The Primary Care Office of the Future Series Anatomy and Physiology of Primary Care: A Clinical Microsystems Approach

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1 SM Volume 4, Issue 2 March 2016 The Primary Care Office of the Future Series Anatomy and Physiology of Primary Care: A Clinical Microsystems Approach This is the second in a series of articles about the future of primary care. Clearly understanding how the structure of primary care practices affects their function is a logical foundation for any transformation effort. It is what the Connecticut Institute for Primary Care Innovation (CIPCI) termed the anatomy and physiology of primary care. The clinical microsystems approach, developed by colleagues at The Dartmouth Institute, offers one useful approach for analyzing the anatomy and physiology of primary care. A clinical microsystem is the smallest replicable unit of care. It includes the team that provides care, the people who receive care and the data systems that support and inform care. Any primary care practice whether an individual practitioner, a group practice or a large clinic is a microsystem. Process mapping is a major part of the analysis it gives an immediate visual sense of the steps involved in care as well as the people involved in each step. The maps are wildly different, setting the stage for asking questions, identifying issues/ opportunities and moving toward productive redesign. CIPCI has conducted clinical microsystem analyses at 10 primary care practices, ranging from large clinics that also serve as residency training sites to very small private practices. Regardless of practice size, results have been eye-opening at each site. (Excerpt from a blog post by Gregory Makoul, PhD, MS: The Anatomy and Physiology of Primary Care. Read the entire post at For more about the Primary Care Office of the future, go to This is a process map that was created for one of the CIPCI practices. The numbers in the circles indicate the average amount of time in minutes that is spent in each area.

2 G Code Incentives for 2016 The Quality Incentive Program (QIP) will begin in March of 2016 and offers incentive payments for certain well-child visits listed on your individual Gaps in Care reports. This year it will also include incentives for cervical cancer screening and breast cancer screening. Participation is limited to primary care physicians in good standing with BlueChoice HealthPlan Medicaid. It includes the specialty types of internal medicine, general practice, pediatrics and family medicine. For each eligible service listed, you will receive a $30 incentive payment in addition to the well-visit reimbursement for that service for those members listed on your Gaps in Care reports. You must bill code G8496 to receive incentive payments in addition to the well-visit code. Bill the G8496 code on the same claim form in position two along with the office visit code. We pay incentive amounts at the time of claims adjudication in addition to the well-visit reimbursement for the eligible service. Code well-infant visits for members who turn 15 months in 2016 with four to six visits documented in the medical record indicating a visit with the evidence of a physical exam, health and developmental history, health education and anticipatory guidance as: ICD 10CM: Z00.0X, Z00.1XX, Z00.X, Z02.X, Z02.71 Z02.79, and Z02.8X, and CPT: 99381, 99382, and Effective May 1, 2016: Knee and Hip Arthroplasty to Require Prior Authorization Effective May 1, 2016, knee and hip arthroplasty will require prior authorization (PA). For dates of service on or after May 1, 2016, you will need to submit a knee and hip arthroplasty PA request for review. This applies to these procedure codes: Hip: 27125, 27130, 27132, and Knee: 27437, 27438, 27440, 27441, 27442, 27443, 27445, and Please visit for specific, detailed authorization requirements under Resources > Prior Authorization. To request PA, please call us at , or fax your request to If you have questions about this communication or need assistance with any other item, call the Customer Care Center at Code well-child visits for members ages 3 through 6 with documentation in the medical record indicating a visit with the evidence of a health and developmental history, a physical exam and health education/anticipatory guidance as: CPT-4 codes 99382, 99383, and billed for children ages 3, 4, 5 and 6. Code adolescent well-care visits for members through age 20 with documentation in the medical record indicating a visit, with the evidence of a health and behavioral assessment, a physical exam and health education/anticipatory guidance as: CPT-4 codes 99384, 99385, and Code cervical cancer screenings for female members ages with documentation in the medical record indicating one or more Pap tests this year with the date and type of test that was performed and the results of the Pap test as: ICD-10: Z12.4 and CPT codes , 88147, 88148, 88150, , , and along with lab code Q0091, which is required. Code breast cancer screening for female members ages who had at least one mammogram to screen for breast cancer during 2016 as: CPT codes Clinical Practice Guidelines The most current clinical practice guidelines for BlueChoice HealthPlan Medicaid can be located on our website, Providers > Resources > Policies & Guidelines > Clinical Practice Guidelines. 2

