2022 Q3

Clinically Integrated Network News

Please continue to document outside records of immunizations within the “Historical Immunizations” tab. If CHIRP is triggered and immunizations are found, these need to be reconciled in the patient chart in order to receive credit.

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1. The Clinically Integrated Network (CIN) had a number of sections that were in the "first wave" of determining their measures for 2023 by April 1. We would like to recognize the sections that met that timeframe and express our appreciation for the continued collaboration throughout the process: Intensivist (Physician lead for CIN: Dr. Joshi), Pediatric Cardiology (Both Dr. Ghazali and Dr. Jayswal), Pediatric Critical Care (Dr. Patel), Pediatric Infectious Disease (Dr. Schmucker), Pediatric Neurology (Dr. Khan), Pediatric Physiatry (Dr. Khan), Pediatric Pulmonology ( Dr. Yalamanchali), PM&R/Physiatry (Dr. Kennedy), Sports Medicine (Dr. Frampton and Dr. Mattox), Virtual Health (Dr. Herstad), and Wound Care (Dr. Edlund).
2. The Cardiology team has had the recurring workflow of running the unmet reports and identifying patients that have a cardio visit scheduled. They then place an appointment note on the schedule for the provider to see concerning unmet CIN measures.
   
   We have added a layer onto the workflow: The Cardiology team will also review the unmet patients for the following points.

• Review the cardiologist that is listed in the care team
• Has the patient seen this cardiologist recently (staff are to consider a 2-year time frame)? If not, evaluate if doctor should be removed from the care team.
• Has the patient seen many cardiologists recently? Evaluate if cardio physicians should be removed from the care team so the inferred method of CIN attribution will assign the patient to the cardiologist seen most recently, in the last 12 months.
• If patient has not been seen in the last 2 years, should they be called to schedule a visit?
  
  In the past, CIN and the Cardio team have done a big attribution clean up every couple of years, which is time consuming. Continuous review of care team attribution will ensure our cardiologists have data that is relevant to their current patients and will eliminate the need of a big clean up every few years. This also helps to ensure that patients who should be scheduled for a follow-up are identified, and outreach can occur.

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Why are quality and star ratings important in our Value Based Agreements?

Most of our value-based agreements contain incentives for closing quality gaps (i.e. HgA1c testing of diabetics) related to the Medicare STARS program. Parkview Care Partners has an opportunity for earning millions of dollars in quality incentive payments by maximizing the quality score. The Medicare Advantage plans are also incented to achieve at least a 4-STAR rating by receiving a 5% increase in the premium dollars. Since our shared saving models are based on the premium that CMS pays.

On top of the higher premium, those payors that achieve a 5-STAR rating are also allowed to do sales and marketing all year long to attract patients versus other plans restricted to only the open enrollment period in the fourth quarter of the year.

As a simple example of the impact of the 5% increase for being a 4 STAR plan. The opportunity for sharing savings can increase by over $15 million annually by improving quality scores.

• Premium PMPM
  • 3-star: $950
  • 4-star: $1,000
• Target Expense PMPM
  • 3-star: $808
  • 4-star: $850
• Actual Expense PMPM
  • 3-star: $800
  • 4-star: $800
• Shared Savings PMPM
  • 3-star: $8
  • 4-star: $50
• Savings on 30k patients
  • 3-star: $2.9M
  • 4-star: $18M

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• Kathie: I would like to highlight Dr. Michael Engle and team for their CIN engagement, especially over the last six months. Their Overall CIN Score has increased 27 percentage points since the start of 2022. They've been a great team to work with and I appreciate the collaboration!
• Marissa: I want to recognize Palliative Care for their efforts to "own" their CIN performance. While I am always here to support them and their efforts, they continue to dive into their measures for a deeper understanding. Manager Denise Bienz and Quality/Accreditation Specialist Emily Miller continue to be engaged, strive to learn more about the measures and have a passion to improve quality.
• Kathie: A huge kudos to Dr. J David Kunberger and team for their hard work over the last seven months to improve their CIN score.  We started the year with some opportunity ahead of us and I am excited to share that they're currently performing at 100%!
• Aisha: Shoutout to Dr. Cohen and team!  You have all worked so hard to advance your CIN score and it is currently at 100%!  Thank you for your continued efforts and engagement as well as your dedication to patient care.
• Aisha: Thank you to Chad (manager) and Brittney (supervisor) for welcoming me into the Carew Family Medicine offices to engage with their providers and clinical team members. It's always a pleasure to engage with your team and witness your support of the CIN mission!
• Melody: The newest Health Maintenance/Best Practice Advisory (HM/BPA) was created with the OB/GYN providers in mind. Dr. Valluru, who is an advocate within the group, recently collaborated with Epic Operations to develop the urinary incontinence HM/BPA option for the clinical care team members. This is also a CIN metric for the specialty. This new tool will help to not only remind clinical providers and staff to complete the urinary incontinence workflow but to also ensure that patients have received the appropriate care and that the physician gets credit for the care that was given.

