DATA COLLECTION GUIDE Direct Data Submission. Depression Care Measures 2014

DATA COLLECTION GUIDE Depressin Care Measures 2014 (02/01/2013 t 01/31/2014 Dates f Service) Changes frm Draft Data Cllectin Guide: 1. Updated Evaluatin & Management CPT Cdes fund n Page 19. Please nte: These are ptinal cdes that can be used t identify visits. 2. Depressin PHQ-9 Fllw-up Assessment at 6-mnths and 12-mnths measures are publicly reprted as f September 2013. These measure results have been available privately t medical grups via the MNCM Data Prtal since the inceptin f Depressin Care data cllectin (2009). They are tw f 10 available Depressin Care measures and revisins have been made t Appendix F t indicate they are publicly reprted measures. 3. Medical grups can uplad denminatr cunts and infrmatin OR they can enter infrmatin directly int the data prtal. See pages 34-35 fr mre infrmatin. Page 1

Table f Cntents Overview f the Prcess and Timeline... 3 Measure Specificatins... 4 Majr Depressin and Dysthymia Diagnsis Cdes...6 Table 1: ICD-9 Diagnsis Cdes fr Identifying Majr Depressin r Dysthymia... 6 Cdes Used t Identify Patients wh Meet Exclusin Criteria...7 Table 2: ICD-9 Diagnsis Cdes fr Identifying Patients Meeting Exclusin Criteria... 7 Measure Lgic/Flw Charts...9 Data Cllectin and Submissin Instructins... 12 Data Cllectin and Submissin Preparatins and Cnsideratins:... 13 Sectin A: Identifying the Patient Ppulatin (Denminatr)... 16 Sectin B: Clinic Level Ppulatin Cunts... 21 Sectin C: Data Cllectin... 23 Data Elements and Field Specificatins... 26 Sectin D: Patient Data File Creatin... 32 Sectin E: Patient Data File Submissin... 34 Sectin F: MNCM Validatin... 38 Appendices... 40 Appendix A: Registratin n the MNCM Data Prtal... 41 Appendix B: Resurces t Help Yu Get Started... 42 Appendix C: Timelines fr Data Submissin and Public Reprting... 43 Appendix D: Ntes abut the PHQ-9 Test... 45 Appendix E: Explaining the Depressin Measures t Prviders and Clinical Staff... 46 Appendix F: Suite f Available Depressin Care Measures... 47 Appendix G: Abut MN Cmmunity Measurement and Measure Develpment... 51 Appendix H:Abut... Errr! Bkmark nt defined. Page 2

Overview f the Prcess and Timeline Prcess Step Registratin Medical grup registers clinics and prviders n MNCM Data Prtal and electrnically signs the Site Terms f Use Agreement and Business Assciate Agreement. Resurces: Dwnlad Clinic & Prvider Registratin Instructins frm the RESOURCES Tab n the MNCM Data Prtal https://data.mncm.rg/lgin r www.mncm.rg. Denminatr Certificatin Medical grup submits a denminatr dcument utlining the methd fr identifying the patient ppulatin t the MNCM Data Prtal. MNCM reviews and apprves the denminatr. MNCM must apprve yur denminatr certificate befre data is cllected. Resurces: Dwnlad Depressin Care 2014 Denminatr Template frm the RESOURCES Tab n the MNCM Data Prtal. Data Cllectin and Submissin Data cllectin begins after the billing cycle is cmpleted fr the measurement perid. Medical grup prepares CSV (.csv) file t submit via MNCM Data Prtal. Resurces: Dwnlad Data Cllectin Depressin Care 2014 and Depressin Care 2014 Data Cllectin Spreadsheet Template frm the RESOURCES Tab n the MNCM Data Prtal. Preliminary Results Review, Quality Checks Medical grup reviews preliminary results internally t verify the rates are as expected; prvides cmments n rate r ppulatin changes. MNCM then reviews preliminary results and cmments. Resurces: Hme tab, Data Submissin (scrll t Data Cmparisn tl). Data Validatin MNCM auditr cnducts audit t validate that the submitted data matches the surce data in the patient medical recrd. Resurces: MNCM will email instructins and pst list f randmly-selected patients fr audit n the data prtal. Tw-Week Medical Grup Review Perid Medical grup reviews preliminary results tgether with statewide results. Final pprtunity t verify results befre they are publicly reprted n MNCM s cnsumer-facing website. Resurces: MNCM will email Infrmatin and directins t apprpriate all medical grup cntacts registered in the prtal. Data Results After the successful submissin and validatin f the clinical data, MNCM will pst the results n www.mnhealthscres.rg. Helpful Dates t Remember Registratin begins December 16, 2013 Deadline: February 7, 2014 Submit denminatr dcument in December 2013 r early January 2014 MNCM respnds within 2-3 business days after receiving the denminatr dcument MNCM Data Prtal pens: January 13, 2014 MNCM Data Prtal clses: February 14, 2014 Cmpleted after data submissin and prir t validatin audit March 2014 April 2014 May 2014 Page 3

Depressin Care Measures 2014 (02/01/2013 t 01/31/2014 Dates f Service) Measure Specificatins Page 4

Descriptin Methdlgy Ratinale Depressin Care Measures 2014 Measurement Specificatins A measure f the percentage f adults patients wh have reached remissin at six mnths (+/- 30 days) after being identified as having an initial PHQ-9 scre > nine. Remissin is defined as a PHQ-9 scre less than five. Ppulatin identificatin is accmplished via a query f a practice management system r Electrnic Medical Recrd (EMR) t identify the ppulatin f eligible patients (denminatr). Data elements are either extracted frm an EMR system r abstracted thrugh medical recrd review. Full ppulatin data is required. The pririty aim addressed by this measure is t imprve the utcmes f treatment fr patients with majr depressin r dysthymia. The Center fr Disease Cntrl and Preventin states that 15.7% f peple reprt being tld by a health care prfessinal that they had depressin at sme pint in their lifetime. Persns with a current diagnsis f depressin and a lifetime diagnsis f depressin r anxiety were significantly mre likely than persns withut these cnditins t have cardivascular disease, diabetes, asthma and besity and t be a current smker, t be physically inactive and t drink heavily. Accrding t Natinal Institute f Mental Health (NIMH), 6.7 percent f the U.S. ppulatin ages 18 and lder (14.8 millin peple) in any given year have a diagnsis f a majr depressive disrder. Majr depressin is the leading cause f disability in the U.S. fr ages 15-44. Additinally, dysthymia accunts fr an additinal 3.3 millin Americans. Suicide rates fr Minnestans are 10.4 per 100,000 r 1.3 suicides per day, with the highest rates amng the fllwing grups: males (fur times greater than females), ages 30 t 49 years, and nn-hispanic whites. Page 5

Denminatr Depressin Care Measures 2014 Measurement Specificatins Patient wh meets each f the fllwing criteria is included in the ppulatin: Patient was age 18 r lder at the index visit. Patient had visit r cntact with an eligible prvider in an eligible specialty between 07/01/2012 t 06/30/2013. Patient had an initial PHQ-9 scre > nine. Diagnsis f Majr Depressin r Dysthymia; ICD-9 diagnsis cdes include: 296.20-296.26, 296.30-296.36, and 300.4. See Table 1. Fr primary care prviders, these diagnsis cdes can be in any psitin. Fr behaviral health prviders, the depressin r dysthymia diagnsis cdes need t be listed as the primary diagnsis. This is t insure that the patient is primarily being treated fr majr depressin and des nt have ther mre serius psychiatric cnditins like psychses, schizphrenia r biplar disrder with underlying depressin. Eligible specialties: Family Practice, General Practice, Internal Medicine, Geriatric Medicine, Psychiatry, and Behaviral Health prfessinals (if physician n site). Allwable Exclusins Numeratr Eligible prviders: Medical Dctr (MD), Dctr f Ostepathy (DO), Physician Assistant (PA), Nurse Practitiner (NP), Clinical Nurse Specialist (CNS). If a physician is n site, then Licensed Psychlgist (LP), Licensed Independent Clinical Scial Wrker (LICSW), Licensed Prfessinal Clinical Cunselr (LPCC), Licensed Marriage & Family Therapist (LMFT). Patient was a permanent nursing hme resident during the measurement perid. Patient was in hspice at any time during the measurement perid. Patient died prir t the end f the measurement perid. Patient has diagnsis f Biplar Disrder (ICD-9 diagnsis cdes 296.00-296.16, 296.40-296.89). Patient has diagnsis f Persnality Disrder (ICD-9 diagnsis cdes 301.0-301.9). The number f depressin patients with an initial PHQ-9 scre > nine whse PHQ-9 scre at six mnths (+/- 30 days) is less than five. Majr Depressin and Dysthymia Diagnsis Cdes Table 1: ICD-9 Diagnsis Cdes fr Identifying Majr Depressin r Dysthymia ICD-9 Diagnsis ICD-9 Diagnsis Cde Descriptin Cde 296.2 Majr depressive disrder single episde 296.20 Majr depressive affective disrder single episde unspecified degree 296.21 Majr depressive affective disrder single episde mild degree 296.22 Majr depressive affective disrder single episde mderate degree Page 6

Depressin Care Measures 2014 Measurement Specificatins ICD-9 Diagnsis ICD-9 Diagnsis Cde Descriptin Cde 296.23 Majr depressive affective disrder single episde severe degree withut psychtic behavir 296.24 Majr depressive affective disrder single episde severe degree specified as with psychtic behavir 296.25 Majr depressive affective disrder single episde in partial r unspecified remissin 296.26 Majr depressive affective disrder single episde in full remissin 296.3 Majr depressive disrder recurrent episde 296.30 Majr depressive affective disrder recurrent episde unspecified degree 296.31 Majr depressive affective disrder recurrent episde mild degree 296.32 Majr depressive affective disrder recurrent episde mderate degree 296.33 Majr depressive affective disrder recurrent episde severe degree withut psychtic behavir 296.34 Majr depressive affective disrder recurrent episde severe degree specified as with psychtic behavir 296.35 Majr depressive affective disrder recurrent episde in partial r unspecified remissin 296.36 Majr depressive affective disrder recurrent episde in full remissin 300.4 Dysthymic disrder Cdes Used t Identify Patients wh Meet Exclusin Criteria Table 2: ICD-9 Diagnsis Cdes fr Identifying Patients Meeting Exclusin Criteria ICD-9 Diagnsis Cde ICD-9 Diagnsis Cde Descriptin 296.00 Biplar I Disrder, Single Manic Episde, Unspecified 296.01 Biplar I Disrder, Single Manic Episde, Mild 296.02 Biplar I Disrder, Single Manic Episde, Mderate 296.03 Biplar I Disrder, Single Manic Episde, Severe Withut Psychtic Features 296.04 Biplar I Disrder, Single Manic Episde, Severe With Psychtic Features 296.05 Biplar I Disrder, Single Manic Episde, In Partial Remissin 296.06 Biplar I Disrder, Single Manic Episde, In Full Remissin 296.10 Manic disrder, recurrent episde; Unspecified 296.11 Manic disrder, recurrent episde; Mild 296.12 Manic disrder, recurrent episde; Mderate 296.13 Manic disrder, recurrent episde; Severe Withut Psychtic Features 296.14 Manic disrder, recurrent episde; Severe With Psychtic Features 296.15 Manic disrder, recurrent episde; In Partial Remissin 296.16 Manic disrder, recurrent episde; In Full Remissin 296.40 Biplar I Disrder, Mst Recent Episde Manic, Unspecified 296.41 Biplar I Disrder, Mst Recent Episde Manic, Mild 296.42 Biplar I Disrder, Mst Recent Episde Manic, Mderate 296.43 Biplar I Disrder, Mst Recent Episde Manic, Severe Withut Psychtic Features 296.44 Biplar I Disrder, Mst Recent Episde Manic, Severe With Psychtic Features 296.45 Biplar I Disrder, Mst Recent Episde Manic, In Partial Remissin Page 7

