Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications‐ April 2014
HCH Care Coordination Measures:
Advance Care Planning
(mm/dd/yyyy to mm/dd/yyyy Dates of Service)
Measure and Field Specifications for Review
DRAFT Following Pilot 4/3/2014
Changes During and Following Pilot
Red Font = Measure or Field Modifications
Green Font = Clarification
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications‐ April 2014
Description
Percentage of patients age 65 or greater at the start of the measurement year who have
evidence (documentation) of advance care planning in their medical record at their
health care home clinic.
Methodology
Population identification is accomplished via a query of a practice management system
or Electronic Medical Record (EMR) to identify the population of eligible patients
(denominator). Data elements are either extracted from an EMR system or abstracted
through medical record review.
Rationale
In its influential report Crossing the Quality Chasm, the Institute of Medicine (2001)
called for ‘patient‐centered care’ that explicitly considers the preferences and desires of
the patients. Bioethicists concur that physicians should share, and in some cases
delegate, medical decision‐making control to dying patients and their families
(President’s Council on Bioethics, 2005). In practice, however, many dying persons are
unable to convey their preferences for medical treatments because they are
incapacitated when the decision is required (Field and Cassel, 1997). As such, difficult
decisions about stopping or continuing treatment often fall to family members, who
may be distressed and may disagree among themselves about appropriate care (Kramer
et al., 2006). When families and health‐care providers cannot agree on a course of
action, the default decision typically is to continue treatments, which may be financially
and emotionally draining for family members, and physically distressing to the patient
(Field and Cassel, 1997). In an effort to prevent problematic, futile, or contested end‐of‐
life, practitioners encourage older adults to express and document their treatment
preferences when they are still on good health (American Medical Association, 1996).
(NIH Public Access, Social Forum (Randolph NJ). 2009 December1:24 (4): 754‐778.)
Minnesota Honoring Choices:
According to a Harvard Medical School study, nearly half of patients with metastasized
lung cancer and their doctors did not discuss hospice care within four to seven months
of their diagnosis.
A recent University of Pittsburgh study showed that when people with Medicare were
asked about their treatment preferences if diagnosed with a terminal illness, the
majority did not prefer life‐prolonging measures.
However, the study found a correlation between end‐of‐life care preferences and race.
African Americans and Hispanics were both more likely to opt for intensive end‐of‐life
care. African Americans were twice as likely as whites to say they would want life‐
prolonging treatments. Theories for this difference include: belief that the health care
system is racially biased, communication barriers, and lack of a regular doctor, which
makes end‐of‐life discussions more difficult within the limited patient‐physician
relationship. The likelihood of a patient‐physician discussion about hospice varied with
race and ethnicity, according to a Harvard study. Hispanics (43%) and African Americans
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications‐ April 2014
(49%) were less likely to have discussions than whites (53%) and Asians (59%).
Having a standard of care for physicians to offer patients advance care planning, as they
would offer a screening for colorectal cancer, might help decrease disparities in care
and increase patient confidence that their wishes will be adhered to.
Minnesota’s Health Care Home certification requires under Care Planning, Subp. 7A,
that a health care home must include goals and an action plan for end‐of‐life care and
health care directives, when appropriate. (MDH)
HEDIS initiated a health care directives (also known as ‘advanced directive’) measure in
2011, as part of the Care for Older Adults (COA) measure, and reports the percent of
commercial/Medicaid and Medicare patients with advance care planning that occurred
in that measurement year.
Measurement Period
The measurement period will be a fixed 12‐month period: mm/dd/yyyy to mm/dd/yyyy
Denominator
Established patient who meets each of the following criteria is included in the
population:



Eligible Providers,
Specialties and
Clinics
Patient age 65 years or greater at the start of the measurement period (date of
birth was on or prior to mm/dd/yyyy)
Patient was seen by an eligible provider in an eligible specialty face‐to‐face at
least two times during the last two years prior to and including the pilot period
(mm/dd/yyyy ‐ mm/dd/yyyy) for any reason by a certified health care home
clinic. Use this date of service range when querying the practice management or
EMR system to allow a count of the visits within this time frame.
Patient was seen by an eligible provider in an eligible specialty face‐to‐face at
least one time during the pilot period (mm/dd/yyyy ‐ mm/dd/yyyy) for any
reason by a certified health care home clinic.
Eligible Clinics: Certified Health Care Home Clinics
Eligible specialties: Family Medicine (Includes General Practice), Internal Medicine, and
Geriatric Medicine, or any other board certified specialty that is health care home
certified.
Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant
(PA), Nurse Practitioner (NP)
Allowable Exclusions
There are no allowable exclusions for this measure.
Numerator
Percentage of patients age 65 or greater at the start of the measurement year with
evidence of advance care planning in their medical record. Patient has a written
advance care plan in the chart with the following documented:
• The patient’s wishes are outlined
•The patient’s decision‐maker is defined
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications‐ April 2014
Patients age 65 or greater with evidence (documentation) of advance care planning in
their medical record at their health care home clinic
Measure Calculation
Established Patients age 65 or greater at the start of the measurement year
Additional
Considerations
Originally, the measure was designed and tested with the Advance Care Plan (ACP)
containing two key elements; the patient’s wishes are outlined and the patient’s
decision maker is defined. While the measure development work group still feels that
both of these elements are important, the requirement for documented decision maker
prohibited the use of some excellent tools like the POLST (Physician Orders for Life
Sustaining Treatment) that do a great job of outlining patient wishes. Following pilot
testing, the work group decided to focus efforts on the documentation of patient
wishes for measurement purposes. Having the patient select a designated decision
maker is still an important part of advance care planning and care coordination and
groups are encouraged to follow best practices for end‐of‐life discussions with patients
and part of this includes identifying a designated decision maker.
