Transcript Recommended 2009 Marketing Investments

Ingenix InSite
User Group
May 11, 2010
Approval Code: IN154
Ingenix InSite User Group: Welcome
Administrative Reminders:
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segment.
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our chat panel for the host to address
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The user group presentation materials will be sent with the meeting minutes.
Ingenix InSite User Group Questions or Product Enhancement requests?
Email [email protected].
 Ingenix InSite Website Questions? Call or email the Ingenix Helpdesk 1-866818-7503 or [email protected].
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© Ingenix, Inc. 2
Ingenix InSite User Group: Agenda
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10:00 AM – 10:05 AM Welcome & InSite Operations Announcements
10:05 AM – 10:20 AM RAF Calculator and RAF Build-up
10:20 AM – 10:40 AM TIA, Stroke & Late Effects of Stroke
10:40 AM – 10:50 AM InSite Custom List for Printing Multiple PAF’s Demo
10:50 AM – 11:00 AM Q & A
© Ingenix, Inc. 3
InSite Operations Announcements
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Data Refresh Update
– InSite data was refreshed May 8th
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Shifted years on the following reports
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Group and Provider Summary (PY 2010, PY 2011)
Summary of Accepted HCCs/Dx (PY 2009, PY 2010, PY 2011) also shifting in the member view
Members without HCCS (PY 2010, PY 2011)
HCC RAF Detail (PY 2009, PY 2010, PY 2011) also shifting in the member view
PCP RAF Report (2009 DOS, 2010 DOS)
Largest Declining RAF Quickview (2009 DOS, 2010 DOS)
Prevalence Report (Relative HCC Factor Current Yr PY 2011, Prior Yr PY 2010 AND Prevalence Rate
Current Yr DOS 2010, Prior Yr DOS 2009)
Patient Management (RAF calculation to be based on 2009 DOS)
– Next data refresh targeting June 5th
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Upcoming Release
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Next InSite Release targeting May 28th
Includes new security features, new report, and new InSite help features
Separate training scheduled to review new release functionality
© Ingenix, Inc. 4
Build-up RAF and RAF Calculator
Presented by:
Ian Moxley
Analytics
RAF Types - CMS
 CMS RAF
– CMS calculates the RAF based on a specific data collection period and
is reflected in the MMR and MOR.
• Data collection periods corresponds to dates of service and moves forward
every six months based on the CMS sweeps.
 MMR (Monthly Membership Report)
– Provides member-level information to reconcile payment from CMS
– Flags and Indicators
– Payment and adjustment information
 MOR (Model Output Report)
– Supplements the MMR by identifying specific information used in making
risk adjustment calculations
– Age/Sex
– Medicaid and Originally Disabled
– HCC disease groups
– Disease Interactions
© Ingenix, Inc. 6
RAF Types – Build-up
 Build-up RAF
– RAF based on Claims/Encounters/MOR
• Members who have been with the health plan for less than six months, the RAF is
calculated from the MOR.
• Members who have been with the health plan for more than six months, the RAF
is built-up and calculated from CMS qualifying claims and encounter data.
– The “Final” that would be in period 9 is not needed because it would exactly
match the “Adjusted” period 8 until the report shifts years in March/April.
After the Shift, the data for that period is reflected in period 6.