ICD-9 Diagnsis Cde Depressin Care Measures 2014 Measurement Specificatins ICD-9 Diagnsis Cde Descriptin 296.46 Biplar I Disrder, Mst Recent Episde Manic, In Full Remissin 296.50 Biplar I Disrder, Mst Recent Episde Depressed, Unspecified 296.51 Biplar I Disrder, Mst Recent Episde Depressed, Mild 296.52 Biplar I Disrder, Mst Recent Episde Depressed, Mderate 296.53 Biplar I Disrder, Mst Recent Episde Depressed, Severe Withut Psychtic Features 296.54 Biplar I Disrder, Mst Recent Episde Depressed, Severe With Psychtic Features 296.55 Biplar I Disrder, Mst Recent Episde Depressed, In Partial Remissin 296.56 Biplar I Disrder, Mst Recent Episde Depressed, In Full Remissin 296.60 Biplar I Disrder, Mst Recent Episde Mixed, Unspecified 296.61 Biplar I Disrder, Mst Recent Episde Mixed, Mild 296.62 Biplar I Disrder, Mst Recent Episde Mixed, Mderate 296.63 Biplar I Disrder, Mst Recent Episde Mixed, Severe Withut Psychtic Features 296.64 Biplar I Disrder, Mst Recent Episde Mixed, Severe With Psychtic Features 296.65 Biplar I Disrder, Mst Recent Episde Mixed, In Partial Remissin 296.66 Biplar I Disrder, Mst Recent Episde Mixed, In Full Remissin 296.7 Biplar I Disrder, Mst Recent Episde Unspecified 296.80 Biplar Disrder NOS 296.81 Atypical manic disrder 296.82 Atypical depressive disrder 296.89 Biplar II Disrder 301.0 Paranid persnality disrder 301.10 Affective persnality disrder unspecified 301.11 Chrnic hypmanic persnality disrder 301.12 Chrnic depressive persnality disrder 301.13 Cyclthymic disrder 301.20 Schizid persnality disrder unspecified 301.21 Intrverted persnality 301.22 Schiztypal persnality disrder 301.3 Explsive persnality disrder 301.4 Obsessive-cmpulsive persnality disrder 301.50 Histrinic persnality disrder unspecified 301.51 Chrnic factitius illness with physical symptms 301.59 Other histrinic persnality disrder 301.6 Dependent persnality disrder 301.7 Antiscial persnality disrder 301.81 Narcissistic persnality disrder 301.82 Avidant persnality disrder 301.83 Brderline persnality disrder 301.84 Passive-aggressive persnality 301.89 Other persnality disrders 301.9 Unspecified persnality disrder Page 8

Measure Lgic/Flw Charts Is the patient age 18 r lder? N Depressin Care Measures 2014 Measurement Specificatins Clinic Level Ppulatin Cunts Measure Lgic Flwchart fr ALL patients Yes Has the patient been seen by a prvider during the measurement perid? N PATIENT NOT INCLUDED N *Answer questins using the fllwing measurement perids: 02/01/2013 t 05/31/2013 06/01/2013 t 09/30/2013 10/01/2013 t 01/31/2014 Yes INCLUDE IN CLINIC LEVEL POPULATION COUNT #1 Des the patient have a diagnsis cde listed in Table 1 n Page 7? N Des the patient have a diagnsis f 311.x? Yes INCLUDE IN CLINIC LEVEL POUPLATION COUNT #3 Yes N Is the diagnsis in the primary psitin if the patient was seen by a behaviral health prvider r in any psitin if they were seen by a primary care prvider? N PATIENT NOT INCLUDED Yes N INCLUDE IN CLINIC LEVEL POPULATION COUNT #2 Did the patient have a PHQ-9 test administered? Yes INCLUDE IN CLINIC LEVEL POPULATION COUNT #4 Page 9

Is the patient age 18 r lder? N Depressin Care Measures 2014 Measurement Specificatins 2014 Depressin Care Measure Flw Chart fr Patient WHO ARE NOT Indexed Please see pages 26-31 fr mre detailed infrmatin abut each cmpnent Yes Has the patient been seen by a prvider during the measurement perid? N *Answer questins using the fllwing measurement perids: 02/01/2013 t 05/31/2013 06/01/2013 t 09/30/2013 10/01/2013 t 01/31/2014 Yes Des the patient have a diagnsis cde listed in Table 1 n Page 7? N PATIENT NOT INDEXED Yes Is the diagnsis in the primary psitin if the patient was seen by a behaviral health prvider r in any psitin if they were seen by a primary care prvider? N Yes Did the patient have a PHQ-9 test administered? N Yes N Was the scre ver 9? Yes INCLUDED IN DENOMINATOR; CONSIDERED INDEXED PATIENT Patient is nw indexed - must submit ALL fllw-up PHQ-9 scre regardless f scre Page 10

2014 Depressin Care Measure Flw Chart fr Patient WHO ARE Indexed Please see pages 26-31 fr mre detailed infrmatin abut each cmpnent *Answer questins using the fllwing measurement perids: 02/01/2013 t 05/31/2013 06/01/2013 t 09/30/2013 10/01/2013 t 01/31/2014 Depressin Care Measures 2014 Measurement Specificatins Was the patient administered a PHQ-9? Yes SUBMIT ALL PHQ-9 SCORES REGARDLESS OF SCORE Answer bth questins t determine numeratr criteria N PATIENT REMAINS IN DENOMINATOR Was the PHQ-9 test administered within 6 mnths (+/- 30 days) f the patient s indexed visit? Yes N N Was the PHQ-9 test administered within 12 mnths (+/- 30 days) f the patient s indexed visit? Yes Answer bth questins t determine if patient meets numeratr criteria Answer bth questins t determine if patient meets numeratr criteria Was the mst recent scre within the timeframe less than 5? Yes INCLUDED IN NUMERATOR FOR REMISSION RATE Was the mst recent scre within the timeframe reduced by 50% f the index visit s PHQ-9 scre? Yes N N PATIENT REMAINS IN DENOMINATOR N N Was the mst recent scre within the timeframe less than 5? Yes Was the mst recent scre within the timeframe reduced by 50% f the index visit s PHQ-9 scre? Yes INCLUDED IN NUMERATOR FOR RESPONSE RATE INCLUDED IN NUMERATOR FOR RESPONSE RATE INCLUDED IN NUMERATOR FOR REMISSION RATE Page 11

Depressin Care Measures 2014 (02/01/2013 t 01/31/2014 Dates f Service) Data Cllectin and Submissin Instructins Page 12

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Cllectin and Submissin Preparatins and Cnsideratins Befre cllecting and submitting data t MNCM, please review the fllwing items. Data submissin preparatins Yur medical grup and clinics MUST BE REGISTERED in the MNCM Data Prtal. Please see Appendix A fr mre infrmatin abut registratin. Save the MNCM websites in yur Favrites internet flder fr future reference. MNCM Data Prtal: https://data.mncm.rg/lgin MNCM website: www.mncm.rg MN HealthScres: www.mnhealthscres.rg Create a flder in yur netwrk drive dedicated t all data submissin dcuments. Save all spreadsheets, frms and data submissin materials in the dedicated flder. Name versins f dcuments clearly, s yu are using the mst recent files. Lg in t the MNCM Data Prtal at https://data.mncm.rg/lgin. In the Resurces tab f the data prtal, yu are able t access the fllwing items: Patient attributin Resurces. Dwnlad the fllwing Depressin Care Measures 2014 Guide Depressin Care Measures 2014 Denminatr Certificatin Frm Depressin Care Measures 2014 Data Cllectin Frm Depressin Care Measures 2014 Spreadsheet Template A patient is attributed t the clinic site and prvider f the indexed visit meaning the visit where the patient had a diagnsis cde fr majr depressin r dysthymia AND a PHQ-9 scre greater than nine. The prtal then matches all subsequent cntact dates and PHQ-9 scres t this patient within the medical grup regardless f the clinic lcatin f the cntact. Nte fr Primary Care Clinics: If a medical grup assigns a primary care prvider fr each patient, it is acceptable t use that prvider ID in this field. If a grup des nt assign a primary care prvider, then use the prvider ID f the prvider wh cared fr the patient at the visit. A patient is attributed t ne clinic and ne prvider within yur medical grup that are cnsidered respnsible fr managing the patient s care. This methd was develped in rder t capture and attribute all eligible patients. Please use the fllwing attributin methds in rder: 1. After identifying the eligible patients fr this measure based n the denminatr criteria, first, attribute the patient t the clinic and prvider within yur medical grup that are assigned t the patient OR are respnsible fr the patient s care. If the patient des nt have an assigned clinic r prvider within yur medical grup, then Page 13

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins 2. Attribute the patient t the clinic and prvider within yur medical grup that saw the patient mst ften in the measurement perid. If mre than ne prvider saw the patient equally, then 3. Attribute the patient t the clinic and prvider within yur medical grup that saw the patient mst recently in the measurement perid. Denminatr Certificatin Yu nly need t submit ne denminatr frm if bth #1 and #2 listed belw are true. If they are nt met, yu will need t submit multiple denminatr certificatin frms. 1. The crrect date f birth and date f visit ranges fr each measurement perid are included in the frm. 2. Yu will pull data fr each measurement perid the same way. Abut Ttal Ppulatin Submissin This measure requires ttal ppulatin submissin. When a medical grup r clinic submits ttal ppulatin, they are submitting data fr all f the eligible visits that ccurred during the measurement perid. The criterin in the Denminatr sectin f the Measure Specificatins n page 6 define the eligible ppulatin and prvides details n wh shuld be identified/included in the patient data file. Yu must submit data fr all patients wh meet inclusin criteria during the current measurement perid and data fr all patients wh have been indexed in previus measurement perids. Patient ID The patient ID number must be maintained fr patients acrss all measurement perids. This means that data fr a patient must always be submitted using the same patient ID. If yu have questins abut this, please cntact MNCM by email at supprt@mncm.rg. PHQ-9 Scres Yu must submit data fr ALL fllw-up PHQ-9 scres nce a patient is indexed regardless f the scre f the PHQ-9 test. Yu shuld expect t have sme scres 9 and belw in yur patient data file. Patient Data File Creatin Data will be cllected and put int an Excel template titled Depressin Care Data Cllectin Spreadsheet which can be fund n the MNCM Data Prtal. Once all data is cllected and input int the Excel template, the file will need t be saved as a CSV file in rder t uplad the file t the MNCM Data Prtal. Please nte: 1. The Excel template prvided has the crrect frmatting. D NOT use General frmatting in Excel. The Excel template prvided n the MNCM Data Prtal will prvide the crrect frmatting. 2. After creating the CSV file, d NOT pen the CSV file in Excel. Opening the CSV file in Excel destrys the frmatting and alters the data. T view the data again, pen the riginal Excel file. If yu need t make changes t yur file, make the changes in yur riginal excel file, nt in the.csv file, and save the Page 14

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins changes t a new.csv file. If the CSV file is mistakenly pened in Excel, simply re-save a new CSV file frm the riginal Excel file. Rename the ld CSV file r delete it entirely. If at any pint in the prcess it is discvered that crrectins t the data are needed, make the necessary changes in the Excel file and save as a new CSV file using a different name. What is a CSV file? Why is a CSV file needed fr data submissin? CSV stands fr cmma separated values. A CSV file is a cmmn and simple frmat that is used t imprt /transprt data between systems r sftware applicatins that are nt directly related (e.g., frm a spreadsheet t a database). Please see page 33 fr mre infrmatin n hw t create a CSV file frm an Excel file. Patient Data File Submissin Data submissin cnsists f submitting clinic level ppulatin cunts AND a patient data file fr each measurement perid. Review Sectin B n pages 21-22 fr mre infrmatin abut the clinic level ppulatin cunts. Review Sectin C n pages 23-31 fr mre detailed infrmatin abut the patient data file. The patient data file must be submitted using the measurement perid dates f service belw. The patient data files must als be submitted t the MNCM Data Prtal in chrnlgical rder as utlined belw: File Measurement Perid Dates f Service Submissin Order File #1 02/01/2013 t 05/31/2013 First File #2 06/01/2013 t 09/30/2013 Secnd File #3 10/01/2013 t 01/31/2014 Third Page 15

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Sectin A: Identifying the Patient Ppulatin (Denminatr) Denminatr Definitin: The denminatr is the bttm number in a fractin. This step f the prcess includes identifying the ttal number f patients wh are eligible fr the measure using a standard set f criteria. Please review the Denminatr sectin nted in the Measure Specificatins in this guide fr the detailed criteria used t identify eligible patients fr the denminatr. Yu will need t identify the patient ppulatin which yu will include n the patient data file AND yu will need t identify the clinic level ppulatins which yu will submit cunts t MNCM during data submissin. Step 1: Denminatr Certificatin This must be dne prir t identifying yur ppulatin and cllecting data. T help medical grups achieve accuracy and/r inadvertently pulling the wrng patient ppulatin fr the measure, MNCM will cmplete an upfrnt review f each medical grup s surce cde r methdlgy that is used t prduce the patient ppulatin (denminatr) t help identify ptential errrs. The denminatr certificatin prcess is intended t help identify ptential issues prir t data submissin. Hwever, the respnsibility t submit an accurate denminatr rests with the medical grup. Cntact supprt@mncm.rg with any specific questins. PLEASE NOTE: Denminatr certificatin may als include a cmprehensive review by MNCM f the prcess steps used t identify the denminatr, including the final list f patients. Save all riginal queries, dcuments, spreadsheets and prcess steps that are used t identify the patient ppulatin. MNCM may ask t review this infrmatin. Denminatr Template Frm This template is prvided t ensure all medical grups are using the same set f criteria t identify patients fr the denminatr. Medical grups are asked t cmplete this frm and submit it t the MNCM Data Prtal. The denminatr frm asks fr surce cde r screen shts, which are helpful in MNCM s review f the denminatr. 1. Lgin t the MNCM Data Prtal ( https://data.mncm.rg/lgin). 2. G t the RESOURCES tab and select Depressin Resurces frm the drp-dwn menu. Dwnlad the Depressin Care Measures 2014 Denminatr Template Frm. 3. Cmplete the frm and save the frm n yur netwrk directry. 4. Lgin t the MNCM Data Prtal and click n Denminatr Certificatin under the Depressin Measure 02/01/2013 t 05/31/2013 sectin. Fllw the instructins t uplad the frm t the data prtal. 5. MNCM will review the methd and respnd within 2-3 business days. MNCM will either (1) cntact the medical grup if mre clarificatin is needed, in which case the medical grup will need t make the necessary revisins and re-uplad the frm, r (2) apprve and certify the methd in the MNCM Data Prtal; an autmatic e-mail will ntify the medical grup that the methd is certified. Page 16