Acceptable Documentation of Advance Care Plan (ACP)
The purpose and intent of this measure is to increase the rates of patients age 65 and older who have
documentation of advanced care planning in their medical record in an effort to improve the coordination of
care and promote end‐of‐life discussions. The measure development group did not want to be prescriptive in
terms of the type, format or content of this documentation; rather wanted to focus on evidence that the
patient’s wishes are documented. Additionally, the work group did not want to add undue data collection and
submission burden by requiring groups to submit detail about the patient’s wishes. Groups indicate if the
patient does indeed have an ACP present in the medical record (yes/no) and then during the validation audit for
a sample of records, the content of the patient’s ACP will be reviewed and validated for content that includes
patient wishes.
Please note that while most medical groups use a type of form to hold this documentation; the use of a form is
not required for numerator compliance. Any documentation of patient wishes is acceptable and can include the
patient identifying a surrogate decision maker. In addition to forms (scanned or part of a paper chart), groups
can use care plans, discrete EMR fields indicating the presence of an ACP, discrete EMR fields that indicate
patient wishes or progress notes as evidence of documentation of an advance care plan present in the record.
The following methods/ types of documentation are acceptable:




Scanned document in an EMR
Paper document in a paper chart
Care plan that includes patient wishes
Order for DNR/DNI (Do Not Resuscitate/ Do Not Intubate)
The following are an examples of forms or types of forms that can be used to meet the intent of an ACP;
however the list is only a suggestion and not all‐inclusive.

Honoring Choices
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications‐ April 2014






Five Wishes
POLST Physician Orders for Life Sustaining Treatment
MN Advanced Directive/ Caring Connections
Advance Directive
Living Will
Durable Power of Attorney
Resources for Advance Directives/ Advance Care Planning and Best Practices:
Organization
Link for More Information
Honoring Choices
www.honoringchoices.org/resources/
www.metrodoctors.com/dev/index.php/healthcare‐directives
Five Wishes
www.agingwithdignity.org/forms/5wishes.pdf
POLST
www.mnmed.org/Portals/mma/PDFs/POLSTform.pdf
MN Advance Directive/
Caring Connections
www.caringinfo.org/files/public/ad/Minnesota.pdf
National Cancer Institute
www.cancer.gov/cancertopics/factsheet/Support/advance‐directives
American Cancer Society
www.cancer.org/treatment/findingandpayingfortreatment/
understandingfinancialandlegalmatters/advancedirectives/advance‐
directives‐toc
NIH National Institute on Aging
www.nia.nih.gov/health/publication/advance‐care‐planning
Centers for Disease Control
http://www.cdc.gov/aging/pdf/acp‐resources‐public.pdf
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications for MARC‐ April 2014
Data Elements and Field Specifications Table
Column
Field Name
Notes
Excel Format
Example
A
Clinic ID
Text
9999
B
Patient ID
Enter the MNCM Clinic ID of the health care home clinic the patient is assigned to.
MNCM assigns the clinic ID at the time of registration. Clinic IDs are also listed in the
MNCM Data Portal.
Do NOT use the Medical Group ID.
Blank values will create an ERROR upon submission.
Quality Check: Verify all IDs match the MNCM ID in the portal.
Enter a unique patient ID that will identify each patient.
• Keep a “crosswalk” between the patient ID and the patient name and DOB to
help clinic staff locate the record for the validation audit
• Enter clinic‐assigned ID (e.g., MRN, account number). Do NOT enter social
security numbers.
Blank values will create an ERROR upon submission.
Quality Check: Verify patients were not duplicated. If patient is duplicated, determine
which clinic you will attribute patient to. If submitting a sample population, you will
need to replace the deleted record with the next sampled patient.
Text
1
C
Date of Birth
Include patients age 65 or greater at the start of the measurement period
(date of birth on or prior to mm/dd/yyyy)
• Blank values will create an error upon submission.
Quality Check: Verify each date of birth is within the accepted range.
Date
(mm/dd/yyyy
)
06/01/1995
D
Gender
Enter the patient’s gender: Female = F; Male = M; Unknown = U
Blank values will create an ERROR upon submission.
Quality Check: Verify each cell has one of the accepted codes.
Text
F
E
Zip Code, Primary
Residence
Enter the patient’s 5‐digit zip code of primary residence at the most recent encounter
on or prior to mm/dd/yyyy.
• If EMR query extracts a 9‐digit number, submit the 9‐digit number (the portal
will remove the last 4 digits automatically).
Blank values will create an ERROR upon submission.
Quality Check: Verify the zip code is five digits long and that each cell has data.
Text
55111
•
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications for MARC‐ April 2014
Column
Field Name
Notes
Excel Format
Example
F
Race1
Number
1
G
Race2
Please refer to a separate document entitled REL Data Field Specifications and Codes
2013 for these field specifications.
H
Race3
I
Race4
J
Race5
K
Country of Origin
Code
Number
2
L
Country of Origin
(Other) Description
Text
Country A
M
Preferred Language
Code
Number
1
N
Preferred Language
(Other) Description
Text
Language B
O
Provider NPI
Number
Enter the ten‐digit NPI number of the provider who manages the patient’s care.
Blank values will create an ERROR upon submission.
Quality Check: Verify that each cell has a ten‐digit number.
