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ENCOUNTER CODING A Shift in Emphasis; Things To Come A New Process: Entering GCBH System for Intake (Clinical Process and Coding Requirements) RSN-Wide.

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Presentation on theme: "ENCOUNTER CODING A Shift in Emphasis; Things To Come A New Process: Entering GCBH System for Intake (Clinical Process and Coding Requirements) RSN-Wide."— Presentation transcript:

1 ENCOUNTER CODING A Shift in Emphasis; Things To Come A New Process: Entering GCBH System for Intake (Clinical Process and Coding Requirements) RSN-Wide Training Sessions: March 25 & 30, 2010

2 What We Will Cover Today Implications of the recent actuarial study for coding practices that will necessitate further training. A process being standardized across the RSN to ensure a consistent approach and “apples-to-apples” data for encounters that impact several Core and Regional Performance Measures. Answers to questions that have been posed to the RSN about coding encounters. Briefly, a change in coding rules coming with the implementation of ProviderOne, that may necessitate further training.

3 Why Is This Topic Important? We currently have inconsistent compliance with coding requirements, and different understandings and practices across Providers. The variation has begun to have negative impacts on the RSN. Case in Point: The Request For Services code (H0046) is critical to several Core and Regional Performance measures. Evidence strongly suggests that our current coding practices (rather than our actual clinical processes) are negatively impacting performance scores. Having accurate, complete data is critical to the outcome for the RSN when actuarial studies are done. Incomplete data results in funding cuts!

4 It’s All About Performance! The increased focus on performance measurement and the methodology used by Mercer to carry out the recent actuarial study make it clear that performance matters from the State’s perspective. “Performance” is being evaluated on the basis of: ▫Encounter Hours ▫Core and Regional Performance Measures The RSN’s financial health depends upon Provider’s responses to the current challenges.

5 Washington’s Managed Mental Health Care Plan Washington operates a public mental health system funded by three major funding streams ▫Medicaid ▫State only ▫Federal Block Grant Medicaid is by far the largest funder of the system A state Medicaid plan, approved by the Federal government, defines the services that may be paid by Medicaid Medicaid can only pay for state plan services to Medicaid eligible individuals

6 Washington’s Managed Mental Health Care Plan Washington operates its Medicaid mental health program as a managed care program under a 1915(b) Medicaid waiver. The waiver gives freedom to limit choice of provider, to assign individuals to a managed care plan, waives statewideness requirements and avoids other restrictions. The waiver also imposes additional requirements including requirements regarding rate setting, documentation, quality management, etc. Washington contracts with managed care organizations referred to in federal law as Pre-Paid Inpatient Health Plans (PIHPs). In all but one case the PIHPs in Washington are county-based RSNs.

7 Washington’s Managed Mental Health Care Plan PIHPs/RSNs receive their Medicaid payments in the form of monthly capitated payments for each Medicaid eligible member. These payments might be thought of as insurance premiums. Groups of Medicaid eligibles are paid at varying levels based on expected utilization. Currently groups include: ▫Non-disabled kids ▫Disabled kids ▫Non-Disabled adults ▫Disabled adults Using these “premium” payments each PIHP/RSN is required to provide all services identified in the Medicaid state plan (including inpatient)

8 Actuarial Studies of Rates One requirement of the 1915(b) Medicaid waiver is that the capitated rates paid to PIHPs/RSNs be “actuarially sound” An independent actuary must define a range of rates and certify that rates that fall within the range will cover the cost of the services delivered while not over or under paying. Simply put, “actuarially sound” means the rates are adequate to allow the provision of services required of the PIHP/RSN to the eligibles served by the PIHP/RSN who require them. The Federal government further requires that rates be regionally adjusted to reflect differences in utilization and cost. Regions are not defined by the Feds.

9 Actuarial Studies of Rates The State is required to update the rates annually and to conduct a full re-basing of rates at least every 5 years. The State can re-base more frequently. Updates usually involve making assumption-based adjustments to the data originally used in an actuarial study. Re-basing is done by taking recent utilization, eligibility, and cost data and applying adjustments, assumptions and projections to ultimately develop rates

10 Actuarial Studies of Rates (this is very simplified) An actuarial study first looks at historical data about utilization and expenditures to develop a raw cost per unit. Eligibility data is then processed to develop a raw cost per eligible. Then adjustments, assumptions and projections may or may not be applied to create rate cells (rates for groups of eligibles). Some assumptions and projections may be in the form of ranges and thus produce a range of potential rates.