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Details fr the Denminatr Methdlgy The fllwing elements are included n the Depressin Care Measures 2014 Denminatr Template Frm. Medical grups will need t indicate n the frm hw they will identify each element fr MNCM: Date f birth range. ICD-9-CM cdes. Visit date range. If submitting ne frm fr all three measurement perids, yu must include all three date f service date ranges. Bard certified specialties f prviders included in the search. Whether exclusins will be taken and hw exclusins will be handled. Keep a Crsswalk : It is very imprtant t keep a crsswalk between the unique identifier and the patient s name and DOB, s that recrds can be lcated by clinic staff at the time f validatin by MNCM. EMR grups can list which accepted exclusins will be filtered thrugh the query prcess. Medical grups that will manually abstract data can describe that exclusins will be identified and dcumented during recrd review. Step 2: Identifying patient ppulatin After yur denminatr frm has been apprved by MNCM, yu will be able t query yur system t determine the patient ppulatin fr this measure. If a medical grup pened r acquired a new clinic in the last year, the new clinic must register and submit data with the medical grup. Please cntact supprt@mncm.rg t discuss submitting this data. Fr medical grups that implemented a new practice management system r EMR in the last tw years, the patient ppulatin list will need t be generated using bth systems. Tw queries r patient lists will be necessary. The lists shuld then be cmbined and a cmmn identifier(s) selected t de-duplicate the list. Cntact supprt@mncm.rg with any questins. 1. Eligible Prviders and Encunter Types Patients wh have visits with prvider wh practice in the fllwing specialties are included in the depressin measurement. Eligible prviders include primary care and behaviral health prviders. Behaviral health prviders are eligible fr the measure if there is a physician wh is n-site (i.e., a physician wh als practices at the clinic anytime during the measurement perid). The fllwing is a list f eligible specialties and prviders: Primary Care Family Practice Internal Medicine Geriatric Medicine Obstetrics/Gyneclgy * Physician Assistant Nurse Practitiner Behaviral Health Psychiatrist Physician Assistant Nurse Practitiner Clinical Nurse Specialist Psychlgist (LP) Clinical Scial Wrker (LICSW) Cunselr (LPCC) Marriage and Family Therapist (LMFT) *OBGYN prviders wh functin in a primary care rle are encuraged t submit data fr their patients, but it is vluntary. Page 17

2. Eligible Patients Depressin Care Measures 2014 Data Cllectin and Submissin Instructins If a patient IS NOT AN INDEXED patient: In rder t be eligible fr this measure, patients must initially meet the fllwing criteria: 1. Depressin Diagnsis. Patients must have ne f the fllwing diagnses (the diagnsis must be in the primary psitin fr behaviral health prviders and can be in any psitin fr primary care prviders): 296.2.x Majr depressive disrder, single episde. 296.3x Majr depressive disrder, recurrent episde. 300.4 Dysthymic disrder. 2. PHQ-9 Scre abve 9. Patients must have been administered a PHQ-9 test at a face-t-face visit with an eligible prvider AND must have scred abve a 9. Once the tw abve criterins are met, the patient is cnsidered an indexed patient. The indexed visit is the visit in which the patient had an eligible diagnsis AND scred abve nine n the PHQ-9 test at a face-t-face visit with an eligible prvider. If a patient IS AN INDEXED patient: Once the patient has been indexed, all fllw-up PHQ-9 scres must be included in the patient data file. Include these scres regardless f diagnsis, wh r where the PHQ-9 test was administered. Acceptable encunter/visit types fr fllw-up PHQ-9 scres fr an indexed patient include: Office visit. Telephne encunter. E-Visit. Any ther cntact with the patient in which a PHQ-9 is administered. System Query: Helpful data elements that can be included in the system query Please refer t the data elements and field specificatins t determine hw t frmat the data elements that must be submitted t MNCM: Patient ID number Patient date f birth Clinic r facility Prvider name and NPI Prvider type/specialty cde Insurance payer Insurance member ID Gender Zip cde Race/ethnicity, cuntry f rigin and preferred language Page 18

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Evaluatin and Management (E & M) Current Prcedural Terminlgy (CPT) Cdes (ptinal) The fllwing list f cdes may be helpful in determining what types f visits t include fr identifying the patient ppulatin (denminatr). E & M cdes d nt need t be used when querying a practice management system t determine visit cunts; hwever, they have been included here t help further define what is meant by a face-t-face visit with a prvider. Please refer t a CPT cding manual fr mre details. Allwable Exclusins: Descriptin Psychtherapy pt / family r diagnstic evaluatin E & M Cdes Preventive Cdes Office Cnsultatin Preventive Medicine Cunseling, Individual Preventive Medicine Cunseling, Grup Other Preventive Medicine Services Other Outpatient Encunters Unlisted E & M Cdes Patient death. Hspice. Permanent Resident f Nursing Hme. Biplar Disrder (see Table 2 n pages 7-8). Persnality Disrder (see Table 2 n pages 7-8). CPT Cdes 90791-90792; 90832-90838; 90832-90838 99201-99205; 99211-99215 99385-99387; 99395-99397 99241-99245 99401-99404 99411-99412 99420; 99429 98960-98962; 99078; 99217-99220; 99341-99345; 99347-99350; 99499 Fr Patient Death, Hspice and Permanent Resident f Nursing Hme Exclusins D NOT exclude patients up frnt in the query prcess fr identifying yur ppulatin. Include the eligible patients as part f the submissin file and enter a valid exclusin cde and date. Please dcument hw yu are identifying exclusins in yur denminatr certificatin dcument. If an exclusin event ccurs after a patient has already been submitted, a subsequent recrd culd cntain data fr the Exclusin Reasn and Exclusin Date fields. Having an exclusin reasn and date wuld prevent the patient being cunted in the utcme calculatins. If yu d nt knw the exact date f the event, it is acceptable t enter a date that represents the mnth in which it ccurs like 06/01/2014 t represent June 2014. Fr Biplar Disrder and Persnality Disrder Exclusins It is acceptable t exclude patients with a biplar r persnality disrder (listed in Table 2 n pages 7-8) in any psitin fr bth behaviral health and primary care prviders upfrnt. Medical grups can nw structure their queries t exclude any patient with a secndary r primary diagnsis f biplar r persnality disrder. Fr patients that have already been submitted t the data prtal and nw have biplar r persnality disrder as a diagnsis (primary r nt), please submit a recrd fr each patient that includes the apprpriate exclusin Page 19

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins cde in the patient data file. It is acceptable t create a fake encunter with the date f 02/01/2013. This will exclude the patient frm the measure. Mving frward, any new patient wh has biplar r persnality disrder can be excluded upfrnt thrugh queries and des nt need t be submitted in the patient data file with a visit and exclusin cde and date. PLEASE NOTE: These exclusins may be taken by the medical grup if the infrmatin is available, hwever, it is ptinal. If the infrmatin is unknwn t the clinic, the patient is t be included. Patient Registries A patient registry is an imprtant tl t help clinics track patient prgress and t use fr quality imprvement purpses. Hwever, MNCM cautins the use f a patient registry fr identifying patients in the ppulatin r fr the cllectin f clinical data. Many registries give a snapsht f patients at a given time and wuld therefre nt include all patients accrding t established patient criteria r may nt reflect the mst recent clinical data (e.g., mst recent screening exam). Registries that are prgrammed t update the patient ppulatin and clinical results n a cntinual basis (24/7) r built using measure specificatins can pssibly be used, hwever, please discuss this with MNCM. Yu can use the data submissin template as a registry, but make sure yu nly send us what we need and in the riginal CSV frmat when dwnladed frm the prtal. If changes are made t the spreadsheet, it will nt uplad crrectly int the MNCM prtal. During the validatin audit, the MNCM auditr will review the patient recrd fr validatin and nt the patient registry. If a clinic uses data frm a patient registry, the auditr may find a mre recent date/value in the medical recrd and this wuld be cunted as a validatin errr. Page 20

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Sectin B: Clinic Level Ppulatin Cunts Clinic level ppulatin cunts are used t calculate general clinic level depressin care rates fr yur clinic (See Appendix F fr mre infrmatin). In additin t creating a file f all yur patients with depressin and their PHQ-9 scres that meet the inclusin criteria fr the measure (see next sectin), yu will be asked t prvide specific summary cunts in the data prtal. These cunts that are calculated will nt necessarily match the number f patients in the patient data file. The ppulatin cunts are imprtant and cntribute t the measurement calculatins. If yur clinic des nt use the phq-9 test, yu still need t submit clinic level ppulatin cunts. Purpse T prvide infrmatin abut the ppulatin f patients cared fr at each clinic site and t understand the prcesses related t diagnsis, mnitring and treatment f depressin. The incidence f majr depressin/dysthymia in the clinic s adult ppulatin. The use r veruse f the nn-specific ICD-9 cde fr depressin (311). The utilizatin f the PHQ-9 tl fr patients with diagnsed depressin/dysthymia. All cunts pertain t the current measurement perid nly. Please review the measurement perid fr which yu are submitting data, the name f the perid will be next t yur medical grup name. All are cunts f unique patients, nt the number f visits. Fr example, this means that a patient culd be cunted nce in the first measurement perid and nce in the third measurement perid. Clinic Level Ppulatin Cunt 1: Ttal Adult Patients The ttal number f unique adult patients (ages 18+) seen in yur clinic fr any reasn with a cntact with an eligible prvider during the measurement perid. Clinic Level Ppulatin Cunt 2: Ttal Adult Patients with Depressin Diagnsis (296.2x, 296.3x r 300.4) These ICD-9 cdes define majr depressin and dysthymia and wuld be a subset f yur ttal adult patients. It des nt matter if this is a new diagnsis r if the patient is returning fr a fllw-up visit. If they have these cdes during the measurement perid, include them in the cunt. If the patient has an exclusin ICD-9 diagnsis cdes, d NOT include them in this cunt. The ttal number f adult patients with a cntact with an eligible prvider wh have at least ne cntact in the measurement perid with the fllwing ICD-9 cdes: 296.2x Majr depressive disrder, single episde. 296.3x Majr depressive disrder, recurrent episde. 300.4 Dysthymic disrder. If the prvider is primary care, the ICD-9 cdes can be in any psitin. If the prvider is behaviral health, the ICD-9 cdes need t be in the primary psitin nly. This excludes patients with ther psychiatric diagnses with a secndary cmpnent f depressin. Page 21

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins If a clinic DID NOT have any patients with a diagnsis f majr depressin r dysthymia: A 0 shuld be entered fr this cunt. Yu must als check N Depressin Patients Seen this Perid. Clinic Level Ppulatin Cunt 3: Ttal Adult Patients with Depressin NOS (311) cde This wuld be anther subset f yur adult ppulatin. The ttal number f adult patients with a cntact with an eligible prvider with a 311 cde (Depressin NOS nt elsewhere classified). Because ne f the gals f measuring this ppulatin is accurate diagnsis (and subsequently cding), please nly include in this cunt patients wh have a 311 cde and nt the majr depressin/dysthymia cdes f (296.2, 296.3 r 300.4). One way yu culd structure yur query wuld be t search fr ICD-9 cde = 311 and is nt equal t 296.2, 296.3 r 300.4. If the patient has an exclusin ICD-9 diagnsis cdes, d NOT include them in this cunt. Clinic Level Ppulatin Cunt 4: Ttal Adult Patients with a Cmpleted PHQ-9 AND diagnsis f Majr Depressin r Dysthymia (296.2x, 296.3x r 300.4) This is a subset f the patients ages 18+ with the majr depressin/dysthymia diagnsis cdes f (296.2, 296.3 r 300.4) Cunt the number f these patients during the measurement perid wh als have a PHQ-9 test dne during the measurement perid. If a patient has an exclusin ICD-9 diagnsis cde, d NOT include them in this cunt. PLEASE NOTE: It is acceptable t cunt a patient has having a PHQ-9 administered if the patient nly partially cmpleted the PHQ-9 tl, but d NOT send partial scres as part f the patient data file. IF YOUR CLINIC DOES NOT USE THE PHQ-9 TEST: Yu will enter a 0 fr this cunt. D NOT check N Depressin Patients Seen this Perid unless yur clinic truly had n patients with a depressin diagnsis seen during this measurement perid. Page 22

