Anthem Pay-for- Performance (HEDIS )*

Transcription

1 Serving Hoosier Healthwise, Healthy Indiana Plan Anthem Pay-for- Performance (HEDIS )* [Candace Adye, RN Amanda Gonzalez, RN] *HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2 Objectives Define HEDIS and identify key preventive service measures Review P4O criteria Highlight HEDIS measures and documentation examples Examine tools for success 2 2

3 What is HEDIS? A registered trademark of the National Committee for Quality Assurance HEDIS = Healthcare Effectiveness Data and Information Set Retrospective review of services and performance of care Used by more than 90% of America s health plans; allows for comparison between plans 3 3

4 HEDIS information is collected in two ways Administrative data obtained from our claims database Hybrid data obtained from claims and medical record reviews; this method allows for data collection that is not available through claims, such as: o Childhood immunizations o Body mass index or percentile o Specific blood pressure measures 4 4

5 P4O

6 P4O 2016 (cont.) 6 6

7 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) compared to HEDIS EPSDT required components: Comprehensive health and developmental history, including review of both physical and mental health development Comprehensive unclothed physical exam Nutritional assessment Vision and hearing screenings Dental observation Laboratory tests, including a blood lead toxicity screening (as appropriate) Appropriate immunizations according to age and health history Health education, including anticipatory guidance (This is often provided but frequently not documented.) 7 7

8 EPSDT compared to HEDIS (cont.) HEDIS required components: Well-infant visits (W15) measure six or more well-care visits completed by 15 months Well-child visits (W34) measure 3 to 6 years old Adolescent well care (AWC) measure 12 to 21 years old All visits must have the following documented: Physical exam Growth and development, physical and mental Anticipatory guidance 8 8

9 Medical record review best practices and lessons learned Well-child: AWC, W34, W15 o Anticipatory guidance o Health history o Providers missing opportunities to bill well visits with their sick visits If a member is seen for a problem/sick visit and well-care visit during the same date of service, the problem/sick visit can be billed separately using modifier 25. The problem/sick visit requires additional moderate level evaluation to qualify as a separate service on the same date. 9 9

10 Example Well-child documentation 10 10

11 W34 Identify on each page: Patient name DOB Provider name Date of encounter 11 11

12 W34 (cont.) Identify on each page: Patient name DOB Provider name Date of encounter 12 12

13 W34 (cont.) Identify on each page: Patient name DOB Provider name Date of encounter 13 13

14 W34 (cont.) Identify on each page: Patient name DOB Provider name Date of encounter 14 14

15 Lead screening Indiana Health Coverage Program requires every Medicaid-eligible child to receive at least one capillary or venous lead blood test at 12 months of age and before the child s second birthday. Documentation must include a note indicating the date the test was performed and the result of the test. Children 3 to 6 years of age who have never been tested need to be screened regardless of their risk factors. MEDTOX offers a sample kit at no charge. Contact Medtox at [ or visit medtox.com] for more information. Your office is reimbursed for this collection by utilizing CPT code Lead assessment does not constitute a lead screening

16 W34 Behavioral Health example Identify on each page: Patient name DOB Provider name Date of encounter 16 16

17 W34 Behavioral Health example (cont.) Identify on each page: Patient name DOB Provider name Date of encounter xxxxxxxxxxxxxxxxxxxxxxxxxxx 17 17

18 W34 Behavioral Health example (cont.) Identify on each page: Patient name DOB Provider name Date of encounter 18 18

19 Best practices for weight, nutritional and physical activity (WCC) Recommendations for pediatric practices: Continue to build parent-provider relationships Address and educate parents on BMI Address and advise parents on children s weight status at each visit Engage in conversation with children and parents on eating habits Provide available resources, counseling and nutritional services to parents Engage in conversation about increasing activity, limiting television and video games, and engaging in age-appropriate sports Provide and document anticipatory guidance on nutrition and activity 19 19

20 Best practices for weight, nutritional and physical activity (WCC) (cont.) Common chart deficiencies: BMI documented as number not percentile based on height, weight, age and gender Anticipatory guidance does not always specify what areas were addressed and is not always age appropriate Electronic medical record data rolls from visit to visit, and preprinted forms do not always address nutrition and physical activity Developmental milestones do not constitute anticipatory guidance or education 20 20

