In This Issue. Issue: 8. Codes Utilization FAQs Harry s Health Highlights. Who s Harry? HEDIS News

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1 Issue: 8 Who s Harry? Born from the mists of success, and integrated into the core of our measures; Harry forges forward in an undying quest to bring H knowledge to Cenpatico s provider network. In This Issue H News Codes Utilization FAQs Harry s Health Highlights Value Added Dental Benefits Six Month Work Training Program H I New S s Cenpatico Integrated Care is very excited to announce an innovative approach to assisting Integrated Care members address their oral health care and dental needs. Adults over the age of 20 with an SMI qualifying diagnosis are eligible for preventative dental services through a prior-authorized process once they complete the six month work training program with their assigned Employment Specialists. The training program is accessed through Relias Learning Systems. Integrated Members employed 1/4 time (10 hours per/week) and/or transition age young adults are eligible for this benefit without completing the training program Who: Any TXIX adult members receiving integrated care (RBHA 79) With a qualifying diagnosis of a Serious Mental Illness (SMI) Who complete a six-month pre-job training program What: Oral Health includes medically necessary dental services including emergency dental services, dental screening and preventive services in accordance with AHCCCS Dental Periodicity Schedule. Prior Authorization for these services is required. When: Value added benefit will become effective on the 1st of the month following acceptance of the demographic record with a qualifying employment code. Length of eligible benefit is 1 year and tracked by Relias Learning Systems. Eligible adults may be granted one additional year following completion of a second training program. Where: Training program is accessed on the Relias Learning Systems under 6 Month Pre-Employment Work Program (Value Added Dental Benefit). Members should partner with the ICC Agency s Employment Specialist to register and start training. Cenpatico Integrated Care (Cenpatico IC) services are funded through a contract with the Arizona Department of Health Services and AHCCCS.

2 Codes! Welcome to the special code issue of Harry s H Hints! The purpose of this issue is to identify commonly used codes to meet some of the contracted performance measures. This is not billing advice. The H measures are split into two tables, standard and utilization. The standard measures have codes included in the specifications that meet the measure. Utilization measures are run through inclusive/exclusive events. For details on how the measures are calculated, please refer to prior issues of Harry s H Hints or the DBHS BQ&I Specification Manual. Breast Cancer Screening Women age 50-74: A mammogram Bilateral Mastectomy Cervical Cancer Screening Women age 21-64: A PAP test (cervical cytology) Women age 30-64: HPV test & a PAP test (cervical cytology) on the same day Cervical cytology: , , 88150, , , Cervical cytology: , , 88150, , , HPV tests: Hysterectomy with no residual cervix Documentation of complete, total or radical abdominal or vaginal hysterectomy meets the criteria. Documentation of hysterectomy alone does not meet the criteria Hysterectomy with no residual cervix Chlamydia Screening Women age and identified as sexually active (by claims or pharmacy data) Documentation of complete, total or radical abdominal or vaginal hysterectomy meets the criteria. Documentation of hysterectomy alone does not meet the criteria 87110,87270,87320, ,87810 Documentation of total hysterectomy with absence of cervix

3 ! es Cod Comprehensive Diabetes Care Adults age with diabetes (type 1 or type 2) , , , , 9341,99345,99347,99350, , , ,99411,99412, 99420, 99429,99455,99456 Members without a diagnosis of diabetes, but with either: Gestational diabetes or Steroid-induced diabetes Comprehensive Diabetes Care: HbA1c The percentage of members age 83036, 83037, 3045F,3044F with diabetes (Type 1 or type 2) who had a Hemoglobin A1c Test Gestational diabetes, steroid induced diabetes Comprehensive Diabetes Care: Retinal Eye Exam Most recent date of dilated eye exam 67028,67030,67031,67036, 67039,67040,67041, 67041,67043,67101,67105,67107, 67108,67110,67112, 67113, 57141,67145,672118,67220, 67221,67227,67228,92002, 92004,92012,92014,92018, 92019, ,92226, 92227,92228,92230,92250, Gestational diabetes, steroid induced diabetes Adult Access to Preventive Care Adults age 20 or older: An ambulatory or preventive care visit 99201,99202,99203,99204, 99205,99211,99212,99213, 99214,99215,99241,99242, 99243,99244,99245,99341, 99343,99244,99245,99347, 99348,99349,99350,99373, 99381,99382,99384,99386, 99387,99391,99392,99393, None 57170,58300,59430,99501, 0503F Deliveries not resulting in a live birth Postpartum Care Deliveries with a postpartum visit on or between 21 and 56 days after delivery