Sectin C: Data Cllectin Depressin Care Measures 2014 Data Cllectin and Submissin Instructins After the patient ppulatin (denminatr) is identified, data will need t be cllected fr the elements fund in the Data Elements and Field Specificatins table n pages 26-31. Recrds are submitted at a patient visit r cntact level; nt at the level f an individual patient such as data submitted fr the Optimal Diabetes Care r Optimal Vascular Care measures data submissins. This means there may be several recrds fr ne patient, ne recrd fr each PHQ-9 scre administered. Please refer t the data elements and field specificatins sectin fr mre detailed infrmatin abut each data element. Medical grups can cllect clinical data frm medical recrds by either: 1) extracting the data frm an electrnic medical recrd thrugh a data query; r 2) abstracting the data frm the medical recrd (paper recrd r EMR). Data cllectin ccurs after: 1. The clinic s billing and medical recrd updates are cmplete fr the measurement perid; 2. The denminatr methd is certified by MNCM; and 3. The patient ppulatin is pulled. Excel Template The Excel template was created t ensure all necessary data elements are cllected fr DDS. This file cntains all f the necessary fields and the crrect clumn frmatting accrding t the measure specificatins. Please dwnlad the Depressin Care Measures 2014 Excel template frm the MNCM Data Prtal by ging t the RESOURCES tab and selecting Depressin Resurces frm the drp-dwn menu. Key Pints fr File Creatin File submissin reflects visit r cntact level infrmatin; ne rw fr each visit r cntact. The PHQ-9 can be administered by means ther than an ffice visit, like a telephne call, and that is why we refer t the date field as a cntact date. Once a patient has been indexed,all fllw-up PHQ-9 scres are t be submitted, regardless f wh administers the tl r diagnsis cdes assciated with susequent visits. All PHQ-9 scres are expected t be submitted. If a patent was administered the PHQ-9 tl three times during ne measurement perid, there shuld be three recrds fr this patient in the patient data file. It is imprtant t nly submit recrds with dates f service during the measurement perid. Dates f service utside f the measurement perid will cause an ERROR upn submissin. Lcating Data Elements in the Patient Recrd Data Cllectin Tips: When manually cllecting data using an EMR, highlight the rw, clumn r cell that cntains the data needed. This reduces the chance f lking at the wrng rw, clumn r cell. Watch fr TYPOS when entering data (number transpsitins, etc.). The primary surce f data is the clinic s dcumentatin in the medical recrd (e.g., flw sheets, prgress ntes, lab reprts, etc.). Data cllectrs may als chse t review the utside crrespndence in the clinic s medical recrd that dcuments mre recent data within the measurement perid, but this is ptinal. If data is used frm utside crrespndence, please dcument this fr the validatin audit. Belw are tips fr lcating data in the patient recrd. Please fllw the measure specificatins fr data cllectin. Page 23

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins As lng as yu are including all yur patients with majr depressin (ICD-9 cdes 296.2, 296.3 r 300.4), there are several different ways that the data cllectin prcess can be achieved: Extract infrmatin frm yur EMR by query. Cmbinatin f extracting inf frm EMR and manual chart abstractin. Establishing an integrated PHQ- 9 tl slely within yur EMR wuld mean that scres can be extracted by query. Registry ppulated with patients with depressin and their visits. Dwnlad as much infrmatin as can be attained frm a billing system int Excel and then abstract remaining data elements. Tracking Where Data is Lcated in the Patient Recrd It is imprtant t keep track f where data is lcated in the patient recrd. Fr example, if data is used frm an utside specialist r prvider nte (that is within the primary clinic s recrd), dcument the surce n the data cllectin frm r Excel spreadsheet. If yu are cllecting data directly in the Excel spreadsheet, create a Ntes clumn and enter the data surce details in this clumn. After yu have cmpleted data cllectin, SAVE A COPY f the Excel file and remve the Ntes clumn in the file that will be used fr submitting t MNCM. Data Quality Checks MNCM recmmends cmpleting several internal quality checks f the data befre submitting data. Perfrming quality checks ensures that the data is accurate and able t be validated by a MNCM auditr. If crrectins are needed, make these in the Excel file. There are several ways t cnduct quality checks: Optin 1: Cmplete data quality checks f specific data elements in the Excel file using Excel s AutFilter. Please use the fllwing directins t set the filter and review specific data elements. 1. Click inside any data cell and activate the AutFilter by ding the fllwing: a. In Excel 2003, click the Data menu, pint t Filter, and then click AutFilter. b. In Excel 2007 and Excel 2010, click the Data tab and in the Srt & Filter area click Filter. 2. The AutFilter arrws nw appear t the right f each clumn heading. 3. Click n the drp-dwn bxes f any clumn and scan fr key entry errrs, ut-f-range r missing data and determine if the data needs t be crrected (e.g., If a date fr a PH9-9 cntact field was utside the measurement perid, the field wuld nt be accepted). 4. T display all data again, click n the same drp-dwn bx and select All. 5. Remve the Filter ptin by ding the fllwing: a. In Excel 2003, click Data, Filter, and AutFilter again. b. In Excel 2007 and Excel 2010, click the Filter ptin again in the Srt & Filter area. Example Quality Check: Verify that if there are PHQ-9 scres 9 and belw. Filter fr all rws in Clumn V (PHQ-9 Scre). When reviewing the list f scres submitted, cnfirm there are scres 9 and belw. Make changes in the riginal Excel file if apprpriate. Page 24

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Optin 2: Cmplete an internal audit f clinical data by reviewing a randm sample f recrds (either 8-10 recrds) r a full sample (30 recrds) t see if the data matches what was cllected frm the patient recrd. If errrs are fund, make the crrectins in the Excel file, hwever als cnsider if the errrs were islated cases r indicative f a larger data cllectin prblem. (e.g., there are n patients with PHQ-9 scres, and yu are certain that PHQ-9 tests were administered.) Optin 3: Cmplete the general quality checks utlined belw: 1. Cmplete quality checks listed in the Ntes sectin f each data element in the Data Elements and Field Specificatins table n pages 26-31. 2. Verify excluded recrds are remved and recrded n Exclusins Template. Please see Table 2 n pages 7-8 fr all applicable cdes used t identify patients wh meet exclusin criteria. 3. Hyphens r zeres (0 s): If the data field is suppsed t be blank, d NOT enter hyphens r zer (leave blank). 4. Blank rws in spreadsheet: Check that the Excel file des nt have blank rws at the bttm f the spreadsheet as blank rws can slw the data submissin prcess. T check fr blank rws: Press Ctrl/End at the same time t g t the bttm-mst cell in the spreadsheet. If there are several blank rws, remve them by highlighting the blank rws, right-clicking in the left margin, and selecting Delete (this deletes the rws and nt nly the text within the cells). Optin 4: Review and answer the fllwing questins. If yu answered N t any f the questins belw, please return t the patient data file and crrect the issues. Did yu use the same patient ID fr patients that were already submitted t the data prtal? Is the file srted by patient ID and then cntact date (ldest t newest)? Did yu include ALL fllw-up PHQ-9 scres fr patients that were indexed in this perid r prir perids regardless f lw PHQ-9 scres, nn-face-t-face visits r visit diagnsis cdes? Did yu include scres frm scanned PHQ-9s, flwsheets, r visit ntes? Des yur excel file match the depressin data cllectin spreadsheet template (the frmatting and clumn headers)? It is imprtant t cmplete quality checks f the file befre submitting data t MNCM. Cmpleting these checks can help avid delays in the file submissin and ensure that yu have the mst accurate data. Make any changes/additins in the Excel file befre submitting data t MNCM. Page 25

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example A Patient ID Enter a unique patient ID that will identify each patient and assigned by the clinic. B Patient Date f Birth The patient ID assigned needs t identify the patient uniquely and the patient ID needs t remain cnstant ver all data submissins in rder t track utcmes at six and twelve mnths. Yu may use any field in yur system that uniquely identifies the patient. If the medical recrd number is the nly field that uniquely identifies the patient ver time, it is acceptable t use this. Blank values will create an ERROR upn submissin. Quality Check: Verify that each cell has an ID listed. Verify same IDs are used fr patients acrss all data submissin perids. Enter the patient s date f birth. Patient must be 18 r lder (n upper age limit) at the start f the measurement perid. Fr example, fr the 02/01/2013 t 05/31/2013 measurement perid, include anyne brn n r prir t 02/01/1995 t ensure that the patient is at least 18 years ld during that measure perid. It is als acceptable t use age at the time f the encunter if the patient is age 18 r lder at the time f the encunter. Blank values will create an ERROR upn submissin. Quality Check: Verify each date f birth is within the accepted range. C Clinic ID Enter the MNCM Clinic ID f the clinic where the visit ccurred fr every patient submitted. MNCM assigns the clinic ID at the time f registratin. Clinic IDs are als listed in the MNCM Data Prtal. Blank values will create an ERROR upn submissin. Quality Check: Verify all IDs match the MNCM ID in the prtal. D Patient Gender Enter the patient s gender: Female = F; Male = M; Unknwn = U Blank values will create an ERROR upn submissin. Quality Check: Verify each cell has ne f the accepted cdes. Text 987654 Date (mm/dd/yyyy) Text 304 Text 05/08/1985 F Page 26

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example E F Zip Cde, Primary Residence Race/Ethnicity1 G Race/Ethnicity 2 H Race/Ethnicity 3 I Race/Ethnicity 4 J Race/Ethnicity 5 K L M N Cuntry f Origin Cde Cuntry f Origin Other Descriptin Preferred Language Cde Preferred Language Other Descriptin Enter the patient s five-digit zip cde f primary residence at the mst recent encunter n r prir t the last day f the measurement perid. If EMR query extracts a nine digit number, submit the nine digit number (the prtal will remve the last fur digits autmatically). Blank values and values less than five digits will create an ERROR upn submissin. Quality Check: Verify the zip cde is five digits lng and that each cell has data. Please refer t a separate dcument entitled REL Data Field Specificatins and Cdes 2013 fr these field specificatins. This dcument can be fund under the RESOURCES tab in the data prtal under the Race/Ethnicity/Language Data (REL) sectin. Fr mre infrmatin abut cllecting this data frm patients in yur clinic practice, please refer t the Handbk n the Cllectin f Race Ethnicity and Language Data available at www.mncm.rg. Quality Checks: Verify accepted cdes are used. Blank cells (if there is n data is available) are acceptable. O Prvider NPI Enter the 10-digit NPI number f the prvider wh manages the patient s care. The prvider frm the index cntact is the prvider that the patient will be attributed t. Blank values are acceptable if the visit was a fllw-up PHQ-9 cntact. Quality Check: Verify each cell has data. Text 55111 Number 1 Number 2 Text Number 1 Text CuntryA LanguageB Text 1234567891 Page 27

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example P Q R S Prvider Specialty Cde Insurance Cverage Cde Insurance Cverage Other Descriptin Insurance Plan Member ID Enter the specialty cde f the physician (see cdes belw). If the prvider is nt a physician, enter the cde that best describes the clinic s specialty. 1 = Family Practice 8 = Psychiatry 2 = Internal Medicine 9 = Obstetrics/Gyneclgy * 5 = Geriatric Medicine *PLEASE NOTE: OBGYN prviders wh functin in a primary care rle and/r treat patients with majr depressin are encuraged t submit data fr their patients with majr depressin and assciated PHQ-9 scres but this submissin is vluntary. Cntact MNCM at supprt@mncm.rg if there is a prvider wh wishes t submit data and the cde is nt listed abve r if yu have questins. Blank values will create an ERROR upn submissin. Quality check: Verify that each cell has an accepted cde. Please refer t a separate dcument entitled Insurance Cverage Data Field Specificatins and Cdes fr these field specificatins. This dcument can be fund under the Resurces tab in the data prtal under the Insurance Cverage Inf sectin frm the drp-dwn menu. PLEASE NOTE: This shuld be the patients mst recent insurance n r prir t the last date f the measurement perid. Number 8 Number 1 Text Text CIGNA FBZXV12345 Quality Checks: Verify accepted cdes are used and that all 99 cdes have a name entered in Clumn R. Verify SSN are NOT submitted. Page 28

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example T Diagnsis Enter the diagnsis cde fr the visit. If a patient has multiple diagnses, nly list ne. 296.2x = Majr depressive disrder, single episde 296.3x = Majr depressive disrder, recurrent episde 300.4 = Dysthymic disrder Please see Table 1 n pages 6-7 fr a list f acceptable diagnsis cdes. Blank values will be accepted ONLY IF the patient is an indexed patient. If this field is left blank and the patient HAS NOT previusly been previusly indexed, the infrmatin will be discarded by the prtal. Quality Check: Verify a diagnsis is listed if the patient has nt been previusly indexed. U Cntact Date Enter the date f visit, telephne call, e-visit r ther cntact that is assciated with the PHQ-9 tl given t the patient. Once the patient has been identified as meeting the inclusin criteria f diagnsis cdes and PHQ-9 greater than 9, include all subsequent cntact dates and PHQ-9 scres fr the patient, regardless f diagnsis, staff administering the PHQ-9 r setting in which the PHQ-9 is administered within yur medical grup. Blank values will create an ERROR upn submissin. Quality Check: Verify each cntact date is within the measurement perid. V PHQ-9 Scre Enter the PHQ-9 ttal scre assciated with the cntact date entered in Clumn U. It is expected that nce the patient has been identified as meeting the inclusin criteria, include ALL subsequent PHQ-9 scres that are a part f yur medical recrd will be included regardless f diagnsis r PHQ-9 scre. If n PHQ-9 was dne, leave blank. Yu d nt need t submit cntact dates in which a PHQ-9 test was nt dne, hwever if yur EMR system autmatically pulls these visits, the prtal will accept them. Page 29 Text 296.32 Date (mm/dd/yyyy) Number 13 08/31/2014

