Health Reform Minnesota
• Health Care Home
• Care Coordination Tiering-Billing Workshop
• October 1, 2014
Objectives
•
Gain a better understanding of how to use the HCH Care
Coordination Tier Assignment tool for population
management and billing
•
Describe implementation examples for effective tiering
and billing workflow processes.
•
Learn from other HCH clinics that are successfully tiering
and submitting claims for care coordination payment.
Laying the Foundation for HCH Care
Coordination Payment
Legislative Requirements
Legislative Requirements for HCH Care Coordination
Payment:
[256B.073]
•
•
DHS and MDH develop a system of per-person care coordination
payments to certified HCHs by January 1, 2010
Fees vary by thresholds of patient complexity
•
Agencies consider feasibility of including non-medical complexity
information
•
Implemented for all public program enrollees by July 1, 2010
[62U.03]
•
Covers SGIP, small group self-insured
Care Coordination Payment Guiding
Principles
• HCHs do population management.
• Every patient is part of the clinic’s HCH
• HCHs determine which patients need care
coordination eligible for payment and which
patients need routine panel management
including preventive care, appointment followup, etc.
• Clinics implement key process steps for successful
care coordination billing
Population Management Goal
•
Have processes in place for systematic
assessment of the clinic population for care
coordination needs including:
• New Patients
• Current Patients, Ongoing Changes
• Established Patients with Chronic Conditions.
• Patients who are identified and decline care
coordination services.
Population Management, What does your
population look like?
Implement HCH Tier Tool
Complexity Tier Level
Needed for Payment
• Patient’s Tier Level (based on the count of
“major” condition groups)
•
Tier 0 (none)
•
Tier 1 (1-3)
•
Tier 2 (4-6)
•
Tier 3 (7-9)
•
Tier 4 (10 or more)
• Presence of either of the two “supplemental”
complexity factors
Clinic Team Develop Tiering & Billing
Workflow Processes
Complete the Care Coordination Tier Assignment tool
and develop your billing workflow processes:
• Determine who does what and when for tiering?
• Tier level is supported by documentation
• Set up work flow process for communicating tier score
• Key: Establish a communication process with billing
• Develop workflows within EMRs to automate, may
begin with a manual process
Coding Structure for Billing
Key Billing Process Steps
1
Key Billing Process Steps
2
Denial Process
* Denial code B20 (CARC) or N472
(RARC)
Multi- Payer Communication
•
•
•
•
Prior to Certification: Determine payer networks you
participate in that you would like to bill for care coordination
payments.
Work with payers to establish payment rates and method of
claim submission and payment
• Tiering Methodology / Codes (Medicaid & Other Payers)
• PMPM Contract Arrangements
• CMS – Medicare Care Coordination
Identify payers where there may be patient liability and
determine process.
Address how to manage billing for uninsured.
Certified Providers Communicated to Payers
•
•
Payer Information is on HCH Certification Letter
DHS certification notification process
– Effective December 2012, providers must notify DHS of certifications
– Fax certification/recertification letter(s) with NPIs to MHCP Provider
Enrollment at 651-431-7462
– Contact provider call center with billing questions
• 651-431-2700 (Twin Cities metro)
• 800-366-5411 (Toll-free line)
• Reminder: Be sure to continuously update providers post
certification in HCH portal
Create Your Clinic’s Roadmap
• Population Management
in Health Care Homes
• Care Coordination
Tiering Processes
• Billing Workflows
• Multi-payer Input
HCH Care Coordination
Tier Tool Learning Exercises
Care Coordination Tier Assignment Tool
Version 1.0
Tier Tool – Determines Patient Complexity
• How many major chronic
condition categories apply to
the patient?
Review Medical Record Documentation
Steps to Completing Tier Tool
1
• Review all documented patient diagnoses and put into
condition groups
• Helpful Tools: Expanded Diagnosis Cluster (EDC’s)
• ICD 9 Manual – assist to identify organ systems codes in.
• Use conditions off the patient’s problem list and/or
documented treatment plan
• Examples:
•
•
•
•
•
•
Congestive Heart Failure = Cardiovascular
Glaucoma = Eye
Adverse effect from medication = Toxic Effects
Obesity = Nutrition
Tobacco Use = Mental Health/Psychosocial
Depression = Mental Health/Psychosocial
Steps to Completing Tier Tool
2
Steps to Completing Tier Tool
3
• Identify those conditions that are chronic
• Chronic conditions are defined as those that:
• Have lasted at least 6 months;
• Can reasonably be expected to continue for a least 6 months;
• Or are likely to recur
Steps to Completing Tier Tool
4
Steps to Completing Tier Tool
5
• Consider the severity of the conditions you listed and
identify those conditions that are severe .