Text
1234567891
P
Provider Specialty
Code
Enter the board certified specialty of the provider (if multiple specialties, choose
primary specialty):
1 = Family Medicine (Includes General Practice)
2 = Internal Medicine
5 = Geriatric Medicine
Blank values will create an ERROR upon submission.
Quality check: Verify that each cell has an accepted code.
Number
5
Q
Insurance Coverage
Code
Number
1
R
Insurance Coverage
“Other” Description
Please refer to a separate document entitled Insurance Coverage Data Field
Specifications and Codes 2013 for these field specifications.
This document can be found under the RESOURCES tab in the data portal under the
“Insurance Coverage Info” section from the drop‐down menu.
Text
Assurant
Health
This document can be found under the RESOURCES tab in the data portal under the
“Race/Ethnicity/Language Data (REL)” section from the drop‐down menu.
For more information about collecting this data from patients in your clinic practice,
please refer to the Handbook on the Collection of Race Ethnicity and Language Data
available at www.mncm.org.
Quality Checks: Verify accepted codes are used. Blank cells (if there is no data is
available) are acceptable
Health Care Homes Care Coordination: Advance Care Planning
DRAFT Measure & Field Specifications for MARC‐ April 2014
Column
Field Name
Notes
Excel Format
Example
S
Health
Plan/Insurance Plan
Member ID
PLEASE NOTE: This should be the patients’ most recent insurance on or prior to
09/30/2013
Quality Checks: Verify accepted codes are used and that all 99 codes have a name
entered in Column R. Verify SSN are NOT submitted.
Text
FBOXZ7969
T
Advance Care Plan
in Patient’s Medical
Record
Enter one of the two options that correlate with the patient having an advance care
plan in their medical record. BOTH of the following documented: 1) patient’s wishes
are outlined and 2) patient’s decision‐maker is defined:
Number
1
Number
2
•
•
1 = Yes, patient has evidence of advance care planning in their medical record
0 = No, patient does not have evidence of advance care planning in their
medical record
Please refer to Section A: Acceptable Documentation of Advance Care Plan (ACP)
Blank values will create an error upon submission.
U
Reason No Advance
Care Plan
If the patient does not have evidence of advance care plan in their record, enter the
correct description of reason why.
•
•
1 = Patient declined advance care planning
2 = Discussion never occurred with this patient/ unknown if discussion
occurred
• 3 = Currently in process
Note: If you don’t know whether or not this discussion occurred, use choice “2”
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications-April 2014
HCH Care Coordination Measures:
Follow‐up After Hospital Discharge
(mm/dd/yyyy to mm/dd/yyyy Dates of Service)
Measure and Field Specifications
DRAFT Following Pilot 4/3/2014
Changes During and Following Pilot
Red Font = Measure or Field Modifications
Green Font = Clarification
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Description
Percentage of patients with selected clinical conditions that have a follow‐up telephonic/
electronic contact within three days of discharge OR a follow‐up face‐to‐face visit with a
health care provider (physician, physician assistant, nurse practitioner, nurse, care‐
coordinator) within seven days of hospital discharge.
Clinical conditions represent those with the highest volume of readmissions in MN1 and
include:
•
•
•
•
Heart failure
Pneumonia; age 65+
Ischemic vascular disease
Chronic obstructive pulmonary disease
Methodology
Population identification is accomplished via a query of a practice management system or
Electronic Medical Record (EMR) to identify the population of eligible patients
(denominator). Data elements are either extracted from an EMR system or abstracted
through medical record review.
Rationale
Benefits of improved care coordination include the reduction of potential harm from
medication errors, transitions, and poor communication.2
Rehospitalization—patient admission to a hospital soon after discharge—is both common
and costly. In the majority of situations, hospitalization is necessary and appropriate.
However, nearly one in every five elderly patients who are discharged from the hospital is
rehospitalized within 30 days. Many of these rehospitalizations are avoidable, and thus
suggest a failure in the systems of establishing patients stably and safely in a new setting
of care.3
A study of over 12 million Medicare fee for service patients discharged in 2003 and 2004,
found that 19.6% were readmitted to the hospital within 30 days, and cumulatively 34.0%
in 90 days and 56.1% in one year. For 50% of patients readmitted within 30 days, there
was no bill for a physician visit during that time. 4
Improving transitions of care through better coordination between hospitals and primary
care providers represents a way to help reduce the risks patient’s face when being
discharged from the hospital. Recent studies support this theory, Hernandez and
colleagues found that among patients being discharged after heart failure those who had
1
MN Hospital Association Potentially Preventable Readmission (3M Software) Data for 2011
Coleman EA, Parry C, Chalmers S, et.al. The Care Transitions Intervention: Results of a randomized controlled trial. Arch Intern Med;
166:1822‐1828, 2006.
3
Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence. Cambridge, MA: Institute for Healthcare
Improvement; Boutwell, A. Hwu, S. 2009
4
Rehospitalizations Among Patients in the Medicare Fee‐for‐Service Program S. Jencks, M.Williams, E. Coleman NEJM April 2009
2
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
an early outpatient follow‐up were less likely to be readmitted to the hospital within 30
days.5 Another study found that patients lacking follow‐up with a primary care physician
within four weeks of discharge from the University of Colorado hospital were 10 times
more likely to be readmitted. 6
Improving communication and coordination between hospitals, patients, and primary
care providers represents a new approach aimed at reducing health care costs and a
patient’s risk of experiencing complications after a hospital discharge.