21 Adolescent well care anticipatory guidance Substance use/abuse Nutrition Alcohol Diet Street drugs Appropriate weight Prescription drugs Eating disorders Physical activity Smoking Sexuality/sexually transmitted diseases (STD) Health consequences STD/AIDS prevention Cessation counseling Partner selection Birth control/condom Violence/injury prevention Emotional well-being Gun safety Depression/anxiety screen Seat belts/safe driving Peer pressure/bullying Helmets Interpersonal relationships 21 21

22 What s important to an adolescent? Graph courtesy of Donovan C et al. Br J General Practice, :

23 Adult access to preventative/ambulatory health services (AAP) Documentation of an ambulatory or preventive care visit during the measurement year For members 19 years and older ICD-10 CM: Z00.00, Z00.01, Z00.8, Z02.0, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.70, Z02.81, Z02.83, Z02.89, Z02.9 CPT: , , , , , , , , 99411, 99412, 99420, 99429, 92002, 92004, 92012, 92014, , 99315, 99316, 99318, ,

24 How can Anthem Blue Cross and Blue Shield (Anthem) help you close AAP gaps? Your practice consultant will: Help you access monthly panel reports Provide gap-in-care reports Strategize with practice leaders on how to close gaps: o Anthem clinic days o Service Navigator project o Create a health care event o Involve our Anthem Connect team to work specifically with your members on outcome improvement 24 24

25 Adult preventive care Exam: History/physical/social Blood pressure Weight, height, BMI Adult immunizations Smoking/alcohol/substance abuse Age-appropriate/annual screenings: Tuberculosis Cervical cancer screening Mammogram Colorectal Chlamydia Cholesterol 25 25

26 Cervical cancer screening Cervical cancer screening for women 21 to 64 years of age using either of the following criteria: Women ages 21 to 64 years who had cervical cytology performed every three years Women ages 30 to 64 years who had cervical cytology/human papillomavirus (HPV) co-testing performed every five years If you refer out for screening, obtain copy of results and record date for test and results in member s medical record 26 26

27 Cervical cancer screening (cont.) The following do not qualify: Lab results indicating inadequate sample or no cervical cells Referral to OB/GYN alone Biopsies are considered diagnostic History of hysterectomy: Record total or complete hysterectomy as applicable 27 27

28 Breast cancer screening (cont.) Women ages 40 to 69 years: One mammogram breast screening every two years The purpose of the breast cancer screening measure is to evaluate primary screening Documentation must include mammogram results or record date of test and result HEDIS does not consider breast ultrasounds, biopsies or MRIs to be appropriate primary screening methods 28 28

29 Breast cancer screening (cont.) Exclusions: Women who have had a bilateral mastectomy (may occur on the same or separate dates) 29 29

30 Comprehensive diabetes care Members ages 1 to 64 years: Documentation requirements (date and result) Hemoglobin A1c test and result LDL Lipid screening test and result Nephropathy: urine tests, angiotensin receptor blockers (ARB), angiotensin converting enzyme (ACE) inhibitors prescriptions or visits to nephrologists Retinal eye exam Blood pressure (BP) documented (BP control is < 140/80 or < 140/90) 30 30

31 Comprehensive diabetes care (cont.) Best practices Retake elevated blood pressures Documentation of prescription for ACE or ARB in measurement year Yearly screenings ordered, follow up for compliance, results documented Exclusions Evidence of gestational or steroid-induced diabetes or polycystic ovary disease 31 31

32 Adult vaccines Recommended immunizations for adults age 19 years and older if risk factors warrant: Pneumococcal: ages 19 to 64 years 1 to 2 doses Hepatitis A: age 19 years and older 2 doses Hepatitis B: age 19 years and older 3 doses Meningococcal: ages 19 to 65 Annual flu vaccine 32 32

33 Medical record review best practices and lessons learned All measures o Initials and signature pages, plus key or index o Very important for frequency of ongoing prenatal care (FPC)/prenatal and postpartum care (PPC) to document the rendering provider (this should not be a nurse) o Member name and DOB on every page o Use standardized templates (for example, The American Congress of Obstetricians and Gynecologists) for records when applicable o Conduct preventive service during sick visits as appropriate and include documentation in the patient record 33 33

34 Medical record review best practices and lessons learned (cont.) Providers o Check membership panels monthly o Review gap-in-care reports and call to schedule members preventive services 34 34

35 Tools to improve completion of preventive services Blue Ticket to Health Anthem clinic days Various forms including: o Well-child documentation forms o Member outreach o Member deletion ER utilization reports Provider and member education collateral Provider and member incentives Health Needs Screening available in kiosks at Walmart pharmacies 35 35

36 Thank you is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC [September 2016] 36 36