 2013 This best practices guide was created to assist Primary Care Providers who are joining Partnership

1 Adapting the Electronic Health Record for Partnership Health Plan Best Practices June, 2013 This best practices guide was created to assist Primary Care Providers who are joining Partnership HealthPlan in 2013 in optimizing your Electronic Health Record configuration. We hope this will make the transition to Partnership HealthPlan go more smoothly, minimizing hassles and maximizing revenue. If you have an EMR configuration committee this would be a good document to go over together. We also recommend assigning each section to the person in the office most knowledgeable about that area: the billing manager, referral coordinator, quality improvement coordinator, office manager, and medication prior authorization coordinator are some examples. The highest priority areas to act upon are noted with a star (*). Disclaimer: These best practices are put together from a variety of sources: staff from Community Health Centers, individual PHC staff, staff from medical groups and private practices. They are intended to summarize advice from many sectors, but do not represent underlying PHC policy. Applicable PHC policies are available for review on the PHC website: Pharmacy Issues: 1. *Order set for diabetes supplies (for Free Style) a. Glucometer options Free Style Lite (small), Free Style Freedom Lite (Larger) b. Test strips: 100 for 3 months; 100 per month are good starting options c. Lancets: same numbers as test strips 2. Activate RxHub (automatic formulary checker) a. If not configured well, will cause performance issues when turned on; be cautious when testing, set up to not check formulary until at least 3 letters of drug entered into search capacity. b. RxHub part of surescripts; no extra charge for individual provider, PHC pays to have formulary loaded into RxHub. c. Some EMRs require eligibility check for particular visit to activate RxHub. 3. In house dispensary/pharmacy: cannot bill PHC for these medications a. Set up notifications/processes to prevent this from happening b. Define location to enter reason for non-formulary medication to communicate to pharmacy for TARS: recommend testing this.

2 Specialty referral issues: 1. *Once PHC specialist list released, enter specialists into system as referral options 2. Decide on location of referral authorization number recording in Electronic Health Record 3. Assure providers clearly delineate in referral: a. Purpose of referral (a short summary or a letter) b. Workup to date, including relevant labs (don t configure to send large numbers of nonspecific progress notes and labs) 4. Podiatry referrals covered only for diagnosis of diabetes and wound/ulcer care a. Configure system to catch this for PHC patients, if possible 5. Pulmonary Rehab is covered, enter local pulmonary rehab into referral list. 6. Note that some specialists will require a specified workup to be complete before the referral. If your system allows this to be built for specific types of referrals, have your referral coordinator contact our provider relations department several months after September 1, to work on setting this up. CT/MRI ordering: 1. Coordination (establish workflow) 2. *Document reason for study with order, so radiology provider can submit TAR 3. System to ensure screening questions for MRI done. Claims Configuration Issues 1. CHDP: a. *PM 160 integration: i. Built by vendors for ECW, Next Gen, some others ii. Individual providers may need to work with EMR vendor to get fully functional iii. Partnership currently only accepts paper PM 160s, so system needs to be configured to print out data b. Medically necessary Interval Health Assessment (MNIHA) i. Although this applies to all providers, it is important (for revenue purposes) for providers not eligible for wrap-around payment. It will not affect revenue for FQHCs, Look-alikes, RHCs, IHC. Will affect revenue of private practice pediatricians, and pediatric groups. ii. Request summary explanation from Provider Relations Rep or Regional Medical Director iii. Needed for CHDP exam when sooner than official CHDP intervals, but still indicated iv. Workflow/Text for explanation into PM *Getting Claims system Electronic Data Interface tested and functional (See separate packet from Claims/IT/Provider Relations) a. Establish workflow for using EDI in claims processing 3. *Health Centers, Rural Health Clinics, Native American Health Services: New Code 18 a. Assure system set up to bill PHC for capitated visits, as well as the state, for wraparound rate 4. CPT coding a. Same coding as State MediCal (Five digit CPT/HCPCS codes). Two digit wrap codes not accepted.