The Hospital to Home initiative co‐sponsored by the American College of Cardiology and
the Institute for Healthcare Improvement calls for a 7 day follow‐up visit after discharge
for individuals hospitalized with cardiovascular disease. Additionally, groups participating
in the CMS sponsored Physician Group Practice Demonstration aimed for a post‐hospital
follow‐up appointment to occur within five days for high‐risk patients.
Alignment with goals of the RARE Reducing Avoidable Readmissions Effectively campaign
in Minnesota (www.rarereadmissions.org) also an important determinate for the
selection of this measure and a perfect fit for the goal improving care coordination for
patients. Additionally, the Minnesota Department of Health’s Health Care Home program
establishes a standard that certified clinic engage their patients in planning for transitions
of care. Minnesota’s Health Care Home certification requires under Care Coordination
subpart 5E requires that clinics must have processes in place timely post discharge
planning according to a protocol for patients discharged from hospitals, skilled nursing
facilities or other health care institutions.
Measurement
Period
5
The measurement period will be a fixed 12 month period: mm/dd/yyyy to mm/dd/yyyy
Relationship Between Early Physician Follow‐up and 30 day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure.
Hernandez AF, Greiner, MA et.al. JAMA 2010;303(17):1716‐1722
6 Post‐Hospitalization Transitions: Examining the Effects of Timing of Primary Care Provider Follow‐up Misky, GJ, Wald, HL, Coleman EA
Journal of Hospital Medicine September 2010
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Patient
Population
Follow‐up Face to
Face Visit after
Discharge
Established patient who meets each of the following criteria is included in the population:





Patients age 18 and older at the start of the measurement period (date of birth
was on or less than mm/dd/yyyy)
AND
Has one or more of the following diagnoses heart failure, pneumonia, ischemic
vascular disease or COPD if age 18 or older at the start of the measurement
period. Please see tables below for diagnosis codes. Diagnosis codes in either the
principle or secondary diagnosis position OR diagnosis is active on the problem list
OR
Has the diagnosis of pneumonia if age 65 or older at the start of the measurement
period (date of birth was on or less than mm/dd/yyyy). Please see tables below
for diagnosis codes. Diagnosis codes in either the principle or secondary
diagnosis position OR diagnosis is active on the problem list AND
Hospitalized with an inpatient discharge date within the measurement year
AND
Meets the following established patient visit criteria:
o
Measure Follow‐
up Visit;
Telephonic/
Electronic within
Three Days or
Face‐to‐Face
within Seven Days
after Discharge
Patient was seen by an eligible provider in an eligible specialty face‐to‐
face at least two times during the last two years (mm/dd/yyyy to
mm/dd/yyyy) for any reason by a certified health care home clinic.
Percentage of established patients 18 and older with heart failure, ischemic vascular
disease or COPD or 65 and older with pneumonia that have a either a telephonic or
electronic contact within three days of discharge or a face‐to‐face visit within seven days
of hospital inpatient discharge.
 Telephonic contacts require actual contact with the patient or family/care giver and the
telephone call is made for the purpose of follow‐up after hospitalization by a health
care provider responsible for coordination of care (e.g. physician, physician assistant,
nurse practitioner, nurse, pharmacist, care coordinator or case manager). The following
types of telephone calls MAY NOT be submitted for numerator consideration: voicemail
messages left for patients, calls to schedule an appointment; medication refills,
reporting of lab results, inbound calls from patients, lab results, or any other call that
does not contain coordination of care activities following hospital discharge.
 Electronic contacts include email contact with patient reply, patient portal contact with
reply and e‐Visits.
 Face‐to‐face visits include all of the following visit types: office, home care visits, visits
with a specialist, visit with a care coordinator or nurse, or visit with a pharmacist for
medication therapy management services (MTMS).
# of patients age 18 & older with select diagnoses and either a telephonic or electronic
contact within 3 days OR a follow‐up face‐to‐face visit within 7 days of discharge
# patients age 18 & older with selected diagnoses and hospital discharge in measurement
period
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Eligible Providers,
Specialties and
Clinics
Eligible Clinics: Certified Health Care Home Clinic
Eligible specialties: Family Medicine (Includes General Practice), Internal Medicine, and
Geriatric Medicine.
Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant
(PA), Nurse Practitioner (NP)
Please note: Eligible providers and specialties are used for determining the visit counts
for established patient criteria, which serve to determine if a patient “belongs” to this
clinic. It does not mean that there is a requirement for the follow‐up contact/ visit to
occur with the above listed provider types.
Allowable
Exclusions
Exclusions include patients with an in‐hospital death, transfer to an acute or long term
care facility, or outpatient/ observation status.
• Patient died during hospital stay
• Patient was transferred from a hospital discharge to another acute or transitional
care facility
• Patients whose hospital status is observation care (hospital outpatient)
Additional
Measures for
Analysis/Quality
Improvement
•
•
•
•
Additional
Considerations
7
8
The average number of days between discharge date and follow‐up contact/ visit
stratified by telephonic/ electronic and face‐to‐face
The average number of days between the discharge date and the date clinic was
notified of discharge. [Optional measure‐ groups can use for internal QI purposes]
Rate of patient follow‐up telephonic or electronic contact within three days of
hospital discharge
Rate of patient follow‐up face to face visit within seven days of hospital discharge
During the evolution of this measure, rather than limiting or requiring the face‐to‐face
visit to be with a physician (or doctor of osteopathy, physician assistant , or nurse
practitioner), the group, from an economical and team care approach, desired the
inclusion of other types of face‐to‐face visits with the patient. Following public comment
period for this measure, the development work group re‐designed the original face‐to‐
face visit measure to incorporate telephonic and electronic contacts, to allow for cost
effective delivery of care. Though the content of the visit is not included as part of the
measure, it is recognized that the type of activities that occur during this follow‐up visit,
particularity medication reconciliation and patient engagement, are recognized as key for
avoiding readmission to the hospital.7,8 See next section on guidance for follow‐up
visits/contacts.
