Arkansas Health Care Payment Improvement Initiative COPD Algorithm Summary

Transcription

1 Arkansas Health Care Payment Improvement Initiative COPD Algorithm Summary

2 Chronic Obstructive Pulmonary Disease (COPD) Algorithm Summary v1.6 Page 2 of 6 Triggers PAP Assignment Exclusions Episode Time Window An episode is triggered when a patient shows an inpatient or emergency room claims with COPD diagnosis code or DRG codes. For specific ICD-9-CM and DRG, please see datasets. The Principal Accountable Provider (PAP) for an episode is the individual facility enrolled in an Arkansas Blue Plan provider network that admits the patient with trigger diagnosis or DRG code. Episodes meeting one or more of the following criteria will be excluded: A. The patient has claims or enrollment records that indicate coordination of benefits with another payer not associated with the Arkansas Blue Plans within the duration of the episode B. The patient does not have continuous coverage with at least one Arkansas Blue Plan throughout the entire episode C. The overall episode cost for the patient exceeds the outlier criteria. Currently, the outlier threshold is set at three standard deviations above the average episode cost for all patients otherwise included in the reporting period for all PAPs D. The episode window overlaps with another episode E. Procedure occurred late in the performance period, episode will likely appear on next report F. Provider terminated prior to report publication G. The patient was discharged against medical advice or due to expiration. H. Patient less than 35 years old I. Patient claims indicate one of the following co-morbidities within 365 days before or within the episode: 1) Abortion complications, 2) Complications from organ transplants, 3) Dialysis, 4) HIV, 5) Head/Neck cancer, 6) Breast cancer 7) Cervix cancer, 8) Leukemias, 9) Poison (non-medical), 10) ESRD (End-Stage Renal Disease), 11) Perinatal jaundice, 12) Respiratory distress, 13) Prostate cancer, 14) Bone cancer, 15) Brain cancer, 16) Bronchial/lung cancer, 17) Colon cancer, 18) Esophageal cancer, 19) GI/peritoneum cancer, 20) Liver cancer, 21) Malignant neoplasm, 22) Neoplasm unspecified, 23) Female genital cancer, 24) Male genital cancer, 25) Ovarian cancer, 26) Pancreas cancer, 27) Rectum/anus cancer, 28) Kidney/renal cancer, 29) Stomach cancer, 30) Urinary organ cancer, 31) Secondary malignancy, 32) Other respiratory cancer, 33) Other primary cancer, 34) Fetal disturbances, 35) Forceps or vacuum extractor delivery, 36) Malposition, 37) Other perinatal diagnosis, 38) Umbilical cord complications, 39) Spontaneous abortion, 40) Suicide and intentional self-inflicted injury, 41) Bladder cancer, 42) Uterus cancer, 43) Thyroid cancer, 44) Testicle cancer, 45) Skin melanoma, 46) Pelvic obstruction, 47) Hodgkin s lymphoma, 48) Non-Hodgkin s lymphoma, 49) Multiple myeloma, 50) Polyarteritis nodosa, 51) Arteritis NOS, 52)Amnios, 53) Louse-borne typhus, 54) Maintenance chemical J. Patient is an Exchange member K. Patient is an Access Only member L. Non-par self-insured groups: ABB/Baldor, Greenbay Packaging, Hytrol, Nabholz, Navistar, Nucor, Replacement Parts, Riceland, Southern Steel and Wire The episode begins when the patient enters the emergency room or is admitted to an inpatient facility for a diagnosis of COPD, and ends 30 days after the patient is discharged from the facility.

