Health Reform Minnesota

• Health Care Home • Care Coordination Tiering-Billing Workshop• October 1, 2014

Objectives

• Gain a better understanding of how to use the HCH Care Coordination Tier Assignment tool for population management and billing

• Describe implementation examples for effective tiering and billing workflow processes.

• Learn from other HCH clinics that are successfully tiering and submitting claims for care coordination payment.

Laying the Foundation for HCH Care Coordination Payment

Legislative RequirementsLegislative Requirements for HCH Care Coordination Payment:

[256B.073]• DHS and MDH develop a system of per-person care coordination

payments to certified HCHs by January 1, 2010• Fees vary by thresholds of patient complexity• Agencies consider feasibility of including non-medical complexity

information

• Implemented for all public program enrollees by July 1, 2010

[62U.03]

• Covers SGIP, small group self-insured

Care Coordination Payment Guiding Principles

• HCHs do population management.

• Every patient is part of the clinic’s HCH

• HCHs determine which patients need care coordination eligible for payment and which patients need routine panel management including preventive care, appointment follow-up, etc.

• Clinics implement key process steps for successful care coordination billing

Population Management Goal• Have processes in place for systematic

assessment of the clinic population for care coordination needs including:

• New Patients

• Current Patients, Ongoing Changes

• Established Patients with Chronic Conditions.

• Patients who are identified and decline care coordination services.

Population Management, What does your population look like?

Implement HCH Tier Tool

Complexity Tier LevelNeeded for Payment

• Patient’s Tier Level (based on the count of “major” condition groups)

• Tier 0 (none)

• Tier 1 (1-3)

• Tier 2 (4-6)

• Tier 3 (7-9)

• Tier 4 (10 or more)

• Presence of either of the two “supplemental” complexity factors

Clinic Team Develop Tiering & Billing Workflow Processes

Complete the Care Coordination Tier Assignment tool and develop your billing workflow processes:• Determine who does what and when for tiering?• Tier level is supported by documentation• Set up work flow process for communicating tier score• Key: Establish a communication process with billing• Develop workflows within EMRs to automate, may

begin with a manual process

Coding Structure for Billing

Key Billing Process Steps 1

Key Billing Process Steps 2

Denial Process

* Denial code B20 (CARC) or N472(RARC)

Multi- Payer Communication• Prior to Certification: Determine payer networks you

participate in that you would like to bill for care coordination payments.

• Work with payers to establish payment rates and method of claim submission and payment• Tiering Methodology / Codes (Medicaid & Other Payers)• PMPM Contract Arrangements• CMS – Medicare Care Coordination

• Identify payers where there may be patient liability and determine process.

• Address how to manage billing for uninsured.

Certified Providers Communicated to Payers

• Payer Information is on HCH Certification Letter• DHS certification notification process

– Effective December 2012, providers must notify DHS of certifications – Fax certification/recertification letter(s) with NPIs to MHCP Provider

Enrollment at 651-431-7462– Contact provider call center with billing questions

• 651-431-2700 (Twin Cities metro) • 800-366-5411 (Toll-free line)

• Reminder: Be sure to continuously update providers post certification in HCH portal

Create Your Clinic’s Roadmap

• Population Management in Health Care Homes

• Care Coordination Tiering Processes

• Billing Workflows• Multi-payer Input

HCH Care Coordination Tier Tool Learning Exercises

Care Coordination Tier Assignment Tool Version 1.0

Tier Tool – Determines Patient Complexity

• How many major chronic condition categories apply to the patient?

Review Medical Record Documentation

Steps to Completing Tier Tool 1

• Review all documented patient diagnoses and put into condition groups

• Helpful Tools: Expanded Diagnosis Cluster (EDC’s) • ICD 9 Manual – assist to identify organ systems codes in.

• Use conditions off the patient’s problem list and/or documented treatment plan

• Examples:• Congestive Heart Failure = Cardiovascular• Glaucoma = Eye• Adverse effect from medication = Toxic Effects• Obesity = Nutrition• Tobacco Use = Mental Health/Psychosocial• Depression = Mental Health/Psychosocial

Steps to Completing Tier Tool 2

Steps to Completing Tier Tool 3

• Identify those conditions that are chronic

• Chronic conditions are defined as those that:• Have lasted at least 6 months;• Can reasonably be expected to continue for a least 6 months;• Or are likely to recur

Steps to Completing Tier Tool 4

Steps to Completing Tier Tool 5

• Consider the severity of the conditions you listed and identify those conditions that are severe .