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example D NOT include decimals as part f the scre, nly submit whle scres. V (cnt.) PHQ-9 Scre (cnt.) D NOT include incmplete PHQ-9 scres. In this situatin, leave the scre field blank. Fr example, if a patient nly answers the first five questins which ttal up t a scre f fur, submitting 4 might falsely indicate remissin when this may nt be the case. Only include a scre f 0 if this is the patient s actual scre (all answers are Nt at All ). DO NOT use zer t indicate a blank scre. If a patient still has a high PHQ-9 (greater than nine) scre 13 mnths r mre after the index visit (activatin) then the patient s recrd will be marked as re-activatin and the measurement cycle will begin again. This patient is still meeting inclusin criteria and has anther chance fr meeting the utcme f remissin. Blank values will create an ERROR upn submissin. Quality Check: Verify nly whle numbers are entered and that n scre is abve 27. W Exclusin Reasn If the patient has a valid reasn fr exclusin frm the depressin measures, enter the exclusin reasn cde. The fllwing cdes are acceptable exclusin cdes. Leave BLANK if the patient des nt meet exclusin criteria. 1 = Death 3 = Hspice 4 = Permanent Resident f Nursing Hme 5 = Biplar Disrder (see Table 2 n pages 7-8) 6 = Persnality Disrder (see Table 2 n pages 7-8) Fr Patient Death, Hspice and Permanent Resident f Nursing Hme Exclusins: D NOT exclude patients up frnt in the query prcess fr identifying yur ppulatin. Include the eligible patients as part f the submissin file and enter a valid exclusin cde and date. Please dcument hw yu are identifying exclusins in yur denminatr certificatin dcument. If an Page 30 Number 1

Depressin Care Measures 2014 Data Cllectin and Submissin Instructins Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example exclusin event ccurs after a patient has already been submitted, a subsequent recrd culd cntain data fr the Exclusin Reasn and Exclusin Date fields. Having an exclusin reasn and date wuld prevent W Exclusin Reasn the patient being cunted in the utcme calculatins. If yu d nt knw the (cnt.) (cnt.) exact date f the event, it is acceptable t enter a date that represents the mnth in which it ccurs like 06/01/2014 t represent June 2014. Fr Biplar Disrder and Persnality Disrder Exclusins: It is acceptable t exclude patients with a biplar r persnality disrder in any psitin fr bth behaviral health and primary care prviders up frnt. See Table 2 n pages 7-8 fr a list f acceptable exclusin diagnsis cdes. Medical grups can nw structure their queries t exclude any patient with a secndary r primary diagnsis f biplar r persnality disrder. Quality check: Verify that each cell has an accepted cde. X Exclusin Date Date the patient exclusin is dcumented. Blank values are accepted if the patient des nt meet exclusin criteria. Quality Check: Verify this clumn is ppulated if Clumn W has a cde in it. Date (mm/dd/yyyy) 08/25/2014 Page 31

Depressin Care Measures 2014 Instructins Sectin D: Patient Data File Creatin If yu cllected yur data n ne spreadsheet fr all dates f service, yu must srt by cntact date and create three separate files fr each measurement perid. Then, in rder fr the prgramming t crrectly evaluate each patient recrd, each measurement perid patient data file must be srted first by PatientID and then by Cntact Date with the cntact dates in ascending r ldest t newest rder. Final Steps t Cmplete in the Excel File: Befre prceeding with the file submissin, be sure t: Cmplete all data cllectin and data entry. Cmplete data quality checks. Cmbine all clinic files nt ne spreadsheet. All clinics must be upladed in ne, single spreadsheet. The clinic identifier is the Clinic ID. Verify that each clumn is frmatted accrding t measure specificatins (TEXT, NUMBER, r DATE frmatting). Clumns can remain at any width. Check that the field labels in the header rw (tp rw) matches the labels n the Excel template exactly. Ensure that all riginal clumns remain in the spreadsheet even if there is n data. D NOT delete any clumns. Once the abve steps are cmpleted, save the Excel template and use the fllwing instructins t save as a CSV file. If at any pint in the prcess it is discvered that crrectins t the data are needed, make the necessary changes in the Excel file and save a new CSV file with using a different name. Instructins fr Srting in Excel These steps will need t be repeated fr each measurement perid. Excel 97-2003 In the upper left hand crner f the spreadsheet between Clumn A and Rw 1 there is a blank gray cell. Click n this cell t highlight yur entire spreadsheet. If yu d nt highlight every rw and clumn yu culd lse the integrity f yur data. G t the menu bar and select Data and then Srt. This will bring up a windw that asks what fields yu wish t srt by. In the first bx select PatientID and ascending. In the secnd bx select Cntact Date and ascending. The data range defaults t selecting a Header Rw and this is fine. Select the OK buttn and the recrds will srt in the crrect rder. Excel 2007 and 2010 Same as 97-2003 except the pp up windw is different. In the drp-dwn bx select PatientID and smallest t largest. Then add a secnd level and select Cntact Date and ldest t newest. The data range defaults t selecting a Header Rw and this is fine. Select the OK buttn and the recrds will srt in the crrect rder. Page 32

Create CSV File fr Data Submissin Depressin Care Measures 2014 Instructins The next step is t create a CSV file that will be used fr uplad t the MNCM Data Prtal. Belw are steps fr creating a CSV file (Excel 2003, 2007 r 2010 users). If multiple tabs were created in the Excel spreadsheet, select the crrect tab and prceed with the fllwing steps (if spreadsheet has nly ne tab, start with step 6). Fr Excel 2003 Users Fr Excel 2007 Users Fr Excel 2010 Users 1. Open the riginal Excel file (.xls) and d the fllwing: 2. Click Edit r right-click the tab f the spreadsheet yu wish t save (near the bttm f the screen). 3. Select Mve r Cpy Sheet T bk (new bk) this is a drp-dwn selectin. 4. Click Create Cpy. 5. In this new bk, click File, Save As. 2. Right-click the tab f the spreadsheet yu wish t save (near the bttm f the screen). 3. Select Mve r Cpy Sheet T bk (new bk) this is a drp-dwn selectin. 4. Select Create a Cpy and click OK. 5. In this new bk, click the Office Buttn (upper left-hand crner f 2. Right-click the tab f the spreadsheet yu wish t save (near the bttm f the screen). 3. Select Mve r Cpy Sheet T bk (new bk) this is a drpdwn selectin. 4. Select Create a Cpy and click OK. 5. In this new bk, click the File tab (upper left-hand crner f screen); Select Save As. screen); Select Save As. 6. Select the flder and file name f yur chice. 7. At the very bttm, yu will see Save as type; chse frm the drp-dwn menu, CSV (cmma delimited). 8. Click Save. When yu save the CSV file, the fllwing warning will appear: may cntain features that are nt cmpatible with CSV. D yu want t keep the wrkbk in this frmat? Click Yes. 9. Nw yu can clse the file; a message will appear: D yu want t save this file...? Click either Yes r N. Yur CSV file is nw ready fr uplad t the MNCM Data Prtal. D NOT pen the CSV file in Excel. If the file is mistakenly pened, simply resave a new CSV file. Example f a Patient Data File PLEASE NOTE: 1.The data is cmpletely fake data (n PHI) 2. Each clr is a separate patient 3. Gender, Zip and Race fields nt displayed due t space 4. Nte that the file is srted by patient ID and then cntact date (ldest t newest) Page 33

Depressin Care Measures 2014 Instructins Sectin E: Patient Data File Submissin G t the HOME tab n the data prtal and scrll dwn t the crrect Depressin measure perid. Yu will need t repeat the fllwing steps fr each f the three measurement perids. REMINDER: Yu must submit the depressin patient data files #1, #2 and #3 in chrnlgical rder. Step 1: Enter Denminatr Medical grups can either manually enter denminatr cunts and infrmatin int the data prtal r they can chse t enter the infrmatin int an Excel sheet and uplad the Excel file t the prtal. Please use either the manual instructins (Instructins A) r the uplad instructins (Instructins B) belw. Instructin A: T manually enter denminatr cunts and infrmatin, use the fllwing instructins. Enter the fllwing infrmatin fr each clinic rw. Once the infrmatin is entered, click n Save and Cntinue. REL Data Cllectin: Please indicate if yu cllect race, Hispanic ethnicity, preferred language and cuntry f birth using best practice methds. Best practice methds include: Hispanic Ethnicity and Race: Allwing patient t self-reprt race AND nt using a multiracial categry AND system allws the cllectin and reprting f mre than ne race. Preferred Language and Cuntry f Birth: Allwing patient t self-reprt these demgraphic data. Clinic Level Ppulatin Cunts: Enter cunts fr each clinic level ppulatin cunt listed belw. Clinic Level Ppulatin Cunt 1: Ttal Adult Patients. Clinic Level Ppulatin Cunt 2: Ttal Adult Patients with Depressin Diagnsis (296.2x, 296.3x r 300.4). Clinic Level Ppulatin Cunt 3: Ttal Adult Patients with Depressin NOS (311) cde. Clinic Level Ppulatin Cunt 4: Ttal Adult Patients Depressin Diagnsis (296.2x, 296.3x r 300.4) and Cmpleted PHQ-9. N Depressin Patients with Diagnsis f 296.2x, 296.3x r 300.4 Seen this Perid: Check this bx if a clinic is nt reprting fr this cycle f data cllectin. Prvide a reasn the clinic is nt reprting. Fr example: The clinic has n patients meeting eligibility criteria. Instructin B: T enter the denminatr cunts and infrmatin int an Excel sheet that will then be upladed t the prtal, use the fllwing instructins. 1. Click n Dwnlad the Denminatr Wrksheet. The clinic names will be displayed in Clumn A and the clinic IDs will be displayed in Clumn B. 2. Cmplete the wrksheet by entering the fllwing infrmatin fr each clinic: Page 34

Depressin Care Measures 2014 Instructins REL Data Cllectin (Clumns C F): Please indicate if yu cllect race, Hispanic ethnicity, preferred language and cuntry f birth using best practice methds. Best practice methds include: Race and Hispanic Ethnicity: Allwing patient t self-reprt race AND nt using a multiracial categry AND system allws the cllectin and reprting f mre than ne race. Preferred Language and Cuntry f Birth: Allwing patient t self-reprt these demgraphic data. Fr each clinic ID indicate if best practices are used by using the fllwing cdes and instructins: 1 = Yes, we fllw the best practice 0 = N, we d nt fllw the best practice Clumn C: Enter the apprpriate cde (1 r 0) t indicate if patients are allwed t self-reprt race and Hispanic Ethnicity Clumn D: Enter the apprpriate cde (1 r 0) t indicate if clinic is NOT using a multi-racial categry AND system allws the cllectin and reprting f mre than ne race Clumn E: Enter the apprpriate cde (1 r 0) t indicate if patients are allwed t self-reprt preferred language Clumn F: Enter the apprpriate cde (1 r 0) t indicate if patients are allwed t self-reprt race and Hispanic Ethnicity Clinic Level Ppulatin Cunts: Enter cunts fr each clinic level ppulatin cunt listed belw. Clinic Level Ppulatin Cunt 1: Ttal Adult Patients (Clumn G). Clinic Level Ppulatin Cunt 2: Ttal Adult Patients with Depressin Diagnsis (296.2x, 296.3x r 300.4) (Clumn H). Clinic Level Ppulatin Cunt 3: Ttal Adult Patients with Depressin NOS (311) cde (Clumn I). Clinic Level Ppulatin Cunt 4: Ttal Adult Patients Depressin Diagnsis (296.2x, 296.3x r 300.4) and Cmpleted PHQ-9 (Clumn J). Nt Reprting (Clumn K): Please indicate if a clinic is nt reprting fr this cycle f data cllectin by entering the fllwing cde. Leave as 0 if a clinic is reprting data. 1 = Clinic is NOT reprting Please be advised that MNCM s plicy is that ALL clinic sites within a medical grup submit their data thrugh the DDS prcess. Likewise, this is a cnditin f participatin fr Minnesta Bridges t Excellence (BTE) and ther pay-frperfrmance prgrams. Reasn nt reprting (Clumn L): Prvide a reasn the clinic is nt reprting. Fr example: The clinic has n patients meeting eligibility criteria. 3. Save the Excel file as a CSV file (please see page 33 fr mre infrmatin abut hw t save a CSV file). Click Brwse t search and find the CSV file and click Submit File. Page 35