11 Adjustments, Assumptions and Projections These are often somewhat subjective and/or driven by policy goals of the Department. Examples of adjustments include: ▫Adjustments for missing or incomplete data ▫Adjustments for inflation ▫Adjustments for changes in data collection, service design, modalities, etc. that have occurred subsequent to the data collection period. ▫Changes in statute or other system changes that have occurred subsequent to the data collection period. ▫Changes in funding, budget, etc. that have occurred subsequent to the data collection period.

12 Adjustments, Assumptions and Projections Examples of assumptions include:  What regions will be used (historically each PIHP/RSN has been a region but the state could do other regions e.g., urban/rural, East/West)  What groupings of eligibles will be lumped into rate cells  Employee salaries and benefit costs  “Productivity” related factors such as travel time, meeting time, time for documentation, paid time off, clinical supervision load, etc.  Provider overhead (what is the relative load of salaries and benefits vs. other costs)

13 Adjustments, Assumptions and Projections Examples of projections include: ▫Service trends ▫Caseload growth or reduction ▫New services to be implemented ▫Changes in program design, requirements, statute, etc. ▫Building room for future growth in funding ▫Building room for future services  Converting PACT to Medicaid  Moving to statewide PACT

14 The Actuary The State hires an “independent” actuary to develop and certify the rates. The State, however, has significant influence over the outcome. In 2005 the actuary was Milliman. In Mercer serves as the actuary. The state influences the study by defining what they hope to pay, accepting or rejecting feedback from stakeholders, suggesting or accepting (or not accepting) projections, assumptions and adjustments and, in general, working with the actuary every step of the way.

15 A Little History Almost exactly a year ago, DSHS leadership informed stakeholders (providers and PIHPs/RSNs) of their plans for actuarial activity. Plans for two activities: ▫Major update to set the rates for FY 2010 ▫New rebasing study to set the rates for FY 2011 and future years Proposed State budget changes can have a huge impact in predetermining the results

16 Things We Must Pay Attention to Data completeness, accuracy, consistency and validation Coding – Getting it Right Adjustments in Services ▫Examples:  Greater Columbia Youth E&T Facility  Pathways ARTF opened July 2008  Sunnyside ARTF changed from IMD to non-IMD  New EBPs initiated since the data collection period ▫Documenting these changes

17 Concerns Assumptions ▫Productivity ▫Travel time ▫Effect of paperwork burden on productivity ▫Provider overhead ▫Clinical supervision

18 The Current Picture A recent analysis of service costs revealed that encounter hours have fallen markedly in the past five years, even as payments to Providers have increased. It is clear that we must turn this trend around. Doing so will be a priority for GCBH for the foreseeable future.

19 Requests & Intakes: The Bottom Lines REQUESTS – Our contracts require that every Request for Services be reported, whether or not it results in an Intake. ▫Doing so is now important for one of the GCBH Regional Performance Measures, as well. INTAKES – The Rule of Thumb is: Every Intake reported needs a companion Request for Services. When both data elements are not correctly reported, there are three undesirable outcomes: ▫The number of Intakes done by this RSN is understated in data that is (or will soon be) published publicly by the State. ▫It is highly likely that the RSN’s score for the “Request to Intake” measure is lowered due to missing Requests. ▫It is highly likely that the RSN’s score for the “Request to Routine Service” measure is lowered as a result of the query pairing a service with a Request from an earlier episode of care.

20 A New, RSN-Wide Process In September of 2009, the Clinical Directors discussed and agreed to a standardized process that: ▫Meets the contractual standard for reporting all Requests. ▫Provides a timeline for closing out a consumer record when a Request doesn’t result in an Intake. ▫Establishes RSN-wide expectations for attempting to engage a potential consumer who misses his/her Intake appointment. ▫Provides explicit guidance for submitting encounter time for direct contacts made in order to engage the potential consumer. ▫Provides explicit guidance for closing cases where no Intake occurs, so that such cases can be reliably identified for measurement and analysis purposes.