• Severe conditions are defined as:
• major and potential unstable conditions
• that without optimal care are likely to worsen and lead to more
serious problems that may result in severe illness, impairment or
death
Steps to Completing Tier Tool
6
Steps to Completing Tier Tool
7
• If both the chronic and severe boxes are checked: consider
whether this to condition requires a care team?
• to coordinate services
• in order to attain or maintain the patients stability
• or to reach their optimal goals.
• This includes coordination of preventive care services or
disease management services to prevent the condition
from
• becoming worse
• deteriorating
• or resulting in gaps in care for the patient
Steps to Completing Tier Tool
8
Steps to Completing Tier Tool
All 3 boxes must be checked to equal 1 :
Condition is Chronic
Condition is Severe
Condition Requires A Care Team
Final Steps:
• Total the score boxes
• Write number in sum count
• Write in corresponding tier level
9
Steps to Completing Tier Tool
10
Sum Count = Complexity Tier
Supplemental Factors
1
• Identify if either or both of the elements apply to the patient:
Needs to communicate about their health care in a non-English Primary
language – includes hearing impaired / those who require a sign language
interpreter.
Patient or caregiver have a serious and persistent mental illness diagnosis
 Active diagnosis -schizophrenia, bipolar disorder, major depression, borderline
personality disorder
 Functional impairment observed.
 If caregiver noted in patient’s record
• If either of these boxes are checked then:
• Assign modifier codes in addition to the tier level
• Supplemental factors account for increased care coordination
efforts needed
Supplemental Factors
2
Tier Example - Patient Gary
1
Tier Example - Patient Gary
2
• Gary’s conditions map to 12 condition categories
• 10 condition categories were determined to be
• Chronic
• Severe
• Requires care coordination between clinic care team, therapists, and other
specialists involved in his care
Tier Example - Patient Gary
3
Tiering of Patient - Michael
1
• Michael is a 4 year old male who lives with his parents, and four siblings.
His parents are married and very involved in his care. They both work
outside the home and unfortunately do not have extended family support
available.
• Michael was born with the following congenital birth defects and
abnormalities:
Cleft Palate (749)
Abnormality of the heart (746)–Ebstein’s anomaly a rare heart defect (746.20)
Abnormality of the esophagus (751)
Congenital Disorder of the bladder (753) - Renal Dysplasia (753.15)
• In the first few months of life Michael was diagnosed with
moderate mental retardation (318)
severe hearing impairment / deafness (389.7) leading to a
developmental delay (315.34)
Tiering of Patient - Michael
2
• Due to Michaels significant medical problems, he has extended care
services 24 /7.
• He requires catheterization 6-8 times per day.
• He has a feeding tube due to severe eating problems.
• His Body Mass Index (pediatric) is less than the fifth percentile for his age
(V85.51)
Other diagnosis Michael has been given are:
Asthma with status asthmaticus (493.91)
Chronic sinusitis (473.0)
Esophageal reflux (530.11)
Chronic urinary tract infections (098.2)
Tiering of Patient - Michael
3
• Michael had 14 diagnoses that mapped to 10 condition categories
• Supplemental factor – language should be checked (deafness)
• Congenital disorders map to GENETIC and the organ systems can be
counted
• Significant signs and symptoms documented that are
chronic/severe/require a care team can be included.
• 10 condition categories were determined to be chronic, severe,
require care team – Tier level 4
Allergy Asthma
Genito-urinary
Cardiovascular
Mental Health / Psychosocial
Ear, Nose and Throat Neurologic
Gastrointestinal
Nutrition
Genetic
Renal
HCH Clinical Scenarios –
Group Exercise
• Form smaller work groups at tables
• Tools for exercise:
• Care Coordination Tier Assignment Tool
• HCH Payment Methodology Expanded Diagnosis Clusters (EDC)
• HCH Clinical Scenarios
Assignment:
1. Individually Tier the assigned scenario’s (Mary, Frank)
2. When everyone in your group completes, share and discuss the
tier level each determined (condition categories, whether
chronic, severe and required a care team)
3. We will discuss scenarios in large group at end
Additional Questions?
MDH Payment Resources:
http://www.health.state.mn.us/healthreform/homes/paym
ent/index.html
Health Care Home Team Email
[email protected]