2009 Payment Year
PY
Period
RAF
Sweep
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2010 Payment Year
2011 Payment Year
1
2
3
4
5
6
7
8
Prelim
Adjusted
Final
Prelim
Adjusted
Final
Prelim
Adjusted
Closed with
Sept 2008
Sweep
Closed with
March 2009
Sweep
Closed with
Jan 2010
Sweep
Closed with
Sept 2009
Sweep
Closed with
March 2010
Sweep
Will build
until Jan
2011 Sweep
Will build
until Sept
2010 Sweep
Will build
until March
2011 Sweep
Example of InSite Report with Build-up RAF
 HCC RAF Detail Report Example
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InSite Report(s) with Build-up RAF
 All InSite Reports impacted by Build-up RAF
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HCC RAF Detail
PCP RAF
Largest Declining RAF Quickview
Patient Management
© Ingenix, Inc. 9
Learning and Resources Deep Dive Review – Part 3
- Overview
 Learning and Resources Tab
– Utilities and Tools
• RAF Calculator
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RAF Calculator
 Purpose of this utility
– User-driven tool to help dynamically calculate a RAF score
– Scores are calculated for a single member at a time
 Components
– Instructions: Guidance on use and functionality of tool
– Calculator: Input screen to enter member and diagnosis information
– Output: RAF score summary and payment calculation
 Technical Details
– Excel based application
– Select “Enable Macros”
when the file initially opens
© Ingenix, Inc. 11
RAF Calculator
 Step 1: Enter Member Information
Key Points
• Enter information into YELLOW cells only
• “Payment Year” can be from 2008-2011 (dates of service
2007-2010)
- RAF adjustments (FFS Normalization & Coding
Intensity) determined based on payment year
• Age: Determined as of February of payment year
© Ingenix, Inc. 12
RAF Calculator
 Step 2: Enter Special Status & Location
Key Points
• Special Status:
- Disabled: Y or N
- Original Eligibility: Aged or Disabled
- Community or Institutional
• County Rate determined based on payment year
© Ingenix, Inc. 13
RAF Calculator
 Step 3: Enter Diagnosis Information (HCCs)
Key Points
• Maximum of 16 HCCs can be entered
• HCC Factors are based on identified payment year
• Disabled & Disease Interactions are listed in shaded grey
section (circled in blue)
© Ingenix, Inc. 14
RAF Calculator
 Step 3: Enter Diagnosis Information (HCCs)
Error Handling: HCC Hierarchy
Key Points
•If HCCs within the same hierarchy are entered, they
will be highlighted in red with a message to remove
one of the duplicate lines
•In the example above, either HCC 19 (Diabetes
without Complications) or HCC 17 (Diabetes with
Acute Complications) should be removed because
they fall within the same HCC hierarchy
© Ingenix, Inc. 15
RAF Calculator
 Step 3: Enter Diagnosis Information (HCCs)
Error Handling: Duplicate HCCs
Key Points
•If duplicate HCCs are entered (HCC 80 in the example
above), they will be highlighted in red with a message to
remove one of the duplicate lines
© Ingenix, Inc. 16
RAF Calculator
 Results: Calculator Sheet
A
B
C
Key Points
• Results will display immediately as inputs are entered
• Total RAF is displayed as: A Subtotal of Age/Sex + Special Status + HCCs,
after Adjustments, C Estimated Annual Revenue for Payment Year
© Ingenix, Inc. 17
B
Total RAF
RAF Calculator
 Results: Output
Key Points
•Total RAF components and calculation are
shown again
•Interactions are displayed as subtotal
•Estimated payment is provided:
• Estimated PMPM = Average County
Rate x Total RAF (after adjustments)
• Estimated PMPY = PMPM x 12 months
© Ingenix, Inc. 18
TIA, Stroke
&
Late Effects of Stroke
Presented by
Mary Jo Groome, CPC-H, CCS-P
Sr. Provider Training & Development Consultant
Ingenix, Clinical Assessment Solutions
Coding Disclaimer
This training and information presented is for
informational purposes only and does not
replace the professional judgment and expertise
of the individual performing coding based on
numerous factors including, but not limited to,
documentation in the medical record and other
industry recognized coding guidance. Because
codes, coding requirements and standards can
and do change, the individual assigning codes is
reminded to verify the accuracy, specificity,
currency and acceptability of such codes and
coding methods used.
© Ingenix, Inc. 20
TIA, Stroke and Late Effects of Stroke
Simply Stated:
 When did the event occur?
 What deficits were left after the event
that are evident today?
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ICD-9-CM Official Guidelines for
Coding and Reporting
 The tense matters to documentation and coding:
–Diagnosis codes have been submitted for acute
conditions when the beneficiary was status post
–Or, had a history of the condition
 Be cautious with the use of the following terms:
– Acute
– Status post
– History of
– Impending
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Transient
Ischemic Attack
(TIA)
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TIA – Transient Ischemic Attack
 Look-up in ICD-9-CM:
– Attack
• Transient ischemic (TIA) 435.9
 Tabular of ICD-9-CM:
– 435.9 Unspecified transient cerebral ischemia
• Impending cerebrovascular accident
• Intermittent cerebral ischemia
• Transient ischemic attack (TIA)
© Ingenix, Inc. 24
TIA – Transient Ischemic Attack
 Category 435
– Includes:
• Cerebrovascular insufficiency (acute) with transient focal
neurological signs and symptoms
• Insufficiency of basilar, carotid, and vertebral arteries
• Spasm of cerebral arteries
– Excludes:
• Acute cerebrovascular insufficiency NOS (437.1)
• That due to any condition classifiable to 433 (433.0-433.9)
© Ingenix, Inc. 25
Stroke & Late
Effects of
Stroke
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Stroke: Common Coding Error
When did the event occur?