3 HEDIS Measure of the Month: Cervical Screening This HEDIS measure looks at the percentage of female patients ages years who have had one or more Pap smears for cervical cancer this year or two years prior. Or Pap smear/hpvcombined testing once every five years for women ages Get Your Efforts on Record! Make sure your medical records reflect: The date and type of the test that was performed The result or finding of the Pap smear and/or Pap smear/ HPV-combined testing Code Your Services Correctly Use these diagnosis and procedure codes to document cervical cancer screening: CPT HCPCS ICD-10-CM Procedure , 88147, 88148, 88150, , , 88174, G0123, G0124, G0141, G0143 G0145, G0147, G0148, P3000, P3001, Q0091 UB Revenue LOINC Z , , , , , , , , , The codes listed are informational only. This information does not guarantee reimbursement. Helpful Tips Discuss importance of well-woman exams and cervical cancer screening with all female patients between 21 and 64 years of age. Conduct outreach calls to patients to remind them of the importance of annual wellness visits. Refer members to other appropriate provider or gynecologists if your office does not perform Pap smears and request copies of the Pap smear/hpv combined-testing results be sent to your office. If patients have a history of hysterectomy, add complete details if it was a complete, total or radical abdominal or vaginal hysterectomy with no residual cervix, also document history of cervical agenesis or acquired absence of cervix. Include at a minimum the year the surgical procedure was performed. Talk to your provider relations representative if scheduling a health screening clinic day in your community is a possibility, and our staff may help plan, implement and evaluate events for a particular preventive screening like a cervical cancer screening or a complete comprehensive women s health screening event. Encourage your staff to use tools within the office to promote cervical cancer screening, such as handheld cards to teach patients, add EMR flags and/or have tracking tools of who needs the screenings, use educational brochures. Posters and educational messages in treatment rooms and waiting areas help motivate patients to initiate discussions with you about screening. Train your staff on preventive screenings or find out if we provide training. Proper coding decreases the need for medical record reviews and helps us meet the HEDIS measure for quality reporting based on the care provided. The codes listed are informational only. This information does not guarantee reimbursement. Your state contract (e.g., Medicare, Medicaid, etc.) and state Medicaid and CMS guidelines determine reimbursement for the applicable codes. 3

4 Let s Get Connected! Our goal is to decrease the administrative burden on your office staff and help increase your quality scores. We do this by using a secure and reliable systemized process to exchange real-time clinical data (medical records and performance reports) between your office and BlueChoice HealthPlan Medicaid, all while maintaining strict Health Insurance Portability and Accountability Act (HIPAA) compliance. What is secure file transfer protocol (SFTP)? It s a network protocol for accessing, managing and transferring files. Unlike standard file transfer protocol (FTP), SFTP prevents passwords and sensitive information, such as protected health information (PHI) from being exposed. Fast, secure communication Advantages include: Potential increase in quality scores using electronic medical record files Secure and fast file transferring (e.g., medical records, Gaps in Care reports, Performance Analysis Reports, etc.) Unlimited number and size of files transferred Expedient, real-time data transfer Potential risk reduction no need to expose confidential health information to risk of loss when files are carried from your office Let us help you get started All we need is: Your site s full name, address and phone number and name of your staff member who will manage your SFTP. We ll contact you within seven business days It s that simple! Your office can now connect to the BlueChoice HealthPlan Medicaid network for safe and secure file transfers with a simple drag and drop. For more information or to sign up, contact your provider relations representative. Potential cost reduction (operations) no need to print, scan or copy to CDs and USB thumb drives We re in Your Community The Feed the Hungry SC program was in Ridgeland, SC. BlueChoice HealthPlan Medicaid sponsored the event. Donna Williams, marketing manager, shared benefit and service information, as well as health tips on diabetes, for National Diabetes awareness month. The crowd was engaged with BlueChoice HealthPlan Medicaid trivia and enjoyed a four-course dinner, along with a bag of groceries. In spite of the rainy weather, more than 100 people participated in the event. At the Bill Durham Community Center in Estill, SC, BlueChoice HealthPlan Medicaid sponsored Christmas Dinner with our community partners, Feed the Hungry SC. BlueChoice HealthPlan Medicaid outreach representative Letitia Lindsay provided attendees with benefit and service information. Attendees played games with the Wii and received a hot meal, breads, canned goods and fresh vegetables. More than 200 attended the event, and everyone also enjoyed live entertainment with inspirational dance and song. 4

5 Top 4 South Carolina Practices Medical Record Standards and Compliance BlueChoice HealthPlan Medicaid Providers must maintain adequate records to appropriately and accurately document the provision of services and demonstrate they met the quality standards and goals. The quality of care our network physicians and their practices provide our members is evaluated, along with identifying areas of excellence and opportunities for improvement. During the summer and early fall of 2015, the Clinical Quality department conducted medical record reviews to assess compliance with medical record standards. These standards are based on national criteria our Clinical Quality Improvement Committee approved. A medical record review consists of five categories and an assessment of the medical record for organization, continuity and coordination of care, and content of the medical record. It also includes documentation of all services the practitioner directly provided, all ancillary services and diagnostic tests the practitioner ordered, as well as preventive care. A random sample of visits, using claims data for the year prior to the scheduled medical record review date with the number of records selected, based on membership at the practice were reviewed. Physicians or practices must get an overall score of 80 percent, with a minimum score of 90 percent, on each category in order to be compliant. We would like to recognize these practices and their physicians for their excellence. Medical Park Pediatrics & Adolescence PA 120 Highland Center Drive, Ste. 100 Columbia, SC Physician: Dr. Susan Claytor-Caldwell Office representative: Jessica Robertson Piedmont Pediatrics 966 Medical Ridge Road Clinton, SC Physician: Dr. Sally Burgess Office representative: Karen Nolan Regenesis HealthCare 1604 N. Limestone St. Gaffney, SC and 750 S. Church St. Spartanburg, SC Physicians: Dr. Margot Butler, Dr. Monique Fox and Dr. Matthew Delfino Office representative: Monica Durisa Clinical Quality Director/Practice Manager: Belinda Renwick Of the 67 practices that were audited in which 381 medical records with dates of service in 2014 were reviewed, the average score of the practices was 95 percent. Of these 67 practices, four exhibited excellence with overall scores of 100 percent. These practices have in place methods to consistently address emergency contact information and advanced directives, with the member s first visit of the year and their records updated to reflect this information. Sweetgrass Pediatrics 2713 Dantzler Drive Charleston, SC Physicians: Dr. Sumita Debroy, Dr. Lisa Lopez and Dr. Shilpa Shah Office representative: Dawn Norris The most impressive contribution is their effort in the Preventive Care section. Consistency is shown in getting and documenting preventive testing for colon, breast, prostate and cervical cancer for adults, as well as in maintaining an up-to-date immunization record for children. 5