4 ! es Cod Timeliness of Prenatal Care Deliveries that received 59400,59425,59426,59510, 59610,59618 prenatal care in the first trimester or within first 42 days of enrollment Deliveries not resulting in a live birth Influenza Vaccine Age Age 65 and older 90654,90655,90656,90658, 90672,90673,90686,90688, 90630,90661 None 90654,90655,90656,90658, 90686,90688,90673,90662, None 99383,-99385, None D0120,D0140,D0145,D0150, D0160,D0171,D0180,D0210, D0220,D0230,D0240,D0250, D0260,D0270,D0272,D0273, D0274,D0277,D0290,D0310, D0320,D0321,D0330,D0340, D0350,D0393,D0470,D0502, D0999,D1110,D1120,D1206, D1208,D1351,D1352,D1353, D1354,D1510,D1515,D1520, D1525,D1550,D1555,D1999 None EPSDT Adults age 18, 19, and 20 who had at least one well visit Dental Adults age 18, 19, and 20 who had at least one preventative dental service

5 n atio iz Util The following information is to help guide your understanding of Utilization Measures. These are calculated differently than the standard measures because utilization measures are reported per member months or as a rate, instead of percent compliant. Inpatient and Utilization measures are listed as per 1,000 member months (mm), while the rest of the utilization measures are listed as per 100,000mm. Reporting these measures in this manner is normalizing, meaning the numbers can be compared across different agencies or plans of varying sizes. The charts below identify criteria from the specification requirements that would either include or exclude a member from each measure. For more information regarding specific measures, please refer to previous issues of Harry s H Hints! Inpatient Utilization (days/1,000 member months) This measure is the number of total inpatient days. Unspecified Emergency Department () Utilization (visits/1,000 member months) This measure is the number of emergency department visits Unspecified Plan All-Cause Hospital (readmissions within 30 days of discharge) This measure is the number of hospital discharges that were followed by a readmission for any diagnosis within 30 days The member died during the stay A principal diagnosis of pregnancy A principal diagnosis of a condition originating in the perinatal period Adult Asthma Admission Rate (discharges/1,000 member months) This measure is members who had a hospital stay due to asthma Transfer from a hospital (different facility) Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) Transfer from another health care facility Pregnancy, childbirth, and puerperium With any diagnosis code of cystic fibrosis and anomalies of the respiratory system

6 Utilization Use of Appropriate Medications for People with Asthma (ASM) This measure is the number of members identified as having persistent Asthma and were appropriately prescribed medication Exclude members who had any diagnosis from any of the following groups, any time during the member s history through the measurement year: Emphysema Other Emphysema COPD Obstructive Chronic Bronchitis Chronic Respiratory Conditions Due To Fumes/Vapors Cystic Fibrosis Follow-up After Hospitalization (all cause within 7 days) This measure is the number of members who were hospitalized and received a 7 day follow up after discharge with their provider Follow-up After Hospitalization (all cause within 30 days) This measure is the number of members who were hospitalized and received a 30 follow up after discharge with their provider Acute Respiratory Failure Exclude discharges followed by readmission or direct transfer to a non-acute inpatient care setting within the 30-day follow-up period, regardless of principal diagnosis for the readmission. To identify readmissions to a nonacute inpatient care setting: Identify all acute and non-acute inpatient stays Confirm the stay was for non-acute care based on the presence of a non-acute code on the claim Identify the admission date for the stay Exclude discharges followed by readmission or direct transfer to a non-acute inpatient care setting within the 30-day follow-up period, regardless of principal diagnosis for the readmission. To identify readmissions to a non-acute inpatient care setting: Identify all acute and non-acute inpatient stays Confirm the stay was for non-acute care based on the presence of a non-acute code on the claim Identify the admission date for the stay

7 n atio iz Util Diabetes Admissions, Short-Term Complications (discharges/100,000 member months) This measure is the number of inpatient hospital admissions for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF), or another health care facility Obstetric admissions Chronic Obstructive Pulmonary Disease (COPD) Admissions (discharges/100,000 member months) This measure is the number of members with COPD (including chronic bronchitis or emphysema) who go to the ER or are hospitalized with a primary diagnosis of COPD Preventative measure only Congestive Heart Failure Admissions (discharges/100,000 member months) This measure is the number of discharges of members with a diagnosis of Congestive Heart Failure Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF), or another health care facility Obstetric admissions