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What is HCC?

Hierarchical Condition Categories (HCC) is CMS’s methodology for determining risk adjustment factors (RAF) for Medicare Advantage programs and payments. In risk adjustment models, diagnosis codes carry a risk adjustment value, similar to the concept of RVU assigned to CPT codes – the more severe or complex a diagnosis, the higher its value.

HCC models use two primary sources of data to determine a patient's RAF, demographic data which includes the patient's age, gender and other factors specific to the population, and the second primary data source, health status, which is based on ICD-10-CM diagnosis codes.

Why pursue improving HCC/RAF score?

Simply stated, if it isn’t documented, CMS doesn’t know it was done or exists. Appropriate and thorough documentation captures the great work done by providers and accurately depicts the true condition/acuity of the patients we serve.

Additionally, HCC allows us to risk stratify our patient population resulting in CMS paying more for high-risk patients. This is why coding the chronic disease state of the patient is so important. Our payer contracts base PMPM on the acuity (or RAF scores) of our patients. Not documenting thoroughly can create a false sense of the patient’s true status.

Here are some of the top FAQs related to HCC pre-charting:

1. There are some dx that have been identified as needing redocumentation that were already documented in prior visits. Does the staff involved check on that before asking us to readdress it?
   
   Our team does a really good job at looking through previous visit notes for addressed diagnoses, but we recognize our process is not perfect. This question was brought to our attention and posed an opportunity for us to improve our process, which is a great reason to ask questions and make our team aware of your concerns!
   
   There are unique situations that will be few and far between, where our team has pre-charted an upcoming visit, but is seen before the CIN pre-charted visit. For example, CIN pre-charted the visit for 11/14, but the patient is seen prior on 11/02 for an acute issue and the provider addressed some of the pre-charted conditions. Should this happen, we apologize, as there is no way for our team to be alerted of newly added visits like the one described above. Please know it won't hurt to address conditions more than once, or you can simply remove any previously addressed dx from the pre-charted visit.
    
2. There are some diagnoses that we are being asked to redocument that are on the problem list in a different form. for example: CKD IIIb on the problem list and Stage 3 chronic kidney disease, unspecified whether stage 3a or 3b is added to the visit diagnoses. Does the staff look for a diagnosis on the problem list that would satisfy the redocumentation before adding a visit dx that is confusing or duplicate?
   
   Yes, we do review the problem list and attempt to align what the payer is looking for with those on the problem list. The example above is a simpler situation and was an oversight from our team member. Please understand, not all situations that arise are this simple as we are only as accurate as the information we are provided. When the payer provides a broader diagnosis like "metabolic disorder" or "other specified cardiac dysrhythmia," our staff (MAs) do their best within their scope to accurately choose the diagnosis that pertains. If our team is ever unsure of which diagnosis satisfies the redocumentation need, they will add those in question for the provider to address.
   
   Since this question had been asked, we have made improvements already to the report that we are using to include the actual IDC10 code that was captured via claim rather than just the description, which has greatly helped with this situation.
    
3. There are some visit dx that we are being asked to redocument where there is no obvious source. Where are they coming from?
   First, this is claims information. If a patient is seen anywhere outside of Parkview and a claim is sent to the payer with an HCC diagnosis, the payer is going to expect it to be redocumented whether the claim originated within Parkview or not. That may be why some diagnoses are not found within Epic. In this situation, it is best to have a discussion with the patient, order any testing should you suspect a need, and address if applicable. If the condition has resolved, you could always document using a “history of” diagnosis. If you feel any diagnosis is completely inaccurate, please remove and do not diagnose.
   
   **We feel it is important to note:
   Our team is working closely with our payers on whether more detail can be provided around the diagnoses, such as the date it was previously coded, the provider who previously coded it, or even the facility the code originated with. At this time, there is not an efficient way to provide this within our pre-charting efforts but we want you to know that we are in the process of trying to provide the most detailed information possible to your teams.
    