6 Event Calendar Date Start Time End Time Event Location March 5 7:30 a.m. 12:30 p.m. Family Services Inc. of Charleston Money Rocks Community Fair Charleston Southern University 9200 University Blvd. North Charleston, SC March 13 2 p.m. 5 p.m. Phillis Wheatley Community Center Repack the Backpack March a.m. 4 p.m. Jewish Community Center Charleston 28th Annual Kids Fair March a.m. 12 p.m. Stork s Nest Mu Pi Zeta Chapter Ultimate Baby Shower March 26 2 p.m. 4 p.m. Dutch Square Center Ultimate Baby Shower Phillis Wheatley Community Center 40 John McCarroll Way Greenville, SC Burke High School 244 President St. Charleston, SC Queen Chapel AME Church 114 Beach City Road Hilton Head, SC Dutch Square Center 421 Bush River Road Columbia, SC

7 Diabetic Complications in ICD-10 The ICD-10 diabetes code categories E08-E13 include the type of diabetes mellitus, body system affected and complications affecting the body system. The combination codes E08-E13 may require additional diagnosis codes to fully describe all associated conditions. Reporting all documented conditions to the highest level of specificity on the claim form helps to promote quality and continuity of patient care. To ensure coding specificity for diabetic complications in ICD-10, medical record documentation must include: Type of diabetes (i.e., Type 1, Type 2, secondary) Complications and body systems affected (e.g., diabetic neuropathy) Control status (document how well diabetes is controlled over time) Long-term use of insulin (report additional code Z79.4 on the claim) If documentation contains terms, such as inadequately controlled, out of control and poorly controlled, then a code for the correct type of diabetes with hyperglycemia would be assigned. Assign as many diabetes codes as are needed to accurately describe the patient s condition(s). Examples of ICD-10-CM Type 2 diabetes combination codes include: Complication type Kidney and renal Correct code category E11.2- Type 2 diabetes with kidney complications Ophthalmic (eye/retinal) E11.3- Type 2 diabetes with ophthalmic complications Neurological (nerve) E11.4- Type 2 diabetes with neurological complications Circulatory Other specified (arthropathy, skin, ulcerations, oral, hypoglycemia and hyperglycemia) E11.5- Type 2 diabetes with circulatory complications E11.6- Type 2 diabetes with other specified complications Note: Not an all-inclusive list. For a complete list consult the current ICD-10-CM coding manual. When diabetic complications are present, it is important that medical record documentation support the cause and effect relationship between diabetes and the other conditions with linking verbiage. Examples of linking verbiage include: Diabetic Due to diabetes Secondary to diabetes Caused by diabetes If documentation does not properly link the condition(s), code each separately. Since diagnosis coding is based on provider documentation, it is critical that providers include all known details about chronic conditions (i.e., diabetes) in the medical record for each patient encounter. Chronic conditions may be reported on the claim form as many times as the patient receives care and/or treatment. Details such as the provider s assessment/evaluation of the condition, medications prescribed, recommendations, referrals and even patient noncompliance help support accurate coding. For complete instructions and guidelines, please refer to the current ICD-10-CM coding manual. 7

8 AX-400-Co1 P.O. Box 6170 Columbia SC PRSRT STD US POSTAGE PAID PERMIT NO 1240 COLUMBIA SC BlueChoice HealthPlan and BlueCross BlueShield of South Carolina are independent licensees of the Blue Cross and Blue Shield Association. Healthy Connections is administered for BlueChoice HealthPlan by WellPoint Partnership Plan LLC, an independent company. Some links in this newsletter lead to third party sites. Those organizations are solely responsible for the content and privacy policies on these sites. In this issue Page 1 The Primary Care Office of the Future Series Page 2 G Code Incentives for 2016 Knee and Hip Arthroplasty to Require Prior Authorization Clinical Practice Guidelines Page 3 HEDIS Measure of the Month Page 4 Let's Get Connected! We're in Your Community Page 5 Top 4 South Carolina Practices Page 6 Event Calendar Page 7 Diabetic Complications in ICD