• Severe conditions are defined as:• major and potential unstable conditions• that without optimal care are likely to worsen and lead to more

serious problems that may result in severe illness, impairment or death

Steps to Completing Tier Tool 6

Steps to Completing Tier Tool 7

• If both the chronic and severe boxes are checked: consider whether this to condition requires a care team?

• to coordinate services• in order to attain or maintain the patients stability• or to reach their optimal goals.

• This includes coordination of preventive care services or disease management services to prevent the condition from

• becoming worse• deteriorating• or resulting in gaps in care for the patient

Steps to Completing Tier Tool 8

Steps to Completing Tier Tool 9

All 3 boxes must be checked to equal 1 : Condition is ChronicCondition is SevereCondition Requires A Care Team

Final Steps:• Total the score boxes• Write number in sum count• Write in corresponding tier level

Steps to Completing Tier Tool 10

Sum Count = Complexity Tier

Supplemental Factors 1

• Identify if either or both of the elements apply to the patient:Needs to communicate about their health care in a non-English Primary

language – includes hearing impaired / those who require a sign language interpreter.Patient or caregiver have a serious and persistent mental illness diagnosis

Active diagnosis -schizophrenia, bipolar disorder, major depression, borderline personality disorder

Functional impairment observed. If caregiver noted in patient’s record

• If either of these boxes are checked then:• Assign modifier codes in addition to the tier level

• Supplemental factors account for increased care coordination efforts needed

Supplemental Factors 2

Tier Example - Patient Gary 1

Tier Example - Patient Gary 2

• Gary’s conditions map to 12 condition categories

• 10 condition categories were determined to be• Chronic• Severe• Requires care coordination between clinic care team, therapists, and other

specialists involved in his care

Tier Example - Patient Gary 3

Tiering of Patient - Michael 1

• Michael is a 4 year old male who lives with his parents, and four siblings. His parents are married and very involved in his care. They both work outside the home and unfortunately do not have extended family support available.

• Michael was born with the following congenital birth defects and abnormalities:Cleft Palate (749)Abnormality of the heart (746)–Ebstein’s anomaly a rare heart defect (746.20)Abnormality of the esophagus (751)Congenital Disorder of the bladder (753) - Renal Dysplasia (753.15)

• In the first few months of life Michael was diagnosed with moderate mental retardation (318)severe hearing impairment / deafness (389.7) leading to a developmental delay (315.34)

Tiering of Patient - Michael 2

• Due to Michaels significant medical problems, he has extended care services 24 /7.

• He requires catheterization 6-8 times per day.• He has a feeding tube due to severe eating problems.• His Body Mass Index (pediatric) is less than the fifth percentile for his age

(V85.51)Other diagnosis Michael has been given are:

Asthma with status asthmaticus (493.91)Chronic sinusitis (473.0)Esophageal reflux (530.11)Chronic urinary tract infections (098.2)

Tiering of Patient - Michael 3

• Michael had 14 diagnoses that mapped to 10 condition categories• Supplemental factor – language should be checked (deafness)• Congenital disorders map to GENETIC and the organ systems can be

counted• Significant signs and symptoms documented that are

chronic/severe/require a care team can be included.

• 10 condition categories were determined to be chronic, severe, require care team – Tier level 4

Allergy Asthma Genito-urinaryCardiovascular Mental Health / PsychosocialEar, Nose and Throat NeurologicGastrointestinal NutritionGenetic Renal

HCH Clinical Scenarios –Group Exercise

• Form smaller work groups at tables• Tools for exercise:

• Care Coordination Tier Assignment Tool • HCH Payment Methodology Expanded Diagnosis Clusters (EDC) • HCH Clinical Scenarios

Assignment:1. Individually Tier the assigned scenario’s (Mary, Frank)2. When everyone in your group completes, share and discuss the

tier level each determined (condition categories, whether chronic, severe and required a care team)

3. We will discuss scenarios in large group at end

Additional Questions?

MDH Payment Resources:

http://www.health.state.mn.us/healthreform/homes/payment/index.html

Health Care Home Team Emailhealth.healthcarehomes@state.mn.us