RARE Reducing Avoidable Readmissions Effectively www.rarereadmissions.org RARE Campaign Minnesota
Coleman, Eric The Post Hospital Follow‐up Visit‐ California Health Care Brief
Diagnosis Codes for Inclusion
Diagnosis codes in either the principle or secondary diagnosis position OR diagnosis is active on the problem list.
If the patient has one or more of these codes and discharged from the hospital during the measurement year,
they are to be included in the denominator.
Table 1: ICD‐9 Diagnosis Codes to Identify Patients with Heart Failure
ICD‐9 Diagnosis Code
ICD‐9 Diagnosis Code Descriptions
402.01
Hypertensive heart disease, malignant, with heart failure
402.11
Hypertensive heart disease, benign, with heart failure
402.91
Hypertensive heart disease, unspecified, with heart failure
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
404.01
chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with
404.03
chronic kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, benign, with heart failure and with
404.11
chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic
404.13
kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with
404.91
chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and
404.93
chronic kidney disease stage V or end stage renal disease
428.0
Congestive heart failure, unspecified
428.1
Left heart failure
428.20
Unspecified systolic heart failure
428.21
Acute systolic heart failure
428.22
Chronic systolic heart failure
428.23
Acute on chronic systolic heart failure
428.30
Unspecified diastolic heart failure
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
ICD‐9 Diagnosis Code
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
ICD‐9 Diagnosis Code Descriptions
Acute diastolic heart failure
Chronic diastolic heart failure
Acute on chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Acute combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acute on chronic combined systolic and diastolic heart failure
Heart failure, unspecified
Table 2: ICD‐9 Diagnosis Codes to Identify Patients with Pneumonia
ICD‐9 Diagnosis Code
ICD‐9 Diagnosis Code Descriptions
480.0
Pneumonia due to adenovirus
480.1
Pneumonia due to respiratory syncytial virus
480.2
Pneumonia due to parainfluenza virus
480.3
Pneumonia due to SARS associated coronavirus
480.8
Viral pneumonia: pneumonia due to other virus not elsewhere classified
480.9
Viral pneumonia unspecified
481
Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]
482.0
Pneumonia due to klebsiella pneumoniae
482.1
Pneumonia due to pseudomonas
482.2
Pneumonia due to hemophilus influenzae (h. influenzae)
482.30
Pneumonia due to streptococcus unspecified
482.31
Pneumonia due to streptococcus group a
482.32
Pneumonia due to streptococcus group b
482.39
Pneumonia due to other streptococcus
482.40
Pneumonia due to staphylococcus unspecified
482.41
Methicillin susceptible pneumonia due to staphylococcus aureus
482.42
Methicillin resistant pneumonia due to staphylococcus aureus
482.49
Other staphylococcus pneumonia
482.81
Pneumonia due to anaerobes
482.82
Pneumonia due to escherichia coli [e.coli]
482.83
Pneumonia due to other gram negative bacteria
482.84
Pneumonia due to legionnaires' disease
482.89
Pneumonia due to other specified bacteria
482.9
Bacterial pneumonia unspecified
483.0
Pneumonia due to mycoplasma pneumoniae
483.1
Pneumonia due to chlamydia
483.8
Pneumonia due to other specified organism
485
Bronchopneumonia organism unspecified
486
Pneumonia organism unspecified
487.0
Influenza with pneumonia
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Table 3: ICD‐9 Diagnosis Codes to Identify Patients with Ischemic Vascular Disease
ICD‐9 Diagnosis Code
ICD‐9 Diagnosis Code Descriptions
410.00
AMI ANTEROLATERAL,UNSPEC
410.01
AMI ANTEROLATERAL, INITIAL
410.02
AMIANTEROLATERAL,SUBSEQ
410.10
AMI ANTERIOR WALL,UNSPEC
410.11
AMI ANTERIOR WALL, INITIAL
410.12
AMI ANTERIOR WALL,SUBSEQ
410.20
AMI INFEROLATERAL,UNSPEC
410.21
AMI INFEROLATERAL, INITIAL
410.22
AMI INFEROLATERAL,SUBSEQ
410.30
AMI INFEROPOST, UNSPEC
410.31
AMI INFEROPOST, INITIAL
410.32
AMI INFEROPOST, SUBSEQ
410.40
AMI INFERIOR WALL,UNSPEC
410.41
AMI INFERIOR WALL, INITIAL
410.42
AMI INFERIOR WALL,SUBSEQ
410.50
AMI LATERAL NEC, UNSPEC
410.51
AMI LATERAL NEC, INITIAL
410.52
AMI LATERAL NEC, SUBSEQ
410.60
TRUE POST INFARCT,UNSPEC
410.61
TRUE POST INFARCT, INITIAL
410.62
TRUE POST INFARCT,SUBSEQ
410.70
SUBENDO INFARCT, UNSPEC