3 Chronic Obstructive Pulmonary Disease (COPD) Algorithm Summary v1.6 Page 3 of 6 Claims Included Quality Measures The following claims are included if incurred within the episode: A. Inpatient facility claims for admit date within 30 days after the trigger procedure, even if discharge is after 30 days. Claims with a DRG on the CMS list of exclusions for respiratory conditions will not be included in the episode. B. Include all claims in the episode window identified by the ETG for Chronic Obstructive Pulmonary Disease. C. Include all claims in the episode window related to the specific COPD procedures as defined in the diagnosis, DRG, procedure code, and NDC lists for the entire window unless otherwise listed in the codes excluded in the attached datasets. Quality measures to pass (payment related): A. Percent of episodes where patient visits an outpatient physician within 30 days after initial discharge. Visits are identified as evaluation and management procedure codes that are performed in provider s office, patient s home, or a rural health clinic, by specialists in the following list: general practice, family practice, internal medicine, pediatric medicine, geriatric medicine, primary-care nurse practitioners, primary-care physician assistant, or pulmonary medicine. Rate to satisfy this measure must be equal to or greater than 75%. Utilization Measures Adjustments Trigger Quality measures to track (not payment related): A. Rate of repeat acute exacerbation within 30 days after initial discharge. Acute exacerbation is a potential trigger within the episode. This is the number of eligible episodes with an acute exacerbation, divided by the total number of eligible episodes for a provider. Utilization measures to track (not payment related): A. Average rate of inpatient admission. This is the number of eligible episodes flagged inpatient, divided by the total number of eligible episodes for a provider. B. Average length of stay for inpatient admissions. This is the average number of days from the trigger date through the end of the inpatient stay. The total reimbursements attributed to the PAP will be adjusted based on complications that resulted in variations in treatment using a multiplier determined by regression. Over time, risk factors may be added or subtracted based on new research and/or empirical evidence. Claims with the following diagnosis codes, and either DRG codes for inpatient visits or Revenue codes for emergency room visits are considered when triggering a COPD episode (see below dataset). Diagnosis codes: 491.0, 491.1, 491.2, , , , 491.8, 491.9, 492.0, 492.8, 496 DRG codes: 0190, 0191, 0192 Revenue : 0450, 0451, 0452, 0456, 0459

4 Chronic Obstructive Pulmonary Disease (COPD) Algorithm Summary v1.6 Page 4 of 6 Excluded Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: ICD-9-CM codes: , 150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9, 151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 155.0, 155.1, 155.2, 156, 156.0, 156.0, 156.1, 156.1, 156.2, 156.2, 156.8, 156.8, 156.9, 156.9, 157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9, 158.0, 158.8, 158.9, 159.0, 159.1, 159.8, 159.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 163.0, 163.1, 163.8, 163.9, 164.0, 164.1, 164.2, 164.3, 164.8, 164.9, 165.0, 165.8, 165.9, 170.0, 170.1, 170.2, 170.3, 170.4, 170.5, 170.6, 170.7, 170.8, 170.9, 171.0, 171.2, 171.3, 171.4, 171.5, 171.6, 171.7, 171.8, 171.9, 176.0, 176.1, 176.2, 176.3, 176.4, 176.5, 176.8, 176.9, 181, 181., 183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 187.1, 187.2, 187.3, 187.4, 187.5, 187.6, 187.7, 187.8, 187.9, 189.0, 189.1, 189.2, 189.3, 189.4, 189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3, 192.8, 192.9, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.1, 195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9, 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, , , , 199.0, 199.1, 199.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 230.1, 230.2, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9, 231.1, 231.2, 231.8, 231.9, 233.3, , , , , 233.5, 233.6, 233.9, 234.0, 234.8, 234.9, 235.0, 235.1, 235.2, 235.3, 235.4, 235.5, 235.6, 235.7, 235.8, 235.9, 236.0, 236.1, 236.2, 236.3, 236.4, 236.5, 236.6, 236.7, , , , 237.0, 237.1, 237.2, 237.3, 237.4, 237.5, 237.6, 237.7, , , , , , 237.9, 238.0, 238.1, 238.2, 238.3, 238.4, 238.5, 238.6, 238.7, , , , , , , , , 238.8, 238.9, 239.0, 239.1, 239.2, 239.3, 239.4, 239.5, 239.6, 239.7, 239.8, , , 239.9, , , , , 443.2, , , , 494.5, , 555, 555., 555.0, 555.1, 555.2, 555.9, 556, 556., 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 585.5, 585.6, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 638.0, 638.1, 638.2, 638.3, 638.4, 638.5, 638.6, 638.7, 638.8, 638.9, 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 760.0, 760.1, 760.2, 760.3, 760.4, 760.5, 760.6, , , , , , , , , , , 760.8, 760.9, 761.0, 761.1, 761.2, 761.3, 761.4, 761.5, 761.6, 761.7, 761.8, 761.9, 762.0, 762.1, 762.2, 762.3

