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April 12, 2011 Approval Code: IN331 Ingenix InSite Provider User Group.

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Presentation on theme: "April 12, 2011 Approval Code: IN331 Ingenix InSite Provider User Group."— Presentation transcript:

1 April 12, 2011 Approval Code: IN331 Ingenix InSite Provider User Group

2 © Ingenix, Inc. 2 Ingenix InSite User Group: Welcome Administrative Reminders:  This call is hosted in a listen only mode for participants until our Q&A segment.  Questions you may want to ask prior to the Q&A segment can be typed in our chat panel for the host to address  Please keep your phones on mute during Q&A.  The webex login password for this call is ‘insite’.  When logging into the webex please enter in your first and last name.  The user group presentation materials will be sent with the meeting minutes.  Ingenix InSite User Group Questions or Product Enhancement requests?  Ingenix InSite Website Questions? Call or the Ingenix Helpdesk or

3 © Ingenix, Inc. 3 Ingenix InSite User Group: Agenda  10:00 AM Welcome  10:02 AM InSite Operations Announcements  10:10 AM EDPS Update  10:25 AM Documentation and Coding Focus On: Diabetic Foot and Peripheral Artery Disease  10:50 AM Q & A

4 InSite Operations Announcements Presented By Jerry Gauchat

5 © Ingenix, Inc. 5 InSite Operations Announcements – Data Refresh Update  Data Refresh Update –InSite data refreshed April 4 th –Next monthly data refresh is targeted for May 9 th  REMINDER: MAY 9 th, 2011 is the next data refresh when years will shift  Reports shifting years in InSite –In January and April data, the new 2012 PY or 2011 Dates of Service (DOS) will begin to be reported and InSite drops the oldest year of data. –Reports shift years on reports depending on which time period is the most actionable for the specific report.  The data in InSite will shift years for the following reports on May 9 th, 2011 Prevalence Members with Declining RAF Patient Management PCP RAF  HCC RAF Detail Report –New FFS Normalization value used for calculations; only impacts 2012 PY data

6 © Ingenix, Inc. 6 InSite Operations Announcements- Q Release (4/4/11)  Recent Enhancements: –Provider Verification Re-Engineering New Group Validation Approver Role New Annual Attestation Process –Re-Formatting (upon export) of Key Reports CSI, MWOV, SOAH & HCC RAF Detail –Modified SSN to a PIN / Removed Collection & Storage of DOB –Learning and Resources Documentation Modifications –Mouseover Content, Label and Tooltip Updates

7 © Ingenix, Inc. 7 InSite – Process Changes for Provider Validation  PREVIOUS PROCESS: –All New Groups must initially validate each provider is associated to their group prior to gaining access to member level data in reports –New Providers to Groups added in a monthly data refresh are not required to be validated –Validation had been required every 6 months (Validation Summary showed a period start/end date)  PROCESS REVISIONS: – NEW ROLE: Each group must have one or more assigned, “Validation Approver(s)”. The new role will be the only ones with read/write access to perform Provider Validation. All other provider group users will only have “read” access to the Provider Validation tab. –Initial Validation is still required for all new groups –New Providers to Groups added in a monthly data refresh are required to be validated each year prior to yearly attestation –Yearly attestation required of designated Validation Approvers

8 © Ingenix, Inc. 8 Re-Formatted Reports (Upon Export)  Reports Re-Formatted: –CSI (including quick views) –HCC RAF Detail –Summary of Accepted HCCs (SOAH) –Members Without Office Visits (MWOV)  Modifications made: –Moved report names to the header –Added page numbers to the footer –Ensured column names appear on each page –Standardized field sizes and page orientation to allow for “print ready” export

9 © Ingenix, Inc. 9 SSN Modification / DOB Removal  Forgot Password Screen - Current  Forgot Password Screen – New –DOB has been removed –SSN has now been re-named PIN; communication to be sent by InSite Operations requesting all users modify their current SSN value with a new 4-digit PIN.