410.71
SUBENDO INFARCT, INITIAL
410.72
SUBENDO INFARCT, SUBSEQ
410.80
AMI NEC, UNSPECIFIED
410.81
AMI NEC, INITIAL
410.82
AMI NEC, SUBSEQUENT
410.90
AMI NOS, UNSPECIFIED
410.91
AMI NOS, INITIAL
410.92
AMI NOS, SUBSEQUENT
411.0
POST MI SYNDROME
411.1
INTERMED CORONARY SYND
411.81
ACUTE COR OCCLSN W/O MI
411.89
AC ISCHEMIC HRT DIS NEC
412
OLD MYOCARDIAL INFARCT
413.0
ANGINA DECUBITUS
413.1
PRINZMETAL ANGINA
413.9
ANGINA PECTORIS NEC/NOS
414.00
COR ATH UNSP VSL NTV/GFT
414.01
CRNRY ATHRSCL NATVE VSSL
414.02
CRN ATH ATLG VN BPS GRFT
414.03
CRN ATH NONATLG BLG GRFT
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
ICD‐9 Diagnosis Code
414.04
414.05
414.06
414.07
414.2
414.3
414.8
414.9
429.2
433.00
433.01
433.10
433.11
433.20
433.21
433.30
433.31
433.80
433.81
433.90
433.91
434.00
434.01
434.10
434.11
434.90
434.91
440.0
440.1
440.20
440.21
440.22
440.23
440.24
440.29
440.4
444.0
444.01
444.09
444.1
444.21
444.22
444.81
444.89
ICD‐9 Diagnosis Code Descriptions
COR ATH ARTRY BYPAS GRFT
COR ATH BYPASS GRAFT NOS
COR ATH NATV ART TP HRT
COR ATH BPS GRAFT TP HRT
CHR TOT OCCLUS COR ARTRY
COR ATH DUE TO LIPID RICH PLAQUE
CHR ISCHEMIC HRT DIS NEC
CHR ISCHEMIC HRT DIS NOS
ASCVD
OCL BSLR ART WO INFRCT
OCL BSLR ART W INFRCT
OCL CRTD ART WO INFRCT
OCL CRTD ART W INFRCT
OCL VRTB ART WO INFRCT
OCL VRTB ART W INFRCT
OCL MLT BI ART WO INFRCT
OCL MLT BI ART W INFRCT
OCL SPCF ART WO INFRCT
OCL SPCF ART W INFRCT
OCL ART NOS WO INFRCT
OCL ART NOS W INFRCT
CRBL THRMBS WO INFRCT
CRBL THRMBS W INFRCT
CRBL EMBLSM WO INFRCT
CRBL EMBLSM W INFRCT
CRBL ART OC NOS WO INFRC
CRBL ART OCL NOS W INFRC
ATHERSCLEROSIS OF AORTA
RENAL ARTERY ATHEROSCLER
ATHSCL EXTRM NTV ART NOS
ATH EXT NTV AT W CLAUDCT
ATH EXT NTV AT W RST PN
ATH EXT NTV ART ULCRTION
ATH EXT NTV ART GNGRENE
ATHRSC EXTRM NTV ART OTH
CHR TOT OCCL ART EXTREM
ABD AORTIC EMBOLISM
SADDLE EMBOLUS OF ABDOMINAL AORTA
OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA
THORACIC AORTIC EMBOLISM
UPPER EXTREMITY EMBOLISM
LOWER EXTREMITY EMBOLISM
ILIAC ARTERY EMBOLISM
ARTERIAL EMBOLISM NEC
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
ICD‐9 Diagnosis Code
444.9
445.01
445.02
445.81
445.89
ICD‐9 Diagnosis Code Descriptions
ARTERIAL EMBOLISM NOS
ATHEROEMBOLISM,UPPER EXT
ATHEROEMBOLISM,LOWER EXT
ATHEROEMBOLISM, KIDNEY
ATHEROEMBOLISM, SITE NEC
Table 4: ICD‐9 Diagnosis Codes to Identify Patients with Chronic Obstructive Pulmonary Disease
ICD‐9 Diagnosis Code
ICD‐9 Diagnosis Code Descriptions
491.20
491.21
491.22
491.8
491.9
492.0
492.8
493.20
493.21
493.22
496
Obstructive chronic bronchitis without exacerbation
Obstructive chronic bronchitis with acute exacerbation
Obstructive chronic bronchitis with acute bronchitis
Other chronic bronchitis
Unspecified chronic bronchitis
Emphysematous bleb
Other emphysema
Chronic obstructive asthma, unspecified
Chronic obstructive asthma, with status asthmaticus
Chronic obstructive asthma, with (acute) exacerbation
Chronic: nonspecific lung disease
For medical groups that have a mix of certified health care home clinics and non‐health care home clinics.
Attribution Method:
a. Run an overall attribution of all adult patients (18 and older)
b. Attribute each patient to a clinic location using the following strategy
A patient is attributed to one clinic and one provider that are considered responsible for
managing the patient’s care. Please use the following attribution methods in order:
1. First, attribute the patient to the clinic and provider that are assigned to the patient and
are responsible for the patient’s care. If the patient does not have an assigned clinic or
provider, then
2. Attribute the patient to the clinic and provider that saw the patient most often in the
measurement period. If more than one provider saw the patient equally, then
3. Attribute the patient to the clinic and provider that saw the patient most recently in the
measurement period.
If a provider has left the clinic, you may attribute the patient to the provider who has
left or to a new provider now managing the patient’s care.
c. Then continue with the denominator criteria for the patients who are attributed to a certified
health care home clinic.
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Guidance for Established Patient Criteria Visits for Numerator
The second type of application for visits in this measure relates to the numerator, whose criteria are broader,
including non‐face to‐face contacts as well.