21 What Constitutes a “Request” (RFS) According to the Service Encounter Reporting Instructions (SERI), a Request for Services occurs when services are sought or applied for through a telephone call, walk in or written request by (1) the individual or those defined as family, or (2) upon receipt of an EPSDT referral by a Physician, ARNP, Physician Assistant, trained public health nurse or RN. The State recently clarified that “family” means “someone who can consent to treatment” on behalf of the individual needing treatment. These definitions exclude any kind of referral other than an “EPSDT referral.”

22 A New Process: The Big Picture Of course, the big picture is only good if you can actually see it. We’ll break it down into sections for training purposes. There is a full-page version of this process in your training materials, so you can stay oriented to how each section fits in the bigger picture.

23 The “Ideal” Scenario At its simplest, the process is straightforward. ▫We receive a request. ▫The potential consumer shows up on the appointed day. ▫The Intake happens. ▫Encounters are submitted for the Request and the Intake. In the real world, it’s often not so simple. Variation happens! A standardized process for managing the variation will: ▫Promote the same quality of care across the GCBH network. ▫Improve the data by which our performance is evaluated.

24 Enter, the “No Show” or Cancellation Here we have a potential consumer who didn’t keep the first appointment, but did request a new one. Notice two things: ▫If a person requests another appointment, their record stays open and you enter a “loop” that is repeated until the person either shows for an Intake, or stops requesting a new appointment. ▫The “Initial RFS” stands while the person is in this loop, no matter how long it lasts or how many times the person goes through the loop. The record is closed, making a new RFS possible, only after the person fails to show and doesn’t request a new appointment.

25 What About “No Show”, “No Reschedule”? When a person neither keeps the Intake appointment nor requests to cancel it (and/or reschedule it), immediately begin attempts to reschedule the Intake. We will not leave records open indefinitely after a Request, but we will make attempts to bring the person into services before closing the record. ▫Attempts that result in direct contact with the person who requested services should be coded as Engagement & Outreach encounters, using H0023-HW. ▫Time spent leaving messages or writing letters is not legitimate encounter time, and must not be submitted to the RSN.

26 “The Loop” Reappears When attempts to engage a person result in a new appointment time, a failure to keep the new appointment puts them into the “the loop.” As before, the record is closed, making a new RFS possible, only after the person fails to show and doesn’t request a new appointment

27 Two Paths to Process Completion Ultimately, one of two things will occur: ▫The person will show up for an Intake, in which case there will be both an RFS and an H0031/90801 submitted. ▫The person will fail to respond to attempts to engage, in which case:  An RFS must be submitted, which requires opening a record.  Any actual contacts with the person while attempting to engage them should be submitted as H0023-HW.  The record should be closed using “34 – Lost to Contact” as the Status code. The steps outlined in the three bullets above are critical to one of our Regional Performance measures, and will help us identify patterns we might be able to impact. Notice: This “No Show” doesn’t send the person back into “The Loop”

28 Enter a Request (H0046) When: A person who has never received services at your agency requests them. A person who requested services and was given an Intake appointment which s/he didn’t show up for, makes another request after his/her record has been closed, per this process. A person who has been out of services long enough to need a new Intake requests mental health services. A request is received from a person with an earlier episode of care that ended for one of the following reasons: ▫The person agreed it was time to stop services and has not received them since that point. ▫Services were not reauthorized or were formally terminated via a Notice of Action (NOA). A person who was previously denied services because s/he didn’t meet Access to Care criteria again requests them.

29 Once Again: The Rule of Thumb “Request > Intake” Measure: You do not get credit for great performance when an Intake cannot be paired with a Request—even if that Intake occurred on the same day as the Request. “Request > First Routine Service” Measure: The absence of a Request for that episode of care results in the first routine service being paired with an old request, which substantially lowers your performance score. If there is an Intake, there should be a Request for Services!

30 Encounter Coding: A Bigger Picture The remainder of this training will focus on: ▫Coding questions that have been posed to the RSN. ▫Changes coming with the implementation of ProviderOne in May.  Some redesigning of your MIS systems may be necessary in response to these new requirements.  Service delivery staff need to be aware of these changes, as they will likely be the staff in the best position to choose the correct code. This information will be presented in the form a “Quiz” which we will then discuss.


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