Step 2 Review and Save Depressin Care Measures 2014 Instructins Verify the numbers entered by reviewing all f the clinic site s infrmatin fr accuracy (n typs r duplicate patients). Click Save and Cntinue, r click Back t Step 1 t re-enter the cunts. Step 3: Uplad Data Click Brwse t search fr the CSV file and click Uplad CSV and Cntinue. The prtal will nw scan the CSV file t identify pssible errrs. The prtal will then prvide an Uplad Status that will indicate if there are errrs r warnings in the patient data file. Yu may have t click n Refresh. T view errrs and warnings, please click View Errrs & Warnings. If there are errrs, the patient data file will need t be crrected and resubmitted t prtal. Please refer t the Data Elements and Field Specificatins (pages 26-31) t review the required data fr each clumn. 1. Errrs: Crrectins must be made t the riginal Excel patient data file and a new patient data file upladed (e.g.: A date f birth is ut-f-range). If crrectins t the patient data file are necessary, prceed t instructins belw. 2. Warnings: Review pssible errrs and decide whether crrectins are needed (e.g.: Health Plan Member ID is blank). If crrectins t the patient data file are necessary, prceed t instructins belw. If crrectins are nt necessary, click Cntinue t Step 4. If crrectins t the patient data file are necessary: T start frm Step 3: If crrectins are nly needed t the patient data file, make crrectins in the riginal Excel file and save the crrected file with a new name. Then save as a new CSV file t uplad. D NOT make crrectins in CSV file as this will destry the frmat and alter the data. G back t the prtal submissin page and click Re-Uplad Data (csv) File. Begin again with Step 3 Uplad Data. T start frm Step 1: Click Clear & Start Over t start the prcess cmpletely ver frm Step 1 Enter Denminatr. Please nte: All denminatr cunt entries and a new file uplad will be necessary if Clear & Start Over is clicked. Once the Data (CSV) File has been upladed t the prtal, click Cntinue t Step 4. Step 4: Review & Submit Review and check each bx f the Pre-Submissin Quality Checklist and cntact MNCM if yu have any questins regarding the Pre-Submissin Quality Checklist. Please review the quality checks fr each item listed in the Data Elements and Field Specificatins table n pages 26-31. If yu need t resubmit the patient data file, please click Re-Uplad Data (CSV) File. If yu need t resubmit the denminatr cunts, click Clear & Start Over at the bttm f the page. If yu have checked all the bxes, please click Cntinue. The page will be refreshed. Yu will be asked t review the current measurement perid s preliminary rates fr each clinic cmpared t the prir perid s data submissin and cnsider any changes between the current perid and the prir perid. Prvide an explanatin in the text bx fr any changes r indicate that the data cmparisn is what yu expected. If yu need t resubmit the patient data file, please click either Re-Uplad Data (CSV) File r Clear & Start Over at the bttm f the page. Page 36

Depressin Care Measures 2014 Instructins If yu need t review infrmatin in mre detailed prir t submitting the file t MNCM, enter Will Review int the text bx and then click Save as Draft. T access yur infrmatin, yu can click n Data Submissin under the apprpriate measurement perid sectin n the HOME tab. Once yu have entered an explanatin, click Save Ntes. Yu can dwnlad the data by clicking Dwnlad Data near the tp f the data cmparisn sectin t see the visit types by viewing the additinal clumns n the right hand side f the dcument. This may be helpful in cnsidering if yu need t resubmit the patient data file. When the data file is ready t submit t MNCM: Click Submit Data t MNCM and prceed t Step 5 Dne. Step 5: Dne The patient data file has been successfully submitted. MNCM will send an e-mail that the data has been received. Page 37

Sectin F: MNCM Validatin Depressin Care Measures 2014 Instructins The validatin audit is cnducted t verify that the submitted data matches the surce data in the medical recrd. After the patient data file is successfully upladed t the MNCM Data Prtal, MNCM will cntact the medical grup abut the validatin prcess. The validatin audit may be cnducted remtely via HIPAA secure WebEx technlgy fr grups with an Electrnic Medical Recrd (EMR). On-site audits will ccur fr medical grups with paper chart systems. A. A medical recrd audit will ccur with a grups last measurement perid submissin in the measurement year after the February 2014 submissin. B. Medical audits may ccur mre frequently fr grups with a histry f unsuccessful direct data submissins. MNCM Validatin Prcess MNCM utilizes the NCQA (Natinal Cmmittee fr Quality Assurance) 8 and 30 prcess fr validatin audits. The fllwing methd is used fr each measure: MNCM randmly selects 33 recrds fr each clinic site fr validatin. At mst, 30 recrds fr each clinic site will be reviewed. The additinal three recrds requested are versamples t ensure there will be 30 recrds available n the day f the review. MNCM auditr reviews the first eight recrds f the clinic site s selected sample t verify that the submitted data matches the surce data in the medical recrd. If all f the first eight recrds reviewed are in perfect cmpliance (100%), the clinic site is determined t be in high cmpliance, and the MNCM auditr may determine that n further recrd review fr that site is necessary. If the first clinic site is in high cmpliance and the data cllectin prcess fr all clinic sites within the medical grup is identical, further review may be abbreviated at the discretin f the MNCM auditr. If clinic sites are nt in high cmpliance after review f the first eight recrds, the MNCM auditr will cntinue t review the remaining 22 recrds. If after review f all 30 recrds the clinic site is nt in high cmpliance n all factrs (less than 90%), the MNCM auditr will review the results with the clinic representative and cmmunicate the results with MNCM. MNCM will then cntact the medical grup t develp a mutually-agreed upn re-submissin plan. Re-submissin plans will nly be allwed fr errrs in the numeratr prtin. Clinic sites that are nt in high cmpliance r have nt been in high cmpliance in a previus MNCM audit may be held t a mre rigrus denminatr certificatin and validatin audit. Validatin Results: Once all clinics within a medical grup have passed the MNCM validatin prcess, MNCM will apprve the data in the MNCM Data Prtal, which generates and autmatic e-mail t the medical grup s data cntact that the data is verified and apprved. Please maintain the data submissin files and ther dcuments fr tw years. Page 38

Depressin Care Measures 2014 Instructins Clinic Preparatins fr the Validatin Audit All medical grups shuld plan fr a validatin audit. MNCM auditr will cntact medical grup t schedule the audit. MNCM will prvide list f sample recrds t be audited. Medical grup r clinic site representative must be available t participate in the entire audit prcess. Fr validatin audits using an EMR, a medical grup r clinic representative will retrieve and display the selected recrds and varius screens necessary t cmplete the validatin. During the audit, the patient s date f birth is used t verify the crrect recrd. All ther patient infrmatin may be blcked ut. Clinics must have the fllwing available at the time f the validatin audit: ALL requested patient recrds. The crsswalk between the unique patient identifier and the patient s name and DOB, s that the recrd can be lcated by clinic staff at the time f validatin audit. Data cllectin frms and ther ntes describing lcatin f data elements in patient recrd. List f patients that were excluded. After Validatin Audit Fllwing the successful submissin and validatin f the clinical data, medical grups can expect t see results psted in Nvember n the MN HealthScres website at www.mnhealthscres.rg. Results will als be included in the annual Health Care Quality Reprt later in the year. DDS results can als be fund n the RESULTS tab n the MNCM Data Prtal. Depressin Specific Results: A new functinality (reprting wizard) has been develped in the Results tab f the data prtal. The gal is t prvide users with the fllwing capabilities: Ease in selecting either prcess measure r utcme measure results. Prcess measures are based n the perid the cunts are submitted. Outcme measures like remissin are based n the patient s index cntact date. Prvide a patient level file back t the users; each medical grup can access their wn file f patients, similar t current functinality fr diabetes and vascular patients. Visit level depressin data that is submitted is nt helpful as n utput back t medical grups. This enhancement prvides the infrmatin summarized by patient (initial PHQ-9, six mnth PHQ-9 scre, achievement f remissin, etc.). This culd als be used t create r update a registry fr grups that are nt yet n an EHR. When selecting parameters fr the utcme measures, remember t specify nly the index cntact dates fr patients that wuld have enugh data. Fr example, if the mst current submissin is dates f service thrugh 05/31/2013 yu wuld need t cunt back seven mnths t get patients with enugh data t measure the six mnth remissin measure. Therefre the index cntact date wuld need t be in a range where the upper index cntact date limit is less than 10/31/2012. The prtal cannt pull data it des nt have, but yu may think yu are reprting n smething ther than what is available. Pay-Fr-Perfrmance Prgrams Medical grups will receive individual cmmunicatins frm health plans and MN Bridges t Excellence regarding their pay-fr-perfrmance prgrams that utilize DDS results. Page 39

Depressin Care Measures 2014 (02/01/2013 t 01/31/2014 Dates f Service) Appendices Page 40

Depressin Care Measures 2014 Appendices Appendix A Registratin n the MNCM Data Prtal Yur medical grup/clinic shuld be registered with MN Cmmunity Measurement. Registratin must be cmpleted prir t data submissin. Registratin must be cmpleted nce annually. Please refer t separate registratin instructins fr this prcess. A dwnladable registratin instructin guide is available n the MNCM Data Prtal. Please cntact MNCM if yu did nt register. PLEASE NOTE: If yur medical grup pened r clsed clinics after the 2014 Clinic and Prvider Registratin ended in February 2014, please cntact MNCM t discuss updating registratin and clinic infrmatin. Page 41

Depressin Care Measures 2014 Appendices Appendix B Resurces t Help Yu Get Started T identify yur ppulatin, cllect data, and get started in the data submissin prcess, MN Cmmunity Measurement ffers a selectin f resurces and tls. T access the resurces and tls fr Depressin measure, lg in t the data prtal at: https://data.mncm.rg and click n the RESOURCES tab. Select Depressin RESOURCES frm the drp-dwn menu. The Depressin RESOURCES screen cntains Frequently Asked Questins, Depressin Patient Assessment Tls and Depressin resurces. The dcuments yu will need t dwnlad include: Depressin Care Measures Data Cllectin Guide 2014 Depressin Care Measures 2014 Excel Template Depressin Care Measures 2014 Denminatr Template Depressin Care Measures 2014 Data Cllectin Frm (mst useful fr medical grups and clinics using paper recrds) Using Multiple Data Cllectrs Inter-Rater Reliability (IRR) Ideally, ne data cllectr r data cllectin prcess is preferred because it ensures that the data is cllected in ne cnsistent way. If, hwever, mre than ne persn will abstract data, we recmmend cnducting several sample audits with all abstractrs fr training purpses t imprve IRR. Internal training culd include a review f the guide and data cllectin frm, and instructins fr lcating infrmatin in the clinic s medical recrd. Als, refer t data cllectin errrs made in previus submissins, make plans t imprve the data cllectin prcess, and perfrm quality checks n the data. This ensures that the measurement specificatins are interpreted cnsistently and that the data is cllected in a unifrm way. Page 42

Depressin Care Measures 2014 Appendices Appendix C Timelines fr Data Submissin and Public Reprting Data Submissin Submissin fr the depressin measure fllws a file structure cnsisting f three separate measurement perids. The defined dates are t allw a +/- 30 day windw t btain a PHQ-9 scre within six mnths. Measurement Perid: Refers t the fur-mnth perid that is assciated with patient data files #1, #2 and #3. See belw fr specific measurement perid dates f service. Measurement Year: Refers t the twelve-mnth perid that encmpasses all measurement perids. The measurement year fr the Depressin Measure is 02/01/2013 t 01/31/2014. There are tw different timeline ptins fr submitting data fr the depressin measure. Regardless f what ptin is chsen, medical grups will need t submit the data in three separate files using the measurement perid dates f service utlined belw. Bth data submissin timeline ptins fulfill the requirements f the Minnesta Statewide Quality and Reprting Measurement System. Thse submitting via Timeline 1: Yu may use ne spreadsheet t cllect all f yur data fr the measurement year. Hwever, prir t uplading yur data yu will need t srt yur file by cntact date and then create three separate files fr the three measurement perids. Timeline 1: Yu will submit three separate files ne time after the end f the measurement year in sequential rder t the MNCM Data Prtal in February 2014. Yur data cllectin can ccur n ne master spreadsheet but the files will need t be separated by date f service befre submissin. Timeline 1: Grups Submitting in February 2014 (One time submissin) File Measurement Perid Dates Prtal Opens Prtal Clses File #1 02/01/2013 05/31/2013 File #2 06/01/2013 09/30/2013 02/03/2014 02/28/2014 File #3 10/01/2013 01/31/2014 Timeline 2: Yu will submit three separate files t the MNCM Data Prtal, ne file after the end f each f the measurement perids. Yu will submit the first file in June 2013, the secnd file in Octber 2013 and the third file in February 2014. In rder t submit thrughut the year, yu must adhere t these timelines. If yu miss the 06/30/2013 deadline, yu must then submit using Timeline 1. Timeline 2: Grups Submitting Three times during Measurement Year (Multiple submissins) File Measurement Perid Dates Prtal Opens Prtal Clses File #1 02/01/2013 05/31/2013 06/04/2013 06/29/2013 File #2 06/01/2013 09/30/2013 10/08/2013 10/31/2013 File #3 10/01/2013 01/31/2014 02/03/2014 02/28/2014 Page 43