5 Chronic Obstructive Pulmonary Disease (COPD) Algorithm Summary v1.6 Page 5 of 6 Excluded (continued) ICD-9-CM codes: 762.4, 762.5, 762.6, 762.7, 762.8, 762.9, 763.0, 763.1, 763.2, 763.3, 763.4, 763.5, 763.6, 763.7, 763.8, , , , , , 763.9, 766.0, 766.1, 766.2, , , 769, 769., 770.0, 770.1, , , , , , , , , , 770.2, 770.3, 770.4, 770.5, 770.6, 770.7, 770.8, , , , , , , , , 770.9, 771.0, 771.1, 771.2, 771.3, 771.4, 771.5, 771.6, 771.7, 771.8, , , , 772.0, 772.1, , , , , , 772.2, 772.3, 772.4, 772.5, 772.6, 772.8, 772.9, 773.0, 773.1, 773.2, 773.3, 773.4, 773.5, 774.0, 774.1, 774.2, , , , 774.4, 774.5, 774.6, 774.7, 775.0, 775.1, 775.2, 775.3, 775.4, 775.5, 775.6, 775.7, 775.8, , , 775.9, 776.0, 776.1, 776.2, 776.3, 776.4, 776.5, 776.6, 776.7, 776.8, 776.9, 777.1, 777.2, 777.3, 777.4, 777.5, , , , , 777.6, 777.8, 777.9, 778.0, 778.1, 778.2, 778.3, 778.4, 778.5, 778.6, 778.7, 778.8, 778.9, 779.0, 779.1, 779.2, 779.3, , , , , 779.4, 779.6, 779.7, 779.8, , , , , , 779.9, , , , 789.7, 795.1, , , , , , , , , , , , , 996.8, E95.00, E95.01, E95.02, E95.03, E95.04, E95.05, E95.06, E95.07, E95.08, E95.09, E95.10, E95.11, E95.18, E95.20, E95.21, E95.28, E95.29, E95.30, E95.31, E95.38, E95.39, E95.4, E95.50, E95.51, E95.52, E95.53, E95.54, E95.55, E95.56, E95.57, E95.59, E95.6, E95.70, E95.71, E95.72, E95.79, E95.80, E95.81, E95.82, E95.83, E95.84, E95.85, E95.86, E95.87, E95.88, E95.89, E95.9, V10.00, V10.03, V10.04, V10.05, V10.06, V10.07, V10.09, V10.11, V10.12, V10.20, V10.22, V10.29, V10.40, V10.43, V10.44, V10.45, V10.48, V10.49, V10.50, V10.52, V10.53, V10.59, V10.81, V10.84, V10.85, V10.86, V10.88, V10.89, V10.9, V10.90, V10.91, V13.7, V42.0, V42.0, V42.1, V42.5, V42.7, V45.1, V45.1, V45.11, V45.12, V50.2, V55.2, V55.3, V56., V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, V62.84, V71.1 Claims with the following CPT/HCPCS procedure codes will be excluded: Procedure codes: 00520, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74263, 75571, 75572, 75573, 75574, 75635, 76380, 76497, 77011, 77012, 77013, 77014, 77078, 78452, 81001, 81003, Claims with the following CPT/HCPCS procedure codes will be excluded: Procedure codes: 82040, 82150, 82247, 82553, 83605, 83690, 83880, 84075, 84443, 84460, 85651, 85652, 86140, 93016, 93018, 93306, 95810, 95811, 99000, A0425, A4927, E0163, E0260, E1399, J1170, J3010, S9097 Claims with the following DRG codes are excluded based on the CMS exclusions for respiratory conditions: MS-DRG codes: 0001, 0002, 0005, 0006, 0007, 0008, 0010, 0011, 0012, 0013, 0014, 0016, 0017, 0020, 0021, 0022, 0023, 0024, 0025, 0026, 0027, 0028, 0029, 0030, 0031, 0032, 0033, 0034, 0035, 0036, 0037, 0038, 0039, 0040, 0041, 0042, 0113, 0114, 0115, 0116, 0117, 0129, 0130, 0131, 0132, 0133, 0134, 0135, 0136, 0137, 0138, 0139, 0216, 0217, 0218, 0219, 0220, 0221, 0222, 0223, 0224, 0225, 0226, 0227, 0228, 0229, 0230, 0231, 0232, 0233, 0234, 0235, 0236, 0237, 0238, 0239, 0240, 0241, 0242, 0243, 0244, 0245, 0246, 0247, 0248, 0249, 0250, 0251, 0255, 0256, 0257, 0258, 0259, 0260, 0261, 0262, 0263, 0264, 0265, 0326, 0327, 0328, 0329, 0330, 0331, 0332, 0333, 0334, 0335, 0336, 0337, 0338, 0339, 0340, 0341, 0342, 0343, 0344, 0345, 0346, 0347, 0348, 0349, 0350, 0351, 0352, 0353, 0354, 0355, 0405, 0406, 0407, 0408, 0409, 0410, 0411, 0412, 0413, 0414, 0415, 0416, 0417, 0418, 0419, 0420, 0421, 0422, 0423, 0424, 0425, 0453, 0454, 0455, 0456, 0457, 0458, 0459, 0460, 0461, 0462, 0463, 0464, 0465, 0466, 0467, 0468, 0469, 0470, 0471, 0472, 0473, 0474, 0475, 0476, 0477, 0478, 0479, 0480, 0481, 0482, 0483, 0484, 0485, 0486, 0487, 0488, 0489, 0490, 0491, 0492, 0493, 0494, 0495, 0496, 0497, 0498, 0499, 0500, 0501, 0502, 0503, 0504