One of the most common coding errors seen in chart review
is the assignment of a stroke code in the present tense
when the coder is actually trying to code for the residual
conditions left behind by a prior stroke.
© Ingenix, Inc. 27
Documentation of Stroke
When Did The Event Occur?
 Document Acute Stroke on first admission to the
hospital only. (434.91)
 Document Residual Deficits of Stroke on office
visits following the acute incident. (438.XX) (Late
Effects)
 Document History of CVA if there are no residual
deficits from a prior stroke code. (V12.54)
© Ingenix, Inc. 28
Documentation of Stroke
 Diagnostic statements need to be specific regarding site
or type of CVA.
 Concise documentation will lead to specified code
selection.
– Example:
CVA due to cerebral embolism with infarction
(434.11)
Cerebral artery occlusion (434.9x)
© Ingenix, Inc. 29
Documentation of Late Effects of Stroke
 A late effect is the residual condition that remains after
recovery of the acute phase.
 Document deficits after discharge from the initial acute
episode.
Example:
Aphasia due to CVA 6 months ago (438.11)
CVA two years ago with residual hemiplegia
(438.20)
 There is no time limit for the reporting of a residual.
© Ingenix, Inc. 30
Late Effects Coding: More than just for Stroke
The Coding of “Late Effects”
More than just for Stroke
“Late Effect” coding generally requires two codes. One for the
residual and one for the resolved condition.
Example:
Moderate Mental Retardation due to previous poliomyelitis.
Code: 318.0 - Retardation, Mental, Moderate
Code: 138 - “Late Effects” – poliomyelitis
Normally, this is a two code scenario
Stroke is the exception.
© Ingenix, Inc. 31
Late Effects: The Index
 Late - see also condition
– effect(s) (of) - see also condition
• cerebrovascular disease (conditions classifiable to 430-437) 438.9
• With
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© Ingenix, Inc. 32
alterations of sensations 438.6
aphasia 438.11
apraxia 438.81
ataxia 438.84
cognitive deficits 438.0
disturbances of vision 438.7
dysarthria 438.13
dysphagia 438.82
dysphasia 438.12
facial droop 438.83
facial weakness 438.83
fluency disorder 438.14
Late Effects: The Index
– Late Effects, cerebrovascular disease, with:
• hemiplegia/hemiparesis
– affecting
» dominant side 438.21
» nondomiant side 438.22
» unspecified side 438.20
• monoplegia of lower limb
– affecting
» dominant side 438.41
» nondominant side 438.42
» unspecified side 438.40
• monoplegia of upper limb
– affecting
» dominant side 438.31
» nondominant side 438.32
» unspecified side 438.30
© Ingenix, Inc. 33
Late Effects: The Index
– Late Effects, cerebrovascular disease, with:
• paralytic syndrome NEC
– affecting
» bilateral 438.53
» dominant side 438.51
» nondominant side 438.52
» unspecified side 438.50
• speech and language deficit 438.10
• specified type NEC 438.19
• stuttering 438.14
• vertigo 438.85
• specified type NEC 438.89
© Ingenix, Inc. 34
Coding Late Effects of Stroke
Example:
Cerebrovascular accident two years ago with residual
hemiplegia
Code: 438.20 “Index” - Late Effects,
Cerebrovascular Disease,
with Hemiplegia,
Unspecified Side
© Ingenix, Inc. 35
Coding Stroke & Late Effects of Stroke
 Acute embolic CVA with infarction; previous CVA
with residual dysphagia.
– 434.11 – Infarction, cerebral, embolic
– 438.82 – Late effect(s), cerebrovascular disease, with
dysphagia
 Aphasia due to Cerebrovascular Accident 6 months
ago.
– 438.11 - Late effect(s), cerebrovascular disease, with
aphasia
© Ingenix, Inc. 36
Late Effects: The Index
Documentation states: Patient has left sided weakness due to
previous CVA two years ago”.