4. If there are multiple variations of the same condition, which one do I address?
   We come across this often! Our team is not able to make the medical decision of which condition is most accurate for the patient, so we would add all conditions and ask the provider to decide and diagnose the most appropriate condition. Remember, this is claims information. At some point in the past 2 years, each condition was diagnosed for the patient.
   
   It is best practice for conditions to be diagnosed to the highest specificity. We ask that the provider diagnose and select the most appropriate option or modify the diagnoses to best fit the patient.
    
5. Can diagnoses be removed if the provider does not feel they are accurate?
   Yes. In fact, we want you to do so. If a diagnosis does not pertain to the patient, we would never want it to be diagnosed just because we have added it from payer claim information.
    
6. How is a patient on the unmet list for HCC RAF when the chronic condition, that the outcomes team pre-charted, is not one of the scored diagnoses for HCC?
   While the CIN BPA is currently looking at a limited number of diagnoses, with the potential for more to be added, there are thousands of HCC conditions. This would explain why a patient may flag on the unmet report for say COPD, but our team pre-charted a need for COPD, Amputation and CKD to be redocumented. There will be situations where additional diagnoses will need to be considered for redocumentation, and we ask that you address all of them that are pre-charted, if applicable.
    
7. If a provider addends a note to add the HCC dx, will it count?
   From an insurance or payer perspective, if the note is addended AND the claims are updated, then yes, this would count as being redocumented and would have a positive impact on our redocumentation performance.
   
   From a CIN measure perspective, the HCC measure is built to look at whether the diagnosis was added to an office visit encounter. So yes, again, this would also be satisfied. However, if a provider does addend a note, a monthly refresh will need to occur to capture the addended diagnosis.
    
8. If an appointment gets rescheduled after the Outcomes team has already completed pre-charting, do the dx follow over to the next appointment?
   Our team is finding that the pre-charted conditions are NOT staying with the encounter if the visit is rescheduled. We have a weekly audit process in place to do our best at capturing these rescheduled visits. To our knowledge, this improvement has been able to capture each of these rescheduled visits and allows us to pre-chart again for the rescheduled visit date. If you or your office come across situations where “CIN: HCC Visit DX Added” is listed in the appointment notes, but no diagnoses are within the encounter, please reach out to our team so we can troubleshoot.
    
9. If a provider codes “Diabetes without Complications” (HCC19) but the BPA fires “Diabetes with Complications” (HCC18), will it count?
   Unfortunately, it will not, as the two conditions mentioned are from different HCC categories. Our suggestion is to look at the patient’s other health conditions and see if they would be considered a complication.
   
   For example, we find where a provider will diagnose “Diabetes Without Complications AND Chronic Kidney Disease Stage 3A,” this would not satisfy the BPA or the redocumentation of the HCC18 category.
   
   In this same scenario, the CKD is considered a complication and would be best coded as “Diabetes with Complications, Chronic Kidney Disease Stage 3A,” where the two conditions are coded together as one. Coding in this manner would satisfy the BPA and would provide redocumentation credit for the HCC18 category.

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(Applicable to FM/IM/IM Peds) The attribution process for our Medicare Advantage patients takes place at the beginning of each year. To ensure we are accurately contacting members still aligned with us, we wait for memberships to be solidified. Our CIN outcomes team began HCC outreach and pre-charting efforts in June. As a reminder, for any visit in which our team has pre-charted, you will see "CIN Outreach: HCC Visit DX Added" in the appointment note. For patients who have not been seen and do not have an upcoming appointment scheduled for 2022, the goal is to get them scheduled for a visit with their PCP to provide an opportunity to address open care gaps, as well as recapture any remaining HCC conditions, if/when appropriate.

Diabetic Eye Exam Process/Timeframe

We currently have a turnaround time of 30 days or less! For any eye exam sent to us from PPG offices and/or eye providers, results are visible and the document is scanned into the chart within 30 days. Thank you for your patience as we navigated through the transition from Access Anywhere to Onbase.

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The CIN team on Pulse

As a reminder, the CIN site on Pulse, Parkview Health’s intranet, includes a number of resources, including past newsletters, Collaborative Learning Sessions, a “meet the team” section and much more.

Please note if you are an independent group outside of Parkview Health, you will be unable to access this information. Your Provider Relations Specialist is happy to provide you with any requested materials.

If you have questions or suggestions about measures, appeals, scorecards or other CIN tools, please contact your provider relations specialist.

If you would like to join or have general questions about Parkview Care Partners, please contact Nicole Krouse, CIN director, at 260-266-3709 or Nicole.Krouse@parkview.com.

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