Public Reprting Depressin Care Measures 2014 Appendices Since the reprting functinality needs t accunt fr the six and twelve-mnths (+/- 30 days) wrth f histry needed t calculate rates fr each patient, there is a lag time f when the six and twelve mnth rates are able t be calculated. Belw is the anticipated timeline fr reprted Depressin Measure rates n the MNHealthScres website. Depressin Measure Index Cntact Dates* Fllw-up Dates (Due t the +/- 30 Days, the dates d nt fall n mnth start/end days) Anticipated Reprting n MN HealthScres Six Mnth Fllw-up, Respnse and Remissin Measures 07/01/2008 t 06/30/2009 12/02/2008 t 01/30/2010 May 2010 07/01/2009 t 06/30/2010 12/02/2009 t 01/30/2011 May 2011 07/01/2010 t 06/30/2011 12/02/2010 t 01/30/2012 May 2012 07/01/2011 t 06/30/2012 12/02/2011 t 01/30/2013 May 2013 07/01/2012 t 06/30/2013 12/02/2012 t 01/30/2014 May 2014 Twelve Mnth Fllwup, Respnse and Remissin Measures 01/01/2009 t 12/31/2009 12/02/2009 t 01/30/2011 June 2011 01/01/2010 t 12/31/2010 12/02/2010 t 01/30/2012 June 2012 01/01/2011 t 12/31/2011 12/02/2011 t 01/30/2013 June 2013 01/01/2012 t 12/31/2012 12/02/2012 t 01/30/2014 June 2014 01/01/2013 t 12/31/2013 12/02/2013 t 01/30/2015 June 2015 01/01/2014 t 12/31/2014 12/02/2014 t 01/30/2016 June 2016 + Index Cntact Date is the date in which the patient meets inclusin criteria (diagnsis f majr depressin r dysthymia and PHQ-9 greater than 9) and serves as the anchr date frm which the measurement by date ccurs fr six and twelve mnth remissin. Utilizatin f PHQ-9 Tl Number f patients with majr depressin r dysthymia seen during the measurement perid (4 mnths) wh are administered at least ne PHQ-9 during that fur-mnth measurement perid. Dates f Service 10/01/2010 t 01/31/2011 May 2011 10/01/2011 t 01/31/2012 May 2012 10/01/2012 t 01/31/2013 May 2013 10/01/2013 t 01/31/2014 May 2014 Page 44

Appendix D Ntes abut the PHQ-9 Test Depressin Care Measures 2014 Appendices PLEASE NOTE: If yu have nt already implemented the PHQ-9 assessment tl in yur clinic, yu need t start in rder t participate in these measures, which are based n serial PHQ-9 assessments, and resulting scres. If yu need t btain a cpy f the PHQ-9 tl, please access www.phqscreeners.cm r yu can dwnlad a cpy frm the data prtal in the Resurces sectin. Please include the fllwing cpy right infrmatin n all PHQ-9 assessment tls utilized by clinicians. Develped by Drs. Rbert L. Spitzer, Janet B.W. Williams, Kurt Krenke and clleagues, with an educatinal grant frm Pfizer Inc. N permissin required t reprduce, translate, display r distribute. Prtal Functinality In rder fr the prgramming t crrectly evaluate each patient recrd, the file must be srted first by PatientID and then by Cntact Date with the cntact dates in ascending r ldest t newest rder. (e.g., A visit in March shuld be listed befre a visit in May). This allws the prtal prgram t evaluate each patient and incming visit recrd crrectly. Recrds that are ut f srt rder will nt have the index and fllw-up visits assigned apprpriately and will nt pass validatin audit. The prtal is structured t lk at each incming patient recrd accrding t Medical Grup ID and Patient ID t determine index visits and fllw-up cntacts. Fr patients wh HAVE NOT BEEN indexed: If a patient visit recrd is submitted t the prtal with the crrect diagnsis cdes but a lw PHQ-9 scre, this recrd will be rejected and the prtal will keep searching until a visit with diagnsis cdes and PHQ-9 greater than nine ccurs. Likewise, if a visit recrd is submitted with a high PHQ-9 scre but n assciated diagnsis cdes, the recrd will be rejected. Fr patients wh HAVE BEEN indexed: All subsequent visits are allwed t match up t that patient. This is t allw fr the varius settings in which a PHQ-9 can be administered (phne, e-visit r ther type f visit) fr which there may nt be a diagnsis cde r insurance infrmatin. If the patient des nt yet have an index visit and ther diagnsis cdes are submitted, the recrds cntaining the ther diagnsis will cause an errr n file submissin and will need t be remved. The index visit recrd will cntain the infrmatin that is stred fr each patient. This recrd cntains the clinic ID, the prvider ID, gender, zip cde, diagnsis cde and insurance cverage infrmatin. The clinic site and the prvider ID that are a part f the indexed visit is where the patient will be attributed t. The insurance cverage will be updated if it changes, but the rest f this recrd will remain the same. A patient s measurement perid will end 13 mnths frm the activatin date; this allws fr the +30 days t btain subsequent PHQ-9 scres. If, after this pint a patient des meet the inclusin criteria again by having a PHQ-9 scre abve nine; a new index/re-activatin recrd will be created and measurement will start ver fr his patient. In these situatins, the patient is still meeting criteria fr inclusin. Page 45

Depressin Care Measures 2014 Appendices Appendix E Explaining the Depressin Measures t Prviders and Clinical Staff These measures apply t patients wh are diagnsed with majr depressin r dysthymia; either newly diagnsed r have existing depressin. If yu are cding a patient s visit as 296.2x, 296.3x r 300.4, the cdes fr majr depressin r dysthymia, then yu shuld als be using the PHQ-9 tl. Need t have bth f the fllwing: A cnfirmed diagnsis f majr depressin r dysthymia and a PHQ- 9 scre greater than nine in rder t be eligible fr the measure denminatr. Patients are nt eligible t be included in the measure denminatr based n PHQ-9 scre alne. Fr behaviral health prviders, the diagnses need t be in the primary psitin. Fr primary care prviders, the diagnses are either primary r secndary (any psitin). It is an expectatin that patients with majr depressin r dysthymia are assessed n an nging basis using the PHQ-9 tl and that the PHQ-9 is used with every patient visit; hwever MNCM cannt dictate hw frequently yu administer the PHQ-9 t yur patients. It is ur experience that grups that are nly trying t btain a six mnth scre miss the benefits re-assessment f patient status and need fr interventin sner that the pint f measurement. Once the patient is identified as having depressin and an elevated PHQ-9 scre (inclusin criteria), then any time a PHQ-9 is administered, the scre needs t be included in the submissin, regardless f the reasn fr the visit/cntact. Each patient s starting pint is different (index visit). Fr the six mnth remissin measure, a windw f time is allwed t cnnect with the patient, either 30 days prir t the six mnth date r 30 days after the six mnth date. It takes seven mnths f data cllectin t reprt the utcme f the six mnth measure. The data prtal calculates the reprting perid fr each patient by date. Only scres within this 60 day windw cunt twards measuring remissin. The mst recent PHQ-9 scre within this windw is the scre that will be used. Remissin is defined as a PHQ-9 scre f less than five. This crrespnds with the validated PHQ-9 tl interpretatin f scres: 0 t 4 N depressive symptms 5 t 9 Mild depressin 10 t 14 Mderate depressin 15 t 19 Mderately severe depressin 20 t 27 Severe depressin Patients wh are nt assessed within the 60 day windw are cnsidered t nt be in remissin and are cunted in the denminatr f the remissin measure. Rate is calculated as fllws: # adult pts with a PHQ-9 scre < 5 at 6 mnths (+/- 30 days) # adult pts with depressin with index cntact PHQ-9 > 9 The patient data file is structured at the visit/cntact level. Fr example, a patient seen and assessed in February, June and August wuld have three recrds in the file, ne fr each PHQ-9 scre btained. There are several measures that are captured thrugh a single file submissin prcess. Page 46 X 100

Appendix F Suite f Available Depressin Care Measures Depressin Care Measures 2014 Appendices The fllwing is a list f measures fr the depressin ppulatin. All f these measures are calculated based n the ppulatin cunts and file submissin f patients meeting inclusin criteria, n additinal calculatins r submissins are required frm the medical grups. Nt all measures will be used fr public reprting r payer reward prgrams, but all rates will be available t the medical grups fr internal use and quality imprvement purpses. Measure and Purpse Definitin Reprting* #1 Percentage f the adult ppulatin with majr depressin r dysthymia during the measurement perid Prevalence f depressin Calculated frm clinic level ppulatin cunts #2a Percentage f the adult ppulatin with unspecified depressin diagnsis during the measurement perid Calculated frm clinic level ppulatin cunts Adults age 18 and lder with a diagnsis f majr depressin r dysthymia with at least ne visit t an eligible prvider during the measurement perid. ICD-9 cdes: 296.2x - Majr Depressive disrder, single episde 296.3x Majr depressive disrder, recurrent episde 300.4x Dysthymic Disrder # adult patients with depressin (296.2x, 296.3x and 300.4) ttal # adult patients Adults age 18 and lder with a diagnsis f Depressin; Nt Otherwise Specified with at least ne visit t an eligible prvider during the measurement perid ICD-9 cdes: 311 - Depressive disrder, nt elsewhere classified # f adult patients with diagnsis f depressin nt elsewhere classified (311) # ttal adult patients Nte: If a patient has bth cdes during the measurement perid (311 and ne f the majr depressin r dysthymia cdes) cunt the patient as having majr depressin r dysthymia, nt depressin NOS Internal Internal Page 47

Depressin Care Measures 2014 Appendices Measure and Purpse Definitin Reprting* #2b Percentage f the adult ppulatin with depressin wh have unspecified depressin diagnsis during the measurement perid Ptential fr veruse f 311 Calculated frm clinic level ppulatin cunts #3 Percentage f the adult ppulatin with majr depressin r dysthymia wh had a PHQ-9 during the measurement perid Prcess supprting implementatin and use f PHQ-9 Calculated frm clinic level ppulatin cunts #4 Percentage f the adult ppulatin with majr depressin r dysthymia whse index PHQ-9 scre is greater than nine Calculated frm clinic level ppulatin cunts and patient level file Adults age 18 and lder with a diagnsis f depressin during the measurement perid. This measure is tracking the rate f the use f 311 unspecified depressin as a percent f all patients diagnsed with depressin. # f adult patients with diagnsis f depressin nt elsewhere classified (311) (# adult patients with 311) + (# adult patients with 296.2x, 296.3x and 300.4) Percent f patients with a diagnsis f majr depressin r dysthymia (296.2, 296.3 r 300.4) with a cmpleted PHQ-9 during the measurement perid. This measure is determining the rate f the use f the PHQ-9 tl fr the medical grup s ppulatin f patients with majr depressin r dysthymia. # adult pts with depressin (296.2x, 296.3x and 300.4) wh had a PHQ-9 administered # adult patients with depressin (296.2x, 296.3x and 300.4) Percent f patients with a diagnsis f majr depressin r dysthymia (296.2, 296.3 r 300.4) with a cmpleted PHQ-9 during the measurement perid whse PHQ-9 scre is greater than nine. # adult pts with depressin (296.2x, 296.3x and 300.4) and PHQ-9 > 9 # adult pts with depressin (296.2x, 296.3x and 300.4) wh had a PHQ-9 administered Nte: Index cntact is the first cntact with cnfirming diagnsis and PHQ-9 scre is greater than nine; serves at the starting measurement pint fr each patient included in the denminatr. Internal Public Internal Page 48

Depressin Care Measures 2014 Appendices Measure and Purpse Definitin Reprting* Six mnth PHQ-9 scres are calculated frm the index cntact date with a grace perid f 60 days, + 30 r - 30 days frm the date f the index cntact. The mst recent PHQ-9 scre within this windw is the scre that will be used. #5 PHQ-9 fllw-up assessment at six mnths Prcess supprting the achievement f the utcme f remissin Calculated frm patient level file #6 PHQ-9 with a 50 percent r mre decrease in scre (respnse) at six mnths Intermediate utcme measure twards the gal f remissin Calculated frm patient level file #7 PHQ-9 scre < five (remissin) at six mnths Outcme measure demnstrating imprvement in depressin symptms Calculated frm patient level file Percent f patients with a diagnsis f majr depressin r dysthymia (296.2, 296.3 r 300.4) and a PHQ-9 scre at the index cntact is greater than nine wh have a fllw-up PHQ-9 test at six mnths frm the index cntact date. # adult pts with depressin and PHQ-9 > 9 wh have 6 mnth PHQ-9 (+/- 30 days) # adult pts with depressin with index cntact PHQ-9 > 9 Based n the denminatr f patients with majr depressin r dysthymia (296.2, 296.3 r 300.4) whse initial PHQ-9 is greater than nine, the percent f patients wh have a reductin in their PHQ-9 scre at six mnths by 50 percent r greater. Fr example, if a patient s initial PHQ-9 was 21 and the six mnth PHQ-9 is 10, this patient has achieved a respnse utcme. # adult pts with >/= 50% decrease in PHQ-9 scre at 6 mnths(+/- 30 days) # adult pts with depressin with index cntact PHQ-9 > 9 Based n the denminatr f patients with majr depressin r dysthymia (296.2, 296.3 r 300.4) whse initial PHQ-9 is greater than nine, the percent f patients whse six mnth PHQ- 9 scre is less than five. Fr example, if a patient s initial PHQ-9 was 10 and the six mnth PHQ-9 is 3, this patient has achieved a respnse utcme. # adult pts with a PHQ-9 scre < 5 at 6 mnths(+/- 30 days) # adult pts with depressin with index cntact PHQ-9 > 9 Public Public Public and Payer Reward Prgrams, Required fr MDH Page 49

