Reporting Performance Measures. An Introduction for PCPs & Staff Nov. 4, 2016

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Jayson Cobb
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1 Reporting Performance Measures An Introduction for PCPs & Staff Nov. 4, 2016

2 Agenda Prepare Now for 2017 Patient Attribution Reporting Performance Measures Monthly Payment and Claims 121

3 Important Reminders about Reporting Measures All codes on claims submitted to HMSA, whether claim line is approved or denied, are captured for numerator credit in Cozeva Some CPT codes used in reporting may trigger member copayments Please consider coding options that will minimize impact on your patients 122

4 Reminders about Benefits New! Some performance measures are recognized as Affordable Care Act (ACA) preventive services that have no member copayment when a specific combination of procedure code and diagnosis code is billed Check on HHIN to determine if member has a commercial HMSA ACA-compliant plan On HHIN, look under Special Instructions heading for text: This is a Non-Grandfathered Patient Protection and Affordable Care Act (PPACA) Compliant Plan. HHIN displays ACA benefits under Routine Preventive Care for HMO plans, and under Preventive Services for PPO and ACA Individual HMO Metallic plans 123

5 Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Influenza vaccine (ages 18 and older). Does not have to be administered by PCP Influenza vaccine CPT codes --Standard trivalent flu vaccine Preservative-free flu vaccine 90654, 90656, 90661, Nasal spray flu vaccine Quadrivalent flu vaccine 90686, HCPCS codes: Q2034-Q2039 (suggested) Z23 Encounter for immunization New! Supplemental reporting on Cozeva will be allowed for flu shots. Medical record evidence must include: name and title of individual who gave shot; date of administration; vaccine product and route of administration. 124

6 Reporting Adult Measures New! Measure Influenza vaccine (ages 18 and older). When patients report they got their flu shots Procedure Code 4037F Influenza immunization ordered or administered 4274F Influenza immunization administered or previously received Supplemental Data Documentation Requirements for 4037F and 4274F Medical record evidence must include the date the physician administered the vaccine or the date the physician confirmed with the patient that they received the vaccination during the measurement year 125

7 Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Screening for symptoms of clinical depression and anxiety (ages 18 and older) Brief emotional/ behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument G0444 with mod 59 Annual depression screening, 15 minutes 3725F Screening for depression performed *Z13.89 Encounter for screening for other disorder *Credit will be given based on No member copayment when code combination Z13.89 is used for ACA-compliant plans For Akamai Advantage members: use G0444 with mod 59 New! Depression screening may be done by PCP via telephone, if appropriate, but must be fully documented in medical record 126

8 Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Non-tobacco user: G9459 Currently a tobacco non-user [for members 20 years and younger] or G9275 Documentation that patient is a current non-tobacco user or 1036F Current tobacco non-user New! Tobacco screening may be done by the PCP via telephone, but must be fully document in medical record 127

9 Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Option 1: 1 proc code Tobacco user: G9458 Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco cessation program) if identified as a tobacco user [for members 20 years and younger] (suggested*) Z72.0 Tobacco use or Z Personal history of nicotine dependence *Credit given based on the G9458. These ICD-10 codes are optional. If G9458 is used for patients over 20 it will deny at the claim line level with a message about patient age, but credit still given in Cozeva 128

10 Reporting Adult Measures Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Option 2: 1 proc code + 1 DX code Tobacco user: Smoking and cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes Smoking and cessation counseling visit; intensive, greater than 10 minutes + New! Z72.0 Tobacco use *Z Personal history of nicotine dependence *F Nicotine dependence, unspecified, uncomplicated *F Nicotine dependence, cigarettes, uncomplicated * No copayment when these code combinations are used with ACA-compliant plans Time-based G0436 and G0437 not recognized after dates of service 9/30/16 129

11 Reporting Adult Measures Measure Tobacco screening and cessation counseling (ages 18 and older) Option 3: 2 DX codes Procedure Code ICD-10 Tobacco user: Z72.0 Tobacco use or Z Personal history of nicotine dependence + Z71.6 Tobacco abuse counseling 130

Sharecare RealAge Assessment New! Commercial members 18 and older who complete Sharecare RealAge assessment at least once during the measurement year.

