CODING: A Paradigm Shift

Transcription

1 UIHA PROVIDER NEWS 4TH QUARTER 2015 CODING: A Paradigm Shift The Medicare Shared Savings Program (MSSP) for the University of Iowa Health Alliance Accountable Care Organization is a shared risk arrangement, which provides for incentive payments based on cost reduction and quality performance. Coding plays an important role in how quality and cost is measured by the Centers for Medicare and Medicaid Services (CMS) and other commercial carriers. ACCURATE DOCUMENTATION & CODING CMS assigns a risk score to individual members based on demographics and disease related factors. The risk score is dependent on accurate documentation in a patient record and coding of diagnosis codes submitted through claims. It is important to depict an accurate risk picture of patient health so the health systems can operate to the best of its abilities in meeting the needs of our patients. Understandably, patients with more complex diagnosis profiles have a higher cost of care and could benefit from care management resources. BILL LANGLEY, MD UIHA Chief Population Health Officer A new way of thinking about coding is needed said UIHA Population Health Officer William Langley, MD. Traditionally we tend to limit diagnosis codes to the primary problems or conditions addressed during a visit. Now, we want to make sure all applicable diagnosis codes are assessed and properly documented at least one time each year in the patient s medical record. ACCURATE RISK PICTURE 5 TIPS FOR DOCUMENTING CODES Diagnosis codes can be spread throughout the year at different visits. Practice software typically can accept up to 12 diagnoses per visit. All diagnoses that are addressed during a hospitalization should be documented and coded by the physician. When coding complications, use both the appropriate chronic condition PLUS the complication. E.g. Diabetes with polyneuropathy (E11.65) + diabetic polyneuropathy (E11.42). Avoid using history of to describe a current condition. For more information, see Commonly Overlooked Diagnoses on page 2.

2 WELCOMING New Member Great River Health Systems of West Burlington becomes the University of Iowa Health Alliance (UIHA) fifth chapter. Its physicians and clinics cover seven cities in Southeast Iowa. The addition of Great River Health Systems significantly strengthens our efforts to improve clinical integration throughout Iowa, said University of Iowa Health Alliance CEO Dan Kueter. They will also join our new UIHA Accountable Care Organization as we work together to shift from fee-for-service to value-based care delivery. We welcome their participation. Great River Health Systems President and CEO Mark Richardson said, This partnership is an important step for better coordinating and expanding health care for our region. UIHA will enhance our efforts to navigate MARK RICHARDSON Great River Health Systems President & CEO health care reform by helping us to continue to provide high-quality care while saving valuable health care dollars. UIHA now includes 21 hospitals and nearly 2,100 physicians. CODING: A Paradigm Shift continued from p.1 New coding best practices affect how quality and cost are measured by insurance carriers in the new shared risk arrangement. All applicable diagnosis codes should be assessed and documented at least one time per year to provide an accurate risk picture of the patient. HEALTH STATUS BK amputation status Z Breast cancer, personal history Z85.3 Colon cancer, personal history Z Dialysis patient Z99.2 Colostomy status Z93.3 Ileostomy status Z93.2 COMPLICATIONS Diabetic nephropathy E11.21 Diabetic retinopathy E Diabetic polyneuropathy E11.42 CHRONIC CONDITIONS Angina I20.8 Atrial fibrillation I48.2 Bipolar disorder F31.9 Breast cancer C Cardiomyopathy I42.9 Chronic kidney dis. (CKD), 1-5 N COPD J44.9 CVA (stroke), late effects I Deep vein thrombosis, chronic I Diabetes, controlled E11.9 Diabetes, uncontrolled E11.65 Diabetes, w/nephropathy E10.65 Diabetes, w/polyneuropathy E10.65 Diabetes, w/retinopathy E10.65 Epilepsy G Heart failure I50.9 Hypertension, w/ckd I12.9 Malnutrition E46 Obesity, morbid E66.01 Peripheral vascular disease I73.9 Polymyalgia rheumatic M35.3 Rheumatoid arthritis M06.9 Ulcer of lower extremity L97.909

3 NEW PHYSICIAN LEADERSHIP COUNCIL DR. VAN DAELE Physician Leadership Council Chair A new Physician Leadership Council has been established. The council will direct care delivery and performance management for the alliance and is accountable to the ACO board of directors. The UIHA Clinical Integration Team has been disbanded. Some members of that group will serve on the new Physician Leadership Council while others may serve on a care-management workgroup. The Physician Leadership Council is operated with two physicians from each member organization (chapter). One physician will be from a primary care setting and the second from a specialist setting. Appointments are for one year with renewals annually. A council chair will be appointed and also serve on the ACO board of directors. The council will review and adopt clinical strategies, as well as provide clinical oversight, needed to achieve population health and value-based metrics, objectives and deliverables. Members will also work within their own chapters to share and elicit physician input and participation in UIHA efforts. UIHA WELCOMES NEW STAFF MEMBER Jill Norris, RN, MPH, has joined the University of Iowa Health Alliance as Director of Care Management. Her new role is focused on designing, implementing and managing UIHA care management programs, processes and performance. She will chair the care management workgroup and facilitate collaboration among the UIHA chapter's care management leaders. JILL NORRIS UIHA Director of Care Management Norris has a diverse and extensive background in the health care field including population health management, practice transformation and quality improvement. She has worked in the clinic, hospital, insurance, corporate health/benefits and academic settings. She comes to UIHA from Mercy Health Network ACO in Des Moines. She holds a B.Sc. in Community Health and Preventive Medicine from Iowa State University, and a Masters in Public Health from Des Moines University - Osteopathic Medical Center. UIHA Physician Leadership Council Chair: Douglas Van Daele, MD, Leader of University of Iowa Physicians, University of Iowa Health Care Andrew Andresen, MD, Genesis Health System Steve Aguilar, MD, Genesis Health System Tim Quinn, MD, Mercy - Cedar Tony Myers, MD, Mercy - Cedar Cam Campbell, MD, Mercy - Cedar Alison Lynch, MD, University of Iowa Health Care Jim Lehman, MD, Wheaton Franciscan Healthcare - Iowa Bill Langley, MD, Chief Population Health Officer, UIHA Brad Archer, MD, Chief Clinical Officer, UIHA Michael McCoy, MD, Great River Health Systems Michael AbouAssaly, MD, Great River Health Systems UIHA Care Management Workgroup Chair: Jill Norris, UIHA Director of Care Management James Bell, Great River Health Systems Deb Bogs, Genesis Health System Kymm Ehler, Wheaton Franciscan Heathcare - Iowa Rebecca Jacobs, Mercy - Cedar Dianne Wasson, University of Iowa Health Care