Depressin Care Measures 2014 Appendices Measure and Purpse Definitin Reprting* 12 mnth PHQ-9 scres are calculated frm the index cntact date with a grace perid f 60 days, + 30 r - 30 days frm the date f the index cntact. The mst recent PHQ-9 scre within this windw is the scre that will be used. #8 PHQ-9 fllw-up assessment at twelve mnths Prcess supprting the achievement f the utcme f remissin Calculated frm patient level file #9 PHQ-9 with a 50 percent r mre decrease in scre (respnse) at twelve mnths Intermediate utcme measure twards the gal f remissin Calculated frm patient level file #10 PHQ-9 scre < five (remissin) at twelve mnths Outcme measure demnstrating imprvement in depressin symptms Calculated frm patient level file Percent f patients with a diagnsis f majr depressin r dysthymia (296.2, 296.3 r 300.4) and a PHQ-9 scre at the index cntact is greater than nine wh have a fllw-up PHQ-9 test at twelve mnths frm the index cntact date. # adult pts with depressin and PHQ-9 > 9 wh have 12 mnth PHQ-9 (+/- 30 days) # adult pts with depressin with index cntact PHQ-9 > 9 Based n the denminatr f patients with majr depressin r dysthymia (296.2, 296.3 r 300.4) whse initial PHQ-9 is greater than nine, the percent f patients wh have a reductin in their PHQ-9 scre at twelve mnths by 50 percent r greater. This is the definitin f a respnse. Fr example if a patient s initial PHQ-9 was 16 and the twelve mnth PHQ-9 is 8, this patient achieved a respnse utcme. # adult pts with >/= 50% decrease in PHQ-9 scre at 12 mnths # adult pts with depressin with index cntact PHQ-9 > 9 Based n the denminatr f patients with majr depressin r dysthymia (296.2, 296.3 r 300.4) whse initial PHQ-9 is greater than nine, the percent f patients whse twelve mnth PHQ-9 scre is less than five. Fr example if a patient s initial PHQ-9 was 11 and the twelve mnth PHQ-9 is 4, this patient achieved a respnse utcme. # adult pts with a PHQ-9 scre < 5 at 12 mnths # adult pts with depressin with index cntact PHQ-9 > 9 Public Public Public * The fllwing are definitins f reprting audiences: Internal = Medical grups will see their wn results and data may be used fr reprting at a summary statewide level, but nt used fr public reprting at a clinic site level. Public = Measure rates will be reprted publically by clinic site n the MNCM website and in the Health Care Quality reprt. Payer = Measure rates will be used fr payer reward prgrams. Page 50

Depressin Care Measures 2014 Appendices Appendix G Abut MN Cmmunity Measurement and Measure Develpment Missin and Visin f MN Cmmunity Measurement (MNCM) The missin f MN Cmmunity Measurement is t accelerate the imprvement f health by publicly reprting health care infrmatin. MN Cmmunity Measurement s visin is t: Be the trusted surce fr perfrmance measurement and public reprting f quality data acrss the spectrum f health care that; Drive change twards mre safe, effective, patient centered, timely, efficient, and equitable care; Be a resurce used by prviders t imprve care and patients t make better decisins; and Catalyze ur cmmunity t wrk tgether n health care measurement t reduce administrative csts and maximize value. Abut the Measure Develpment Measures are selected accrding t MN Cmmunity Measurement s Strategic Measurement Develpment Prcess. An impact and recmmendatin dcument presents the tpic fr discussin at the Measurement and Reprting Cmmittee (MARC). Tpics fr measure develpment must meet the fllwing criteria fr cnsideratin f develpment: Will the measure/s make a difference? Degree f impact Degree f imprvability Degree f inclusiveness Degree f perfrmance variatin Outcme measures desired Will the measure imprve care by affecting the patient/physician relatinship? Pass the feasibility test (resurces/barriers/culture) Align with natinal, reginal and lcal pririties Relevant t cnsumers Supprt and enhance the patient/prvider relatinship Impact f Majr Depressin and Dysthymia Accrding t Natinal Institute f Mental Health (NIMH), 6.7 percent f the U.S. ppulatin ages 18 and lder (14.8 millin peple) in any given year have a diagnsis f a majr depressive disrder. Majr depressin is the leading cause f disability in the U.S. fr ages 15-44 1. Additinally, dysthymia accunts fr an additinal 3.3 1 Natinal Institute f Mental Health www.nimh.nih.gv The Numbers Cunt: Mental Disrders in America 2008 Page 51

Depressin Care Measures 2014 Appendices millin Americans. The Center fr Disease Cntrl and Preventin states that 15.7% f peple reprt being tld by a health care prfessinal that they had depressin at sme pint in their lifetime. Persns with a current diagnsis f depressin and a lifetime diagnsis f depressin r anxiety were significantly mre likely than persns withut these cnditins t have cardivascular disease, diabetes, asthma and besity and t be a current smker, t be physically inactive and t drink heavily. 2 Suicide rates fr Minnestans are 10.4 per 100,000 r 1.3 suicides per day, with the highest rates amng the fllwing grups: Males (4 times greater than females), ages 30 t 49 years, and nn-hispanic whites. 3 Depressin Care in Minnesta Effrts t imprve care and utcmes fr patients with depressin have been accelerated in Minnesta by tw related initiatives. DIAMOND- Depressin Imprvement Acrss MN, Offering a New Directin is a new care mdel with payment restructuring and utcme measurement; primary care clinics are participating in this prject. MN Cmmunity Measurement (MNCM) is partnering with Bridges t Excellence (BTE), Minnesta Department f Health and ther payers t prvide depressin utcme measurement fr all adults with majr depressin r dysthymia wh are treated in a primary care r behaviral health setting. Patient utcmes fr bth f these initiatives are tracked accrding t the patient s PHQ-9 depressin scres ver time. What is the difference between DIAMOND and MNCM Depressin? Measures fr the tw initiatives are the same in terms f six and twelve mnth utcmes fr depressin; hwever, the patient ppulatins are slightly different. DIAMOND is measuring thse patients wh agree t be in the new care mdel, whereas MNCM measures are applied the whle adult ppulatin f patients with majr depressin r dysthymia. DIAMOND clinics that want t participate in the BTE prgram need t submit data fr all their patients with depressin. DIAMOND is als capturing additinal measures fr the care management prcess. Fr mre infrmatin abut the DIAMOND initiative, please access the ICSI website at www.icsi.rg. MNCM Depressin All patients with majr depressin and a PHQ-9 scre greater than nine Full ppulatin reprting Data cllectin three times/year (r annual submissin f three separate files) DIAMOND Only reprting fr patients with depressin and a PHQ-9 scre greater than nine wh pt in t the care mdel Partial ppulatin reprting Mnthly Data Cllectin Additinal data elements and measures S, fr thse clinics participating in DIAMOND Submit all yur patients with depressin, nt just thse wh enrlled in DIAMOND 2 Centers fr Disease Cntrl and Preventin 2006 Behaviral Risk Factr Surveillance 3 Suicide Preventin Resurce Center www.sprc.rg/stateinfrmatin Minnesta Suicide Preventin Fact Sheet Page 52

Depressin Care Measures 2014 Appendices Hw is the Depressin Submissin Different frm Other DDS Measures? Example: Diabetes Measure A snapsht with a retrspective lk back Over the last year what was the value f the mst recent A1c File = Patient Level Recrds; ne rw fr each patient Annual submissin Depressin Measure Prspective, lking frward. Lngitudinal ver time Patients meet inclusin criteria and then measured fr utcme at six mnths File = Visit Level Recrd; a single patient has many rws ne fr each cntact with PHQ-9 test administratin Three times a year submissin (Or annual submissin f three separate files) Page 53

Depressin Care Measures 2014 Appendices Appendix F Abut (DDS) The gal f (DDS) is t cllect data frm medical grups n specific health care cnditins and publicly reprt cmparable rates f health care quality at the clinic site level. All medical grups fllw the same instructins fr ppulatin identificatin and data cllectin. MNCM certifies methdlgies prir t data cllectin. Then, each medical grup submits data t MNCM via a secure, nline data prtal. As an independent auditr and as a service t each medical grup, MNCM validates the data fr accuracy, calculates rates frm the validated data, and publicly reprts the data n the MNCM Web site www.mnhealthscres.rg. Required Reprting DDS fulfills participatin requirements fr the Minnesta Department f Health s Minnesta Statewide Quality Reprting and Measurement System as well as ther health plan pay-fr-perfrmance prgrams and Minnesta Bridges t Excellence. In additin, DDS results can be used by medical grups fr quality imprvement purpses. Health Care Hmes If yur medical grup has prviders r clinics that are certified by the Minnesta Department f Health as a health care hme then yu will need t enter the patient s primary care prvider NPI in the data file. Please nte the additinal health care hme data fields have been remved frm the specificatins and are NOT part f data submissin fr health care hmes. DDS Terms and Cnditins T participate in the DDS prcess, medical grups must agree t: MNCM s DDS terms and cnditins (sign electrnically n the MNCM Data Prtal). Cmplete a Business Assciate Agreement with MNCM (signed electrnically n the MNCM Data Prtal). Submit a patient-level file t the secure MNCM Data Prtal that autmatically calculates rates. Participate in the data validatin prcess as required by MNCM. Have results publicly reprted n www.mnhealthscres.rg and ther reprts. Submit data fr ALL clinic sites. Submit data in required frmat (.csv). Submit data in gd faith. Adhere t and fllw all data submissin timelines and frmatting specificatins. Medical grups als understand that: MNCM wrks with crrespnding health plans t determine Primary payer type (Cmmercial/Private, Medicaid, Medicare, uninsured/self/pay) n yur behalf t reduce burden The MN Bridges t Excellence prgram and mst Minnesta health plans nly accept results generated frm the DDS methd fr their incentive prgrams, because the results can be validated Page 54

Depressin Care Measures 2014 Appendices Cmpliance with Federal and State Regulatins Our legal cunsel has assured us that the DDS methd cmplies with applicable prvisins f the Health Insurance Prtability and Accuntability Act (HIPAA), Health Infrmatin Technlgy fr Ecnmic and Clinical Health (HITECH) Act, and Minnesta statute as lng as we are acting as a business assciate t each participating medical grup (e.g., by gathering and submitting data n its behalf) and have a signed Business Assciate Agreement (BAA) with the medical grup. The BAA can be signed electrnically n the MNCM Data Prtal, r MNCM is pen t signing a medical grup s standard BAA dcument versin if certain key prvisins frm MNCM s BAA are added t the grup s standard BAA. The BAA is signed nce and remains in effect fr all DDS measures. Health Insurance Prtability and Accuntability Act (HIPAA) Law: The activities f data cllectin, data submissin, public reprting and use f results fr quality imprvement are cnsidered within the scpe f health care peratins assciated with the medical grup quality imprvement effrts. The federal HIPAA law specifically allws release f individually identifiable health infrmatin - withut the cnsent r authrizatin f the individual - fr treatment, payment and health care peratins f, r fr, the prvider. MNCM s business assciate agreement has been updated t include all prvisins required by the HITECH Act and its implementing regulatins. Minnesta Statute: The primary gverning Minnesta statute is MN Stat. Sectin 144.335. Subd. 3a. entitled "Patient cnsent t release f recrds; liability" states: (a) A prvider, r a persn wh receives health recrds frm a prvider, may nt release a patient's health recrds t a persn withut a signed and dated cnsent frm the patient r the patient's legally authrized representative authrizing the release, unless the release is specifically authrized by law. Hwever, the statute des nt restrict release (withut patient authrizatin) t nly thse circumstances authrized by state law the statute als applies t a release authrized by federal law. Legal cunsel assures us that it is reasnable t cnclude that the HIPAA privacy regulatin des specifically authrize the release f such infrmatin. A cvered entity is authrized by HIPAA t release patient infrmatin fr, amng ther things, health care peratins and t its business assciate that is prviding such health care peratins n its behalf. As stated abve, the services MNCM is engaged in with prviders falls within the scpe f health care peratins, and MNCM is acting as a business assciate t the medical grups when perfrming the services discussed abve. Page 55