Paula LeSueur MSN, CNP

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1 HEDIS Measures 2014 Presented at Envision NM Telehealth April 24, 2014 Paula LeSueur MSN, CNP 1 NEW To connect audio, please telephone Conference Code # Please mute/un-mute your telephone line by pressing *6. You may also press your mute button on your headset or speakerphone during the webinar when you are not speaking. Do not place your phone on hold. If you wish to receive CME/CEU/ or an attendance certificate, you must announce your name when we ask who is participating both at the start and at the end of the session. Your certificate will be ed to you after the end of this calendar quarter. If you are called on and do not wish to answer, feel free to say pass. 4/23/

2 Disclosure: UNM CME policy, in compliance with the ACCME Standards of Commercial Support, requires that anyone who is in a position to control the content of an activity disclose all relevant financial relationships they have had within the last 12 months with a commercial interest related to the content of this activity. The presenter discloses that he/she/they have no relevant financial relationships with any commercial interest. Accreditation: The University of New Mexico School of Medicine, Office of Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Office of Continuing Medical Education designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. Envision NM is a division of the UNM Department of Pediatrics and receives funding from the NM Department of Health and the NM Human Services Department. 4/23/ Molina Healthcare is offering payment to NM primary care providers who seek specialty consultation for their Molina patients through Envision New Mexico Telehealth In addition, on behalf of the primary care provider, non-physician providers (eg. RN, PA, NP, RD, LMSW, LISW) involved with a Molina patient s care may present cases to an ENM Telehealth clinic and your practice will receive the reimbursement. Enter code Q3014 with GT modifier on a standard Medicaid claim form and receive a $150 reimbursement for the presentation of Molina member cases to one of the above Envision New Mexico Telehealth clinics. Eligible clinics are: Childhood Overweight Medical Management - Telehealth Clinic (COMM-TC) Pediatric Nutrition Telehealth Clinic (PNT) Telepsychiatry: Pediatric Integrated Case Conference (T:PICC) Telepsychiatry Consultation for Pediatric and School-Based Clinic Providers SBHC Provider Integrated Behavioral Health Case Conference Forum Asthma/Pulmonary Telehealth Clinic (APT) For the specifics on how to request your Specialty Consultation, please contact: Clancey Tarbox, Envision New Mexico Program Coordinator, ctarbox@salud.unm.edu For more information about the reimbursement, please contact: Michel Faust, Care Coordinator, Molina Healthcare of New Mexico Direct Line: Toll Free: Ext Fax: Michel.Faust@MolinaHealthCare.Com Molina also offers a Healthy Incentives Program including health services for diabetes, asthma, mammograms, yearly Pap Exams, well child checkups and more. See the Molina website for more information: University of New Mexico * Department of Pediatrics 4 2

3 BCBS will use a level 4 reimbursement rate of $79.45 per claim with the use of the GT modifier. This began with Centennial Care effective 01/01/2014. In addition, on behalf of the primary care provider, non-physician providers (eg. RN, PA, NP, RD, LMSW, LISW) involved with a BCBS patient s care may present cases to an ENM Telehealth clinic and your practice will receive the reimbursement. Enter code Q3014 with GT modifier on a standard Medicaid claim form and receive a $79.45 per claim reimbursement for the presentation of BCBS member cases to one of the above Envision New Mexico Telehealth clinics. Eligible Envision NM clinics are: Childhood Overweight Medical Management - Telehealth Clinic (COMM-TC) Pediatric Nutrition Telehealth Clinic (PNT) Telepsychiatry: Pediatric Integrated Case Conference (T:PICC) Telepsychiatry Consultation for Pediatric and School-Based Health Clinic Providers SBHC Provider Integrated Behavioral Health Case Conference Forum Asthma/Pulmonary Telehealth Clinic (APT) For the specifics on how to request your Specialty Consultation, please contact: Clancey Tarbox, Envision New Mexico Program Coordinator, ctarbox@salud.unm.edu For more information about the reimbursement, please contact: Shawnna Romero, Director, NM Medicaid Operations shawnna_romero@bcbsnm.com (505) Office University of New Mexico * Department of Pediatrics 5 If you wish to receive CME/CEU/ or an attendance certificate, please tell us your name. Please un-mute your telephone line by pressing *6. 4/23/

4 HEDIS Measures 2014 Presented at Envision NM Telehealth April 24, 2014 Paula LeSueur MSN, CNP 7 To increase knowledge and understanding of medical procedural coding and documentation Become familiar with HEDIS measurements. Increase knowledge of Pediatric overweight/obesity, STI, URI, EPSDTclinical standards of practice. 8 4

5 Quality Clinical Standards for SBHC Practice HEDIS (Healthcare Effectiveness Data and Information Set) Institutes of Medicine AAP, AAFP, ACOG, etc NCQA Centers for Medicare and Medicaid Services Consumers have access to the reports 9 Children 3-17 years of age who had an outpatient visit with a primary care physician or OB/GYN and who had evidence of the following during the measurement year. BMI percentile documentation or BMI plotted on age appropriate growth chart (height, weight and BMI must be documented) Counseling for nutrition Counseling for physical activity *For adolescents years on the date service, documentation of a BMI value expressed as kg/m2 is acceptable. 10 5