3 b. Codes paid Fee for service may pay at higher than state rate and may change over time (depends on many factors). It is therefore good practice to assure that charges in your system are high enough to not under-bill the PHC/State MediCal rate (some areas that may be affected include: prenatal care, vaccinations, E&M codes, Health Maintenance codes. Using at least the allowable MediCare payment is a common practice. 5. Setting up different payer types: a. PHC Capitated b. PHC Special Member 6. Eligibility Documentation a. Location for recording eligibility check 7. ICD9 coding a. Coding guide: available on PHC website: b. Recommend removing unacceptable codes or labeling them (not PHC) c. ICD 10 coding: PHC will be ready to test our capacity to accept ICD10 from your claims system starting in January, 2014; please plan accordingly. 8. Telehealth services a. *If your practice is a originating site or distal site for telehealth, it is worth building template with the proper billing codes. For full telehealth policy, see b. Recommend including reference to verbal consent and appropriate modifiers on billing codes. 9. OB visits a. Up to 15 prenatal visits covered without TAR, if medically indicated (see policy on PHC website, Provider MediCal Manual, Claims Section, Subsection X.K.) i. Assure system can allow billing of up to 13 Z1034 visits without TAR. b. Set up the ZL modifier for the initial visit for those members who enter prenatal care before 16 weeks for the extra $50 bonus. It is only paid if they get into care with the 16 weeks and it is documented in the remarks section of the claim assuming you are billing electronically. If you bill it on a CMS1500 paper claim form, there is a space designated for this information. This is the same as the state requirement. Many forget to enter the date so they do not get paid. 10. Newborn circumcision a. Covered for routine newborns, if the mother had PHC insurance at time of delivery. b. Set up system if possible to prevent charging cash for parents of child getting circumcision, if child covered by Partnership through mother s MediCal. 11. In office labs covered by PHC (paid FFS) a. For all new counties: Labs allowed under your CLIA waiver may be done and billed to PHC. Quality Improvement/Quality Assurance Issues: 1. *Optimization of Quality Measures a. Assure BMI automatically calculated for adults, when height and weight are captured. b. Assure that BMI percentile is displayed for children c. Build into well-child exam templates: i. Nutrition assessment and counseling ii. Physical activity assessment and counseling

4 d. Set a standard location for recording Advanced Care Plan/Code status/advanced Directive/POLST status i. Recording the nuances of the conversation ii. Storing forms/documents related to this iii. Alert system for adults over 65 to ensure conversation occurring iv. Template for documenting the conversation (See example from PA annual physical) 2. Staying healthy assessments (Link to assessments: ) a. Integrate questions/responses into well child visit: Best Practices i. Integrate questions/responses into adult health maintenance examination ii. MA asks questions/records results iii. Ensuring this part of template completed: options 1. Some EMRs: color code elements of template to ensure important elements done 2. Train staff to do this part 3. Choose as default and ensure everyone does it. 3. TB screening (start by screening with questions, then test as indicated) a. Establish clinic screening protocol b. Build into workflow for electronic health record c. Medical Assistants legally allowed to ask review of systems questions and record answers. 4. Set up alerts for QIP measures a. Pap smears b. Diabetes Measures: A1C, LDL, microalbumin, eye exam, blood pressure c. Role of MA vs. Provider vs. Care Manager d. Workflow definition 5. Workflow and recordkeeping for use of State Vaccination registry (CAIR) a. Interface versus data entry options. 6. Looking to the future: Medi-Medi Dual integration: a. For older adults and disabled, documentation of the functional status as part of the regular health exam for adults. Examples are available on line, but should include: i. Physical status ii. Cognitive status iii. ADL's/IADL's iv. Environmental/Social Factors Who to contact if you have questions or comments: Robert Moore, MD, MPH Rebecca Mannella Chief Medical Officer Claims Customer Service Manager RMoore@partnershiphp.org RMannella@partnershiphp.org (707) Marshall Kubota, M.D. Regional Medical Director Provider Relations Department MKubota@partnershiphp.org (707) Gary Louie, PharmD Pharmacy Services Director glouie@partnershiphp.org Quality questions: QIP@partnershiphp.org

Important Billing Guidelines

Important Billing Guidelines The guidelines contained herein are meant to assist GHP Family Participating Providers in billing appropriately for medically necessary services rendered to GHP Family Members.