Telephonic, Electronic and Face‐to‐Face Contacts for Numerator
Types of visits that are included in the numerator, that is they count as either a telephonic for electronic contact
with interaction with the patient or caregiver (not simply a message pushed out) or a face to face visit with the
patient following hospital discharge, include any of the flowing types of visits:
•
•
•
•
•
•
•
•
•
•
•
Office visit with primary care provider
Office visit or consultation with a specialist
Office visit with care coordinator or nurse
Home care visit
Visit to an assisted living facility
Visit with pharmacist for medication therapy management services (MTMS)
Telephone contact with patient reply
o Purpose of the call is for follow‐up after hospital discharge
o By one of the following types of providers: physician, physician assistant, nurse practitioner, nurse,
pharmacist, care coordinator or case manager
The following types of telephone calls MAY NOT be submitted for numerator consideration: voicemail
messages left for patients, calls to schedule an appointment; medication refills, reporting of lab results,
inbound calls from patients, lab results, or any other call that does not contain coordination of care activities
following hospital discharge.
Email contact with patient reply
Patient portal contact with patient reply
E‐Visit with patient
Groups may use classifications of visits types stored within their EMR to classify these types of visits, many of
which may not be available within standardized billing and coding systems. CPT codes are included for guidance,
but they are not all‐inclusive of the types of face‐to‐face visits acceptable for the numerator. Visit types
submitted will be reviewed during the validation audit.
Guidance for Exclusion: Transferred from a Hospital Discharge to Another Acute or Transitional Care
Facility. Definition of acute and transitional care facilities includes any of the following:
•
•
•
•
•
•
•
•
Acute care hospital
Critical access hospital
Designated cancer center
Hospice (residential facility)
Hospital based Medicare swing bed
Inpatient rehabilitation facility
Intermediate care facility (ICF)
Long term care hospital
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
• Psychiatric hospital or psychiatric unit of a hospital
• Short term general hospital for inpatient care
• Skilled nursing facility (SNF)
Please note: Patients who are transferred to an assisted living type facility are NOT to be excluded from the
measure. These patients may not be monitored as closely as those in acute or transitional care facilities and are
appropriate for post discharge follow‐up.
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Data Elements and Field Specifications Table
The following data elements should be collected for each hospital discharge for a patient that occurs during the measurement period.
Column
Field Name
Notes
Excel Format
Example
A
Clinic ID
Text
9999
B
Patient ID
Enter the MNCM Clinic ID of the health care home clinic the patient is assigned
to. MNCM assigns the clinic ID at the time of registration. Clinic IDs are also
listed in the MNCM Data Portal.
Do NOT use the Medical Group ID.
Blank values will create an ERROR upon submission.
Quality Check: Verify all IDs match the MNCM ID in the portal.
Enter a unique patient ID that will identify each patient.
• Keep a “crosswalk” between the patient ID and the patient name and
DOB to help clinic staff locate the record for the validation audit
• Enter clinic‐assigned ID (e.g., MRN, account number). Do NOT enter
social security numbers.
Blank values will create an ERROR upon submission.
Quality Check: Verify if a patient was duplicated that they had two separate
hospital discharge events.
Text
1
C
Date of Birth
Include patients age 18 or greater at the start of the measurement
period (date of birth was on or between (06/01/1995).
Blank values will create an ERROR upon submission.
Quality Check: Verify each date of birth is within the accepted range.
Date
(mm/dd/yyyy
)
06/01/1995
D
Gender
Enter the patient’s gender: Female = F; Male = M; Unknown = U
Blank values will create an ERROR upon submission.
Quality Check: Verify each cell has one of the accepted codes.
Text
F
•
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Column
Field Name
Notes
Excel Format
Example
E
Zip Code, Primary
Residence
Enter the patient’s 5‐digit zip code of primary residence at the most recent
encounter on or prior to 11/30/2013.
• If EMR query extracts a 9‐digit number, submit the 9‐digit number (the
portal will remove the last 4 digits automatically).
Blank values will create an ERROR upon submission.
Quality Check: Verify the zip code is five digits long and that each cell has data.
Text
55111
F
Race1
Number
1
G
Race2
Please refer to a separate document entitled REL Data Field Specifications and
Codes 2013 for these field specifications.
H
Race3
I
Race4
J
Race5
K
Country of Origin
Code
Number
2
L
Country of Origin
(Other) Description
Text
Country A
M
Preferred Language
Code
Number
1
N
Preferred Language
(Other) Description
Text
Language B
O
Provider NPI
Number
Text
123456789
1
This document can be found under the RESOURCES tab in the data portal under
the “Race/Ethnicity/Language Data (REL)” section from the drop‐down menu.
For more information about collecting this data from patients in your clinic
practice, please refer to the Handbook on the Collection of Race Ethnicity and
Language Data available at www.mncm.org.
Quality Checks: Verify accepted codes are used. Blank cells (if there is no data is
available) are acceptable
Enter the ten‐digit NPI number of the provider who manages the patient’s care.
Blank values will create an ERROR upon submission.
Quality Check: Verify that each cell has a ten‐digit number.
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Column
Field Name
Notes
Excel Format
Example
P
Provider Specialty
Code
Enter the board certified specialty of the provider (if multiple specialties, choose
primary specialty):
1 = Family Medicine
2 = Internal Medicine
5 = Geriatric Medicine
Blank values will create an ERROR upon submission.
Quality check: Verify that each cell has an accepted code.
Number
5
Q
Insurance Coverage
Code
Number
1
R
Insurance Coverage
“Other” Description
Text
Assurant
Health
S
Health
Plan/Insurance Plan
Member ID
Please refer to a separate document entitled Insurance Coverage Data Field
Specifications and Codes 2013 for these field specifications.