See> Late effects, cerebrovascular disease>specified type NEC
Under 438.89 Other late effects of cerebrovascular disease
Use additional code to identify the late effect
TIP: Assign 438.89 and 728.87 muscle weakness, for
residual weakness secondary to late effect of
CVA.
© Ingenix, Inc. 37
Category 438
 Late effects of cerebrovascular disease
– Excludes:
• Personal history of:
– Cerebral infarction without residual deficits (V12.54)
– PRIND (Prolonged reversible ischemic neurologic
deficit) (V12.54)
– RIND (Reversible ischemic neurological deficit)
(V12.54)
– Transient ischemic attack (TIA) (V12.54)
© Ingenix, Inc. 38
History of TIA & Stroke
 When a provider documents “History of TIA” or “History of
Stroke”
– Code V12.54
• Personal history of
– Transient ischemic attack (TIA) , and cerebral infarction
without residual deficits
 When a provider documents a history of stroke with residual
deficits
– Code from the Late Effects category 438
• Late effects of cerebrovascular disease
– Specific to the documented residual
© Ingenix, Inc. 39
Question about Stroke Syndrome
 How would you code if the provider documented “stroke
syndrome” or “little stroke syndrome”?
– If you look in the Index under Syndrome, you will find:
• Stroke (see also Disease, cerebrovascular, acute) 436
– Little 435.9
– If you look in the Index under Disease, cerebrovascular, you will
find:
• Acute 436
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Embolic – see Embolism, brain
Late effect – see Late effect(s) (of) cerebrovascular disease
Puerperal, postpartum, childbirth 674.0x
Thrombotic – see Thrombosis, brain
 “Stroke syndrome” is coded as 436; “little stroke syndrome” is
coded as 435.9
© Ingenix, Inc. 40
A Final Word about 436
 436 – Acute, but ill-defined, cerebrovascular disease
Apoplexy, apoplectic:
NOS
attack
cerebral
seizure
Cerebral seizure
TIP: Do not assign when documentation indicates “CVA,
stroke, or cerebral infarction.” See instead default code
434.91.
© Ingenix, Inc. 41
Ingenix / Team members would like to …
Thank
You
Questions will be
taken later
© Ingenix, Inc. 42
InSite Custom List for Printing
Multiple Patient Assessment Forms
(PAFs) Demonstration
Presented by:
Francesca Siciliano
InSite Product Business Analyst
Overview of Downloading Multiple PAFs

Multiple PAF Download (By Criteria)
– New functionality in InSite as of 3/31/2010
– Suggested Uses
1. Identify the patients to be seen for a day, add those member’s PAFs to the
custom list, and download all the PCP’s PAFs at once
2. Identify all the members without office visits that are newly enrolled to a
plan, add to custom list, and download all the PAFs at once
– Functionality Highlights
1.
2.
3.
4.
Users have the ability to select member records from any report
User can add selected records to the custom list
User can add all records on the report to the custom list
User will go to the Custom List Tab to export records (100 records can be
downloaded at one time) – Can export PAF, PAF with Problem List or
Problem List alone
5. User can delete the entire list or individual records if they decide to NOT
export
© Ingenix, Inc. 44
March 2010 InSite Release
 Multiple PAF Download (By Criteria)
1. User will have the ability to select member records from any
report
© Ingenix, Inc. 45
March 2010 InSite Release
 Multiple PAF Download (By Criteria)
2. User can add selected records to the custom list
(note: User must add them to the custom list before moving to the next page)
Check box
to select
member
record
Click Add
to Custom
List
© Ingenix, Inc. 46
March 2010 InSite Release
 Multiple PAF Download (By Criteria)
3. User can add all records on the report to the custom list
Click Add
ALL to
Custom
List to add
all records
on the
report to
the
custom
list
© Ingenix, Inc. 47
March 2010 InSite Release
 Multiple PAF Download (By Criteria)
4. User will go to the Custom List Tab to export records (50 or
more records can be downloaded at one time – final # of
records to be determined) – Can export PAF, PAF with
Problem List or Problem List
© Ingenix, Inc. 48
March 2010 InSite Release
 Multiple PAF Download (By Criteria)
5. User can delete entire list or individual records the decide to
NOT export
To Remove
the Entire List
To remove an
individual
record from
this list
© Ingenix, Inc. 49
User Group Feedback Discussion
 Best Practices Agenda Item
© Ingenix, Inc. 50
Question and Answer
© Ingenix, Inc. 51
Approved: IN071