6 ICD 9 Code Language Comment BMI Percentile ICD 9 Primary Codes ICD 9 Secondary Codes Underweight < 5 th % ile V85.51 Healthy Weight 5 th % ile to < 85 th % ile V85.52 Overweight 85 th to < 95 th % ile V85.53 Obese 95 th % ile V85.54 Morbid obesity >99 th % ile Counseling for nutrition: V65.3 Counseling for physical activity: V65.41 Counseling for Nutrition by Registered Dietician or Certified Diabetic Educator CPT: ICD-9: V

7 When counseling for nutrition document: appetite, meal patterns, eating and dieting habits. When counseling for physical activity document: Exercise routine, participation in sports activities and exam for sports participation yo female, established patient. Follow-up for BMI% >85% Significant findings: none, other than elevated BMI CPT ICD-9-CM Weight category diagnosis V65.3 Nutrition counseling V65.41 Physical activity counseling Since more than 50% of this 25 minutes visit was spent counseling and coordinating care the E&M procedure code is Chart the specifics of the risk assessment, key messages, treatment plans for changes in nutrition and physical activity. Chart any referrals. Schedule follow-up app t. Required CPT documentation and resulting Reimbursement - NM Medicaid Rate: approximately

8 13 yo NA male; first visit for WCC-EPSDT. Significant findings: FHx-DM, HTN both grandparents, BMI% >95%, acanthosis nigricans, UA-wnl, hgb-wnl, fasting glucose 100 CPT ICD-9-CM V20.2 V85.54 Since there is a significant, separately identifiable E&M service by the same provider on the same day that is above and beyond the service use Modifier 25. Documentation* in the chart should reflect the separate service: the history, physical and level of decision making in a separate note. 15 CPT Acanthosis Nigricans (CLIA-waived test for fasting glucose) Order further lab tests: fasting lipid profile, AST/ALT, HgbA1C Provide counseling, using principles of motivational interviewing for lifestyle changes, focusing on nutrition and physical activity. Add V65.3 Nutritional counseling Add V65.41 Physical activity counseling 16 8

9 OR: Schedule patient to return for a follow-up visit with documentation of the history, physical and level of decision making to support an expanded problem focused visit NM Medicaid rates: EPSDT visit New Patient E&M visit Measure Chlamydia Screening Percentage of women ages 16 to 24 that were identified as sexually active and had at least one test for Chlamydia during the measurement year. 18 9

10 Routine screening for C. trachomatis of all sexually active females aged 25 years is recommended annually. Evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men based on feasibility, efficacy, and cost-effectiveness. However, screening of sexually active young men should be considered in clinical settings associated with high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics). Routine screening for N. gonorrhoeae in all sexually active women at risk for infection is recommended annually. Women aged <25 years are at highest risk for gonorrhea infection. Other risk factors that place women at increased risk include a previous gonorrhea infection, the presence of other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use yo female presents for first visit at SBHC Chief complaint: dry cough, sneezing, itchy eyes Self report: is sexually active on Student Health Questionnaire, no condom use. Complete PFSH hx, review SHQ, perform PE Obtain urine sample for CT/GC screening CPT: 99202: (expanded problem focused): $62.74 ICD-9: Allergic rhinitis: STI screening: V

11 Perform Chlamydia screening every year on every year old female identified as sexually active (use any visit opportunity); Add Chlamydia screening as a standard lab for women years old. Use well child exams and well women exams for this purpose; Ensure that you have an opportunity to speak with your adolescent female patients without her parent; yo female requests pregnancy test. Pt. had unprotected I/C in last 36 hrs, possible exposure to STI. She missed 3 days of OCPs prior to visit. Last menses, 2 weeks ago Perform pregnancy test Assess sexual health Provide education and counseling re: use of protection, partner(s) relationship, pregnancy prevention, etc 22 11

12 Counseling for STI and contraception. Provision of Expedited Partner Treatment (EPT) for STIs (+results or known exposure) Prescribe Plan B and OCPs CPT Expanded problem focused visit CPT hcg test (CLIA-waived). Order urine GC/CT (send to contracted lab) ICD-9 V74.5 STI Screening V25.09 Contraceptive management Schedule return appointment for results/follow-up 23 Measured by the percentage of patients age 5 to adult during the measurement year who were identified as having persistent asthma and who were dispensed an asthma controller medication during the measurement year. Codes to Identify Asthma 493.0, 493.1, 493.8,

13 Ensure proper coding to avoid coding asthma if not formally diagnosing asthma and only asthma-like symptoms were present. Ex: wheezing during viral URI and acute bronchitis is not asthma Educate patients on use of asthma medications Prescribe a long-term controller medication as well as a short-term rescue inhaler 25 Children 2-18 years of age diagnosed with pharyngitis and dispensed an antibiotic should have received a Group A strep test. Codes to Identify Pharyngitis Acute pharyngitis 462 Acute tonsillitis 463 Streptococcal sore throat Codes to Identify Strep Test 87070, 87071, 87081, 87430, ,

14 APPROPRIATE TREATMENT FOR CHILDREN WITH URI Children 2-18 years of age diagnosed with URI should not be dispensed an antibiotic within 3 days of the diagnosis. Note: Claims/encounters with more than one diagnosis are excluded from the measure. Description ICD-9 Code Acute nasopharyngitis (common cold) 460 URI ICD-9 Code Codes to Identify additional or competing diagnoses Description Otitis media 382 Acute sinusitis 461 Acute pharyngitis 034.0, 462 Acute tonsillitis 463 Chronic sinusitis 473 Pneumonia

15 Barriers or Challenges? Success Stories? Changes in policy? 29 15

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