8 y Harr SEZ Harry SEZ (Frequently Asked Questions) Please send your questions about H to Tony DeQuinzio, our H contact. Call ( x84452) or Tony (ADeQuinzio@Cenpatico.com) with your question and we ll post it and his answer under the next edition of HARRY S H HINTS in the Harry SEZ section. We look forward to responding to your questions in the newsletter! Q. Why are there members that qualify for a H measure but are not on the non-compliant list? A. There are 2 reasons why a qualified member would not show up on the non-compliant list. The first reason would be that the member is compliant with the measure. The second reason would be that the member is not assigned to the correct agency and could be listed on a different agency s non-compliant list or is not assigned. If a member is showing on your non-compliant list and is not enrolled with your agency, verify demographic information and contact Cenpatico-IC Member Services to report the discrepancy at CAZmembership@cenpatico.com. Q. How many times should our agency do outreach to a member for a H service? Is one outreach attempt all that is needed? A. Your agency should have an outreach plan and goals for members with gaps in H care services. Outreach attempts continue until the member has received the required services. All outreach attempts must be recorded in the EHR or logged for quarterly reporting to Cenpatico-IC. Q. Does Cenpatico-IC require that member outreach be completed by a RC/DRC? A. Member outreach can be completed by anyone on the integrated care team. Receptionists, peers, medical assistants, community health workers, RNs/LPNs and anyone on the team who communicates directly with member can be effective in completing outreach. Q. Do denied claims count toward meeting my agency s H score targets? What about claims billed by other agencies or specialists? A. Pended, denied and approved claims all count toward a positive H score for the measures that are currently reported on. All claims that Cenpatico-IC receives count towards the measure for the member regardless of who initiated the claim.

9 Harry s Health Highlights Minority Health Determines the Health of the Nation The United States is increasingly diverse: 36 percent of the population belongs to a racial or ethnic minority group (2010 census). Life expectancy and infant mortality have improved for most Americans. However, minorities experience a disproportionate burden of preventable diseases, deaths, and disabilities compared with non-minorities. The overarching goal of CDC Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups.

10 Harry s Health Highlights What is Health Equity? All people have an opportunity to attain full health potential regardless of their social position or other socially determined circumstances. What are Social Determinants of Health? Poverty, unemployment, education, urban/rural, race, ethnicity and other determinants shaped by social distribution of money, power and resources. What is Health Disparity? A difference in presence of disease, health outcomes, or access to health care between populations. This can include a different race, ethnicity, socioeconomic status, gender, sexual orientation, mental health, sexual orientation, geographic location or cognitive, sensory or physical disability As a result of social or economic disadvantage stemming from historical discrimination or exclusion

11 Harry s Health Highlights How does Quality of Care affect Health Disparities? Communication is critical for the delivery of appropriate and effective treatment and care o It is linked with improved patient satisfaction which can lead to improved health outcomes o Miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. This can result in poor medical compliance, poor health outcomes, and greater medical expenditures. o 19% of the time minority patients have problems understanding the doctor, feeling the doctor listened, and had questions but did not ask o 33% of the time the Hispanic population had problems communicating with their provider o Less than half of non-english speakers who say they need an interpreter during clinical visits report having one o Inability of providers to communicate with Limited English Proficiency (LEP) patients leads to more diagnostic procedures, more invasive procedures, and over prescribing of medications o Providers need to assess patients health beliefs and practices to understand a patients view of health and disease for improved diagnosis and treatment o Patient health decisions (screening and medication compliance) are influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles Provider discrimination (unconsciously or consciously) occurs when health care providers treat certain patients differently from other patients using stereotypes o Racial/ethnic group stereotypes; heterosexist attitude towards LGBT patients and lack of understanding Lack of access to preventive care: o Limited English Proficiency (LEP) patients are less likely to receive preventive health services such as mammograms o Use of professional interpreters significantly reduces disparities in the rates of fecal occult testing, flu immunizations and pap smears How to achieve Health Equity Advocacy: Promote policy change that supports provider knowledge transfer and uptake and targets the specific population and social context Increase provider awareness: Recognize health disparities in ethnic and minority populations and teach on how to reduce it Use AIM ability, incentives, and management feedback: Successfully reduce care disparity in providers through (1) training to enhance ability, (2) monetary incentives to enhance motivation, and (3) management feedback to enhance accountability