This document can be found under the RESOURCES tab in the data portal under
the “Insurance Coverage Info” section from the drop‐down menu.
PLEASE NOTE: This should be the patients’ most recent insurance on or prior to
11/30/2013
Quality Checks: Verify accepted codes are used and that all 99 codes have a
name entered in Column R. Verify SSN are NOT submitted.
Text
FBOXZ7969
T
Hospital Discharge
Date
Enter the date that the patient was discharged from the hospital.
Blank values will create an ERROR upon submission.
Quality Check: Verify all dates are within the measurement period.
Date
(mm/dd/yyyy
)
06/30/2013
U
Facility ID
Enter the code for the hospital where the patient was discharged from. Please
refer to Appendix C for a list of hospital codes.
This data element will be used to additionally analyze the communication of
discharge from hospital facility to HCH clinic and will be tested during the pilot
for feasibility of capturing the information.
If the hospital is not listed in Appendix C facility is not a hospital, leave BLANK
and supply the name in the field Delivery Facility (Other) Description.
Quality Check: Verify one of the accepted codes is used.
Text
41
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Column
Field Name
Notes
Excel Format
Example
V
Facility (Other)
Description
Enter the name of the facility if the facility is not listed on the table and Column
Q was left blank.
Leave column BLANK if Column U (“Facility ID”) has an acceptable code.
Quality Check: Verify that in each row that has text entered in this cell, Column
Q is left blank.
W
Date Clinic Notified
by Hospital of
Discharge
[Optional Field]
Enter the date that the clinic was notified by the hospital of the patient’s
discharge
If the date is unknown, leave this field BLANK.
This will be tested during the pilot for feasibility of capturing the information.
Quality Check: Verify the date is within measurement period.
Date
(mm/dd/yyyy
)
07/01/2013
X
Date Follow‐up
Face‐to‐Face
Visit
Enter the date that the patient was seen for a follow‐up face‐to‐face visit.
Leave BLANK if a follow‐up face‐to‐face visit did not occur.
Date ranges for this follow‐up visit are: 06/01/2013 to 12/07/2013. For visit
dates that are within 30 days of discharge date, an additional measure for QI/
Analysis will be calculated to determine the average number of days between
discharge and follow‐up visit date.
Quality Check: Verify the date is within the acceptable date range listed above.
Date
(mm/dd/yyyy
)
7/3/2013
Y
Face‐to‐Face
Visit Type
Enter the type of face‐to‐face visit:
1 = Office visit with primary care provider
2 = Office visit or consult with a specialist
3 = Care coordinator or nurse visit
4 = Home care visit
5 = Assisted living visit
6 = MTMS medication therapy management services (pharmacist)
Leave BLANK if a follow‐up face‐to‐face visit did not occur.
If Column W is populated, blank values will create an ERROR upon submission.
Quality Check: Verify that each cell has an accepted code.
Number
3
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Column
Field Name
Notes
Excel Format
Example
Z
Date Telephonic or
Electronic Contact
Date
(mm/dd/yyyy
)
08/01/13
AA
Telephonic or
Electronic Contact
Type
Enter the date that the patient had a telephonic or electronic contact.
Leave blank if a follow‐up telephonic or electronic visit did not occur.
Date ranges for this electronic contact are: mm/dd/yyyy to mm/dd/yyyy. For
visit dates that are within 30 days of discharge date, an additional measure for
QI/ Analysis will be calculated to determine the average number of days
between discharge and follow‐up visit date.
Quality Check: Verify the date is within the acceptable date range listed above.
Enter the type of telephonic or electronic contact with patient or
family/caregiver:
1 = Telephone contact with patient or family/caregiver reply
2 = Email contact with patient or family/caregiver reply
3 = Patient portal contact with patient or family/caregiver reply
4 = e‐Visit with patient
Contact implies that the patient was reached and participated in the contact,
not just a message left or sent.
Telephone contact with patient reply
Number
2
Purpose of the call is for follow‐up after hospital discharge
By one of the following types of providers: physician, physician
assistant, nurse practitioner, nurse, pharmacist, care coordinator or
case manager
The following types of telephone calls MAY NOT be submitted for numerator
consideration: voicemail messages left for patients, calls to schedule an
appointment; medication refills, reporting of lab results, inbound calls from
patients, lab results, or any other call that does not contain coordination of care
activities following hospital discharge.
Note about Follow‐up visits and contacts:
Either contact type with the patient is acceptable towards meeting the
numerator target. Though some patients may have both contacts, it is not
required, nor is an expectation that patients would have to have both contacts
post discharge
o
o
HCH Care Coordination: Follow‐up After Hospital Discharge
DRAFT Measure & Field Specifications‐ April 2014
Column
Field Name
Notes
Excel Format
Example
AB
Readmission within
30 Days (Field
Removed)
Number
2
AC
Date Clinic Notified
by Patient of
Discharge
Was the patient readmitted to the hospital for an inpatient stay for any reason
within 30 days?
1 = Yes, readmitted to the hospital within 7 days
2 = Yes, readmitted to the hospital within 8 to 30 days
3 = No, not readmitted to the hospital within 30 days
4 = Unknown
This is an optional field to be used for QI/ Analysis purposes.
Enter the date that the clinic was notified by the patient or caregiver of the
patient’s discharge.
This field may be used to track situations in which the clinic learns about the
discharge from the patient or caregiver
Leave BLANK if date is unknown.
This will be tested during the pilot for feasibility of capturing the information.
Quality Check: Verify the date is within measurement period.
Date
(mm/dd/yyyy
)
07/01/2013
(Field Removed)