6 Chronic Obstructive Pulmonary Disease (COPD) Algorithm Summary v1.6 Page 6 of 6 Excluded (continued) Included MS-DRG codes: 0505, 0506, 0507, 0508, 0509, 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0570, 0571, 0572, 0573, 0574, 0575, 0576, 0577, 0578, 0579, 0580, 0581, 0582, 0583, 0584, 0585, 0614, 0615, 0616, 0617, 0618, 0619, 0620, 0621, 0622, 0623, 0624, 0625, 0626, 0627, 0652, 0653, 0654, 0655, 0656, 0657, 0658, 0659, 0660, 0661, 0662, 0663, 0664, 0665, 0666, 0667, 0668, 0669, 0670, 0671, 0672, 0673, 0674, 0675, 0707, 0708, 0709, 0710, 0711, 0712, 0713, 0714, 0715, 0716, 0717, 0718, 0734, 0735, 0736, 0737, 0738, 0739, 0740, 0741, 0742, 0743, 0744, 0745, 0746, 0747, 0748, 0749, 0750, 0765, 0766, 0767, 0768, 0769, 0770, 0799, 0800, 0801, 0820, 0821, 0822, 0823, 0824, 0825, 0826, 0827, 0828, 0829, 0830, 0856, 0857, 0858, 0876, 0901, 0902, 0903, 0904, 0905, , 0908, 0909, 0927, 0928, 0929, 0955, 0956, 0957, 0958, 0959, 0969, 0970, 0984, 0985, 0986 The episode will include all claims classified with an ETG of Chronic Obstructive Pulmonary Disease. In addition, patients who have claims including any of the following CPT/HCPCS procedure codes and NDC codes will be included (see below dataset): Procedure codes: E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406, K0738, K0741, S8120, S8121 NDC codes: There are more than 2,100 NDC codes, can provided upon request. Quality Utilization Claims with the following diagnosis codes, and either DRG codes for inpatient visits or Revenue codes for emergency room visits are considered for a repeat exacerbation: Diagnosis codes: 491.0, 491.1, 491.2, , , , 491.8, 491.9, 492.0, 492.8, 496 DRG codes: 0190, 0191, 0192 Revenue : 0450, 0451, 0452, 0456, 0459 No codes for utilization.