10 © Ingenix, Inc. 10 Learning and Resources Documentation Updates  Training –Updated PAF Program Tab Help file –2011 InSite Years Shifting Guide  Ingenix Insider –Feb 2011 (Atrial Fibrillation) –Mar 2011 (Chronic Kidney Disease)  Utilities and Tools –Updated ICD9 to HCC Mapping with Descriptions, RAF & Hierarchy document  Information Resources –Updated Provider Solutions (Capitated) document

11 © Ingenix, Inc. 11 Mouseover Content, Label and Tooltip Updates  Mouseover Content Changes –Group and Provider Summary Report Prelim and Adjusted RAF –HCC RAF Detail Report Prelim and Adjusted RAF (for previous PY and one year prior to previous PY); no changes required for current PY –PCP RAF Report HCC RAF & Total RAF for current and previous DOS Year –CSI Report (and CSI High Risk Members Quick View) and MWOV Priority –Patient Management Report HCC RAF & Total RAF –SOAH Report Removed NP reference on PCP Name column

12 © Ingenix, Inc. 12 Mouseover Content, Label and Tooltip Updates  Tooltip Changes –PCP RAF Report Description of calculated average RAF –Members with Declining RAF Description of members included on this report –CSI Quickviews Report description –Provider Validation button Modified verbiage to match “to be” functionality  Label Changes –Members with Declining RAF Report Risk RAF changed to HCC RAF –Patient Management Report Average Risk RAF to Average HCC RAF (Report Summary section) Risk Level, Risk RAF to Risk Level, HCC RAF (Filter) Risk RAF (HCC Score) to HCC RAF (Column Header)

13 © Ingenix, Inc. 13 InSite Operations Announcements – Q Release  Upcoming InSite Updates New HEDIS/STARS PAF Versions –No changes to PAF Management functionality Summary of Accepted HCCs (SOAH) –Modify query to access report more quickly –Upon export - HCC and description will match Systematic User Entitlement Learning & Resources Tab –Adding April, May & June 2011 Ingenix Insiders »Removing all 2010 Ingenix Insiders –Removing 2010 ICD-9 Brochure –Further docs to be added as required

14 FYI #1 Presented By Pam Holt

15 © Ingenix, Inc. 15 Baby Boomers Age-in To Medicare  Two months ago 1 st baby boomers “Aged In” to Medicare –Beginning of an epic wave of growth & change in senior population  64 million people will be enrolled in Medicare in 2020 –17 million more than today (36%) –Making seniors the fastest growing Healthcare market

16 Presented By Patty Brennan Quality and Compliance Director CMS Update Encounter Data Processing System (EDPS) Overview

17 © Ingenix, Inc. 17 CMS Regulation- IPPS Final Rule  CMS issued rule to authorize the expansion of the collection of encounter data beyond the 5 elements required for RAPS submission: –“Given the increased importance of the accuracy of our risk adjustment methodology, in the FY 2009 IPPS proposed rule (73 FR 23667), we proposed to amend § to provide that CMS will collect data from MA organizations regarding each item and service provided to an MA plan enrollee. –This will allow us to include utilization data and other factors that CMS can use in developing the CMS-HCC risk adjustment models in order to reflect patterns of diagnoses and expenditures in the MA program. –Specifically, we proposed to revise § (a) to clarify that risk adjustment data are data used not only in the application of risk adjustment to MA payments, but also in the development of risk adjustment models.”

18 © Ingenix, Inc. 18 Purpose for Expansion of Collection of Encounter Data  CMS has indicated that the expansion is required for the following purposes: –Measure healthcare utilization in MA organizations –Calibrate MA specific Risk Adjustment Models –Calculate Disproportionate Share Hospital (DSH) payments  10/29/2010 – CMS held national meeting to discuss initial requirements and timing –Encounter Data Processing System (EDPS) will eventually replace RAPS

19 © Ingenix, Inc. 19 EDPS Implementation Time-Line JanFebMarAprMayJunJulAugSepOctNovDecOctNovDecJanFebMarAprMay CMS held Industry Meeting Announces policy changes Announces release timeline October 29 th, 2010 Initial file testing begins: >EDI translator & front- end processing edits March 30 th, 2011 Initial file testing begins: >Institutional format testing July 18 th, 2011 September 12 th, 2011 Go-Live for 2012 dates-of-service: >Institutional & Professional formats January 3 rd, Front-end testing (end-to-end) begins: >DME Module >Pricing system February 6 th, 2012 DME processing & pricing system go-live May 7 th, 2012 Initial file testing begins: >Professional format testing Initial file testing ends: >EDI translator & front- end processing edits June 30 th, 2011

20 © Ingenix, Inc. 20 EDPS vs RAPS- Significant Changes There will be major differences between the Encounter Data Processing System (EDPS) and the current Risk Adjustment System. The most significant and consequential are as follows:  Data collection changes from 5 elements to all elements of the HIPAA standard 5010 (up to 900 elements)  Submission of data from all types of service –CMS will be responsible for filtering data to determine if eligible for Risk Adjustment  MA plans must submit data within 12 months from date of service –Under RAPS submission, data for 1/1/2009 – 12/31/2009 is not finalized until 1/1/2011 which allows a 24 month period. –If 12 month rule was adopted by CMS, deadline for 1/1/2010 data would be 1/1/2011 versus 1/31/2012 under the RAPS process