12 Sharecare RealAge Assessment New! Commercial members 18 and older who complete Sharecare RealAge assessment at least once during the measurement year. Gauges how fast you re aging based on lifestyle and medical history. Replaces Well-Being 5 More information to be provided. Explore at 131

13 Pediatric Measures and Due Dates New! Birthday rule: Measures with due dates determined by child s birthday Well-child visits before age 15 months (birthday plus 90 days) Childhood immunizations second birthday Developmental screenings before the child s first, second or third birthday Calendar-year rule: Measures that count only if completed in that calendar year Well-child visits in third to sixth years of life any visit during the measurement year will count (can be before or after birthday), but at least 9 months since previous well-child visit Adolescent well-care any visit during the measurement year will count but at least 9 months since previous well-care visit 132

14 Early-Borns and Late-Borns New! Well-child visits in third to sixth years need to be completed in the calendar year for PCP to receive numerator credit Examples: Kawika turns 6 in January 15, Although his parents prefer a well-child visit before Christmas 2016, he needs to wait until January 2017 for the well-child visit to count for numerator credit for calendar year Kuulei turns 6 on December 28, Visit should be scheduled before end of If the well-visit occurs in January 2018, the visit will not count for numerator credit because Kuulei turns 7 in

15 Aging into Measures New! Calendar-year view: Cozeva displays all members who are eligible for a measure if they will be the qualifying age as of December 31 Example: Immunizations for adolescents required for members by their 13 th birthday Cozeva populates measure registry with all members born in year 2004 as the denominator. Patients are 12 at the beginning of the year and 13 at the end of the year. When required shots (meningococcal and Tdap) are given by child s 13 th birthday, PCPs receive numerator credit 134

16 Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Developmental screening in 12 months before child s 1 st, 2 nd, and 3 rd birthdays CSHCN Screener (Ages 3-17, done every 3 years) HA modifier Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument Screening done; positive finding for chronic or special health care needs: E/M CPT code +HAmodifier + Z Screening done; negative finding: E/M CPT code +HAmodifier * No copayment when code combination used with ACA-compliant plans HA HCPCS code modifier = Child/adolescent program (suggested) * Z Encounter for routine child health examination without abnormal findings * Z Encounter for routine child health examination with abnormal findings Z Personal history of other specified conditions 135

17 Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Adolescent well-care visit (ages 12-21) Initial comprehensive preventive medicine evaluation and management new patient [age-based] Periodic comprehensive preventive medicine reevaluation and management established patient [age-based] (suggested*) Age 15 and older: Z00.00 General adult medical examination without abnormal findings Z00.01 General adult medical examination with abnormal findings Through age 17: Z Routine child health examination without abnormal findings Z Routine child health examination with abnormal findings *No copayment when code combination used with ACA-compliant plans 136

18 Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Screening for symptoms of clinical depression and anxiety (ages 12-17) Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument or New! * Z13.89 Encounter for screening for other disorder G0444 Annual depression screening, 15 minutes or 3725F Screening for depression performed *No copayment when code combination Z13.89 used with ACAcompliant plans New! Depression screening may be done by PCP via telephone, but must be fully documented in medical record 137

19 BMI Reporting Age 3-17 Age Age BMI Percentile + Nutrition Counseling + Physical Activity Counseling BMI Percentile BMI Value 138

20 Support to Providers Your Physician Organization is your transformation leader Call Cozeva at for questions or training about Cozeva display Call HMSA at on Oahu or 1 (877) , toll-free or psinquiries@hmsa.com: Questions about global payment amount Questions about engagement or performance measures Need training/support from HMSA s Training Unit for you and your practice team 139

Payment Transformation 2018 Measure Changes and Updates. June 27, 2018

Payment Transformation 2018 Measure Changes and Updates June 27, 2018 A G E N D A 1. 2018 Performance Measures 2. News & Updates 3. 2018 Engagement Measures 4. Patient Attribution & Panel Management Cozeva