4 IOWA MEDICAID UPDATE Managed Care Organizations Iowa s $4 billion Medicaid program is transitioning virtually all its populations and services to four managed care organizations (MCOs) for a start date of January 1, The Iowa Department of Human Services selected these plans: Amerigroup Iowa, Inc. AmeriHealth Caritas Iowa, Inc. UnitedHealthcare Plan of the River Valley, Inc WellCare of Iowa, Inc. Services traditionally offered through the hawk-i program and the Iowa Health & Wellness Plan are now part of these new plans. The plans will have contractual performance and quality requirements they must meet, as well as shouldering the financial risk. We anticipate the MCOs will use more extensive member information and management activities, as well as utilization management and medical management processes. UIHA is currently discussing 2016 value-based contracts on behalf of its chapters with the MCOs. Additional information regarding the Medicaid managed care contracts will be shared as the process moves forward. New System For Better Coordinated Care Re-admission of patients discharged from the hospital within 30 days is costing our nation as much as $25 billion annually. And by all accounts, it s a largely preventable situation. While care intervention has proven to reduce readmission rates by as much as 30 percent, providers across multiple organizations and systems frequently don t have the technical capability to easily exchange information and monitor patient compliance. A new alert system seeks to streamline that exchange of information to improve communications and reduce gaps in care. Care teams are frequently not aware of occurrences that are taking place outside their facility such as: Discharge from another hospital Unexpected emergency room visit Missed or unscheduled follow up appointment Unfilled prescription Iowa s Statewide Alert Notification System University of Iowa Health Alliance members (chapters) are participating within a federallyfunded grant to the Iowa Department of Human Services to use a statewide alert system to notify care coordinators when a patient is treated in another facility. Their focus is on Iowa Medicaid members with primary care provider assignments. The Iowa Statewide Alert Notification System will share realtime information on emergency department discharges, inpatient admissions and inpatient discharges. By receiving enough information, UIHA chapter care coordinators can work with patients to improve outcomes. In the future secure alerts will be sent to the UIHA ACO chapters. Genesis is First UIHA Chapter Online Genesis Health System went online with the alert system in November. Genesis Information Architect Mary Gardner-Karcher said, "I m excited about this project because it leverages the Health Information Exchange framework to enable more effective care coordination. Event notifications to care coordinators will help control cost and improve quality by increasing awareness of health care utilization at any Iowa hospital."

5 Medicare Shared Savings Program Update As we ve previously reported, the University of Iowa Health Alliance Accountable Care Organization seeks to create its first consolidated contract with the Centers for Medicare and Medicaid Services (CMS). Two existing Medicare Shared Savings Program (MSSP) ACO organizations will consolidate and merge into the new UIHA ACO. These are Genesis Health System and the Mercy - Cedar /University of Iowa Health Care ACO. All UIHA chapter members will be a part of the new MSSP ACO. MSSP establishes financial accountability for the quality and total cost of care for lives covered under the ACO. Our learnings from the MSSP experience will also translate to future ACO agreements with commercial payer agreements. Application in Review The initial application for the MSSP was submitted in July and is presently in its third and final review cycle with CMS. It is anticipated we ll know more about its approval status by early December. This is an important development for the UIHA ACO moving towards a value-based system of care. Wishing You A Happy & Healthy Winter Season! CONTACT US: 100 Court Avenue, Suite 405 Des Moines, IA communications@ uihealthalliance.com UIHA STAFF Dan Kueter, President & CEO Jennifer Vermeer, COO Brad Archer, MD, Chief Clinical Officer William Langley, MD, Chief Population Health Officer Bonnie Braatz, Program Manager Jill Norris, Director of Care Management Brooke Kensinger, Business Health Director Maggie Eischeid, Program Coordinator Steve Palmersheim, Manager, Population Health Analytics OUR MEMBERS The University of Iowa Health Alliance represents some of the largest health care provider organizations in Iowa and its surrounding states. Its membership includes nearly 2,100 physicians and 21 hospitals with key locations in Cedar Falls, Waterloo, Cedar, Davenport, Iowa City and Burlington. Our membership includes: Genesis Health System Great River Health Systems Mercy Cedar University of Iowa Health Care Wheaton Franciscan Healthcare Iowa UIHA PROVIDER NEWS 4TH QUARTER UNIVERSITY OF IOWA HEALTH ALLIANCE. ALL RIGHTS RESERVED. ITEM