21 © Ingenix, Inc. 21 EDPS vs RAPS- Significant Changes, con’t  Submission of adjudicated claims data –Adjudicated claims equals paid and denied, not pended  CMS will apply CEM (Common Edits and Enhancements Module) Edits –These edits are utilized for Medicare FFS but the same level of edits may not be needed for MA data  The process for submission of Alternate Data (i.e. Chart Review) still under review by CMS  Parallel Processing –During the transition phase, plans will submit data through both systems: EDPS – full 5010 standard RAPS format to Risk Adjustment System

22 © Ingenix, Inc. 22 Key Considerations Under Evaluation by CMS  Timing (“Go Live” January 3, 2012) –Aggressive timeline may cause issues for health plans especially given the lack of fully documented requirements from CMS  12 Month Rule –CMS originally indicated 12 month rule would apply but have recently indicated that they are considering expanding the 12 month deadline for submission of data –However, CMS has indicated a strong bias toward decreasing the timeframe for submission of data

23 © Ingenix, Inc. 23 Key Considerations Under Evaluation by CMS, con’t  Submission of Alternate Data –CMS has indicated that their will be a mechanism to submit alternate data. –CMS has signaled they are leaning toward tying the chart audit data to a claim –What happens when you cannot tie a chart audit to a claim?  The flexibility of CEM edits –Soft or hard edits on many of the elements that are currently not required for RAPS submission but are hard edits for Medicare FFS

24 Presentation Title Slide David S. Brigner, MLA, CPC Sr. Provider Training & Development Consultant Diabetic Foot & Peripheral Artery Disease 2011 ICD-9-CM Presented by:

25 © Ingenix, Inc. 25 Diabetic Foot Ulcers

26 © Ingenix, Inc. 26 Diabetic Ulcers Foot Care:  The sequence of events leading to lower extremity amputation is well known in people with neuropathy or peripheral vascular disease. –While vascular disease leading to ischemia is certainly a factor in the pathogenesis, 60–70% of diabetic foot ulcers are primarily neuropathic in origin Gordois, A., et al. (2009). The health care costs of diabetic peripheral neuropathy in the U.S. American Diabetes Association: Diabetes Care, 26:1790–1795. Website:

27 © Ingenix, Inc. 27 Diabetic Peripheral Neuropathy & Ulcers Diabetes with Neurological Manifestations 250.6X  Peripheral neuropathy is common among people with diabetes and can result in foot ulceration accompanied by cellulitis or osteomyelitis, and a severely infected or nonhealing foot ulcer may lead to an amputation. 1, 2 2. Reiber, G.E. et al. (1990). Lower extremity foot ulcers and amputations in diabetes and amputations in diabetes. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Chpt 18. Retrieved from 1. Gordois, A., et al. (2009). The health care costs of diabetic peripheral neuropathy in the U.S. American Diabetes Association: Diabetes Care, 26:1790–1795. Website:

28 © Ingenix, Inc. 28 Manifestations in the Progression of Diabetes LOPS Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes HCPCS Codes G0245, G0246 and G0247 Correct DX coding would be: 250.6X with Note: Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every 6 months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Centers for Medicare & Medicaid Services. "CMS Manual System." Pub Medicare Claims Processing: Transmittal 498 (2005): p. 4. Web. 12 Nov Note: Caution when coding “Loss of Sensation” Consider coding “Loss of Protective Sensation (LOPS)“ 357.2

29 © Ingenix, Inc. 29 Diabetic Ulcers - PVD Diabetes with Peripheral Circulatory Disorders 250.7X Peripheral vascular disease is not uncommon among those individuals with diabetes. The disease causes damage to the large and small blood vessels of the legs and feet. National Center for Chronic Disease Prevention and Health Promotion, (2008, July 23) National Diabetes Fact Sheet. Retrieved March 17, 2009, from CDC: Diabetes Public Health Resource Web site:

30 © Ingenix, Inc. 30 Underlying Disease – Diabetes Mellitus  The underlying disease is coded first, followed by the manifestation(s) code.  The linkage has been established as “diabetic” and the 4 th digit is properly assigned on the 250.7X.  Example: –“Type I uncontrolled diabetic atherosclerosis of the plantar surface of left midfoot with associative ulcerative cellulitis” Diabetