EMR Certification Comprehensive Care Management Billing Support Specification

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1 EMR Certificatin Cmprehensive Care Management Billing Supprt Specificatin Versin 1.0 December 1, 2015

2 Table f Cntents 1 Intrductin Requirements Billing Requirements Billing Alert Guidelines Billing Preventin Guideline Billing Alert and Preventin Messaging... 8 List f Tables Table 1: Related Dcuments... 3 Table 2: Incremental Billing Requirements... 5 Table 3: CCM Tariff Billing Alert Guidelines... 6 Table 4: CCM Tariff Billing Preventin Guideline... 8 Table 5: CCM Tariff Billing Alert and Preventin Messaging

3 1 Intrductin PURPOSE The purpse f this dcument is t utline requirements that enhance billing supprt fr the Cmprehensive Care Management (CCM) tariffs. This specificatin will facilitate user submissin f the CCM tariffs. It is nt a pre-requisite fr claiming these tariffs. Enrlment is a key cmpnent fr the CCM tariffs; enrlment requirements will be issued in an updated versin f this specificatin in the future. BACKGROUND Cmprehensive Care Management (CCM) Tariffs cme int effect n April 1, The CCM tariffs are a cmpnent f the evlutin twards the Cllege f Family Physicians Canada s (CFPC) visin f the Patient s Medical Hme 1. Manitba Health, Healthy Living and Senirs (MHHLS) recgnizes that crdinating care fr mre cmplex patients with multiple chrnic diseases takes additinal effrt. The purpse f the CCM tariffs is t supprt physicians in the prvisin f care t cmplex patients t prmte cntinuity, cmprehensiveness, crdinatin, access and a patient centred apprach. The tariffs als encurage the use f interprfessinal teams t supprt this care and prmte preventative care t prevent and delay chrnic disease. The CCM tariffs use existing primary care quality indicatrs (PCQIs) that MHHLS has adpted fr measuring quality chrnic disease management prcesses in primary care. PRE-REQUISITE Applicants must have met, r be in the prcess f meeting, the assessment criteria fr the Primary Care Quality Indicatr Reminders and Data Extract specificatin prir t certifying against this specificatin. An Applicant will nt be granted certificatin fr this specificatin withut prir certificatin fr the Primary Care Quality Indicatr Reminders and Data Extract specificatin. RELATED DOCUMENTS Table 1: Related Dcuments DOCUMENT VERSION Baseline EMR Requirements Specificatin 1.0 December 1, 2015 Primary Care Quality Indicatr Reminders and Data Extract Specificatin Cmprehensive Care Management Billing Supprt Assessment Guide 1.0 December 1, December 1, The Cllege f Family Physicians f Canada. (2011). A Visin fr Canada: Family Practice The Patient s Medical Hme. 3

4 2 Requirements INTRODUCTION This sectin cntains requirements pertaining t the implementatin f enhanced billing supprt fr CCM tariffs and enrlment. Requirements include: general billing requirements fr CCM tariffs; data supplementary t the Primary Care Quality Indicatr Reminders and Data Extract specificatin that must be captured t supprt CCM tariffs; guidelines that infrm when an alert is t be displayed when submitting CCM tariffs; and guidelines that infrm when a CCM tariff is t be prevented frm being submitted. Unless therwise stated, all functins must be able t be perfrmed by a typical end user. EMR administrative privileges shuld nt be required nr shuld the functin require vendr interventin. REQUIREMENTS STRUCTURE Fr ease f review and understanding, all functinal and nn-functinal requirements are dcumented in a cnsistent manner. Fr each requirement, the fllwing infrmatin is prvided: ID a unique identifier assigned t the requirement by Manitba. Requirement a cncise statement describing the requirement. Guidelines these additinal instructins cnstitute part f the requirement, and are relevant t implementatin f the requirement in the EMR prduct. As such, these guidelines frm part f the assessment criteria and are included in the planned prduct assessment. Additinal Ntes relevant infrmatin r examples intended t give additinal cntext t the requirement and t imprve understanding. Status each requirement is clearly identified as: New (nt included in previus specificatins); Updated (mdificatin t intent f the requirement); r Previus (unchanged frm last issuance f cre requirements). Assessment the methd f assessment specific t the requirement. Relevant assessment ptins include: Demnstratin applicants will demnstrate key functins within their EMR prduct. Demnstratins may be cnducted in persn, by remte means (e.g. telecnference and Internet) r thrugh recrded vide. 4

5 2.1 Billing Requirements This sectin include the incremental requirements related t billing f the CCM tariffs. Fr cmpleteness, we have included the riginal requirement statement and guidelines frm the Billing categry f the Baseline EMR Requirements. Incremental cntent is in italics fr easy identificatin. Table 2: Incremental Billing Requirements ID REQUIREMENT GUIDELINES ADDITIONAL NOTES STATUS ASSESSMENT i Prvides errr checking and claim validity warnings. At a minimum, the errr checking will include: - mandatry billing fields (e.g. prvider ID, service date, patient ID, etc.) - validity f health registratin number frmat, regardless f assigning authrity - gender-specific claims - prcedure claims relevant t diagnses - patient exceeds allwable number f billings fr a tariff within the time specified - eligibility fr annual billing f tariff - when billing fr patients insured by Canadian jurisdictins withut reciprcal billing arrangements r patients insured in nn-canadian jurisdictins Errr checking must ccur prir t claim submissin. An external validatin prcess (i.e. data is extracted and validated externally) wuld nt be an acceptable slutin. e.g. validate prvincial cverage r alerts user when patient ID des nt pass check-digit algrithm e.g. mre than fur 0120 cdes are billed in a 12 mnth perid r patient eligibility fr billing f chrnic disease tariff e.g. care required t supprt CCM tariff claims nt fully dcumented Updated Demnstratin CCM tariff claim alert rules must be preladed. Requiring a user t manually create the alert rule wuld nt be acceptable. 5

6 2.2 Billing Alert Guidelines This sectin describes the alerts required when a claim is submitted t MHHLS frm the EMR prduct. Required care indicatrs are based frm MHHLS PCQIs. These can be viewed within the Primary Care Quality Indicatr Reminders and Data Extract specificatin. Billing alert requirements will be assessed thrugh the demnstratin assessment methd (as defined within the Applicant Guide t EMR Certificatin). Details are utlined in the Cmprehensive Care Management Billing Supprt Assessment Guide. Table 3: CCM Tariff Billing Alert Guidelines TARIFF All CCM Tariffs ( ) ISSUE ALERT IF ANY OF THE FOLLOWING CONDITIONS ARE TRUE Patient is nt enrlled t the clinic Anther CDM r CCM claim was submitted fr the patient within 12 mnths f the CCM claim currently being submitted ADDITIONAL NOTES N alert is necessary if the previus CDM and/r CCM claim was rejected. As f April 1, 2017, the fllwing chrnic diseases are eligible fr a CCM tariff: Diabetes, Asthma, Cngestive Heart Failure, Hypertensin, and Crnary Artery Disease. Beginning April 1, 2018, the fllwing chrnic diseases are eligible fr a CCM tariff: Diabetes, Asthma/COPD, Cngestive Heart Failure, Hypertensin, and Crnary Artery Disease Patient is less than 50 years f age Patient is greater than 74 years f age Required preventin data elements are nt dcumented in the designated lcatin 2 within the patient recrd e.g. if bld pressure measurement recrded in encunter nte using free-text, EMR alerts user that required preventin data is nt present in designated lcatin within the patient recrd Patient is yunger than 75 years f age Required preventin data elements are nt dcumented in the apprpriate lcatin within the patient recrd 2 Designated lcatin as determined by EMR prduct design fr primary care quality indicatr tracking and data extract. 6

7 TARIFF ISSUE ALERT IF ANY OF THE FOLLOWING CONDITIONS ARE TRUE 8456 Patient des nt have a chrnic disease eligible fr CCM tariff The fllwing infrmatin is nt dcumented in the apprpriate lcatin within the patient recrd fr at least ne chrnic disease eligible fr CCM tariff: required preventin data elements required care data elements related t the patient s eligible chrnic disease 8457 Patient des nt have tw r mre chrnic diseases eligible fr CCM tariff The fllwing infrmatin is nt dcumented in the apprpriate lcatin within the patient recrd fr at least tw chrnic diseases eligible fr CCM tariff: required preventin data elements required care data elements related t the patient s tw eligible chrnic diseases 8458 Patient des nt have three r mre chrnic diseases eligible fr CCM tariff The fllwing infrmatin is nt dcumented in the apprpriate lcatin within the patient recrd fr at least three chrnic diseases eligible fr CCM tariff: required preventin data elements required care data elements related t the patient s three eligible chrnic diseases ADDITIONAL NOTES e.g. an alert will be issued if prvider has failed t dcument cmpletin f all applicable indicatrs required fr the tw chrnic diseases. 7

8 2.3 Billing Preventin Guideline This sectin describes when a tariff is t be prevented frm being submitted t MHHLS frm the EMR prduct. Table 4: CCM Tariff Billing Preventin Guideline TARIFF All CDM Tariffs ( ) PREVENT SUBMISSION IF ANY OF THE FOLLOWING CONDITIONS ARE TRUE Prvider claiming tariff is nt a physician ADDITIONAL NOTES 3 Billing Alert and Preventin Messaging This sectin describes the message t be displayed fr each billing alert described in Sectin 2.2 and billing preventin guideline described in Sectin 2.3. The Cnditin clumn identifies cnditins requiring a message and the Message clumn identifies the message t be displayed when the cnditin ccurs at the time f tariff submissin. Tariffs fr which the message may be applicable are utlined in the Applicable Tariffs clumn. Table 5: CCM Tariff Billing Alert and Preventin Messaging CONDITION MESSAGE APPLICABLE Prvider claiming tariff is nt a physician. The prvider is ineligible t claim this tariff. This tariff may nly be claimed by a physician. TARIFFS Patient is nt enrlled t the clinic. This tariff may nly be claimed fr an enrlled patient Patient age is yunger r lder than the allwed age fr the specified tariff. CDM r CCM claim made fr patient frm the same EMR instance in the last 12 mnths. Patient has ne r mre chrnic diseases that are eligible fr a claim. The patient s age is utside the eligible age range fr this tariff A CDM r CCM tariff has been submitted fr the patient within the last 12 mnths. This tariff is applicable t patients with n eligible chrnic diseases. The patient has ne r mre chrnic diseases that are eligible fr

9 CONDITION MESSAGE APPLICABLE Patient des nt have the required number f chrnic diseases eligible fr the tariff. Required preventin data elements and/r care data elements related t the patient s chrnic diseases are nt dcumented in the apprpriate lcatin within the patient recrd. The patient des nt have the required number f chrnic diseases eligible fr this tariff. Cnfirm that the chrnic diseases are eligible and recrded in the apprpriate lcatin within the patient recrd. Required preventin data elements and/r care data elements related t the patient s chrnic diseases fr this tariff are nt dcumented in the apprpriate lcatin within the patient recrd. It is recmmended t cnfirm that all apprpriate care has been prvided and recrded in the apprpriate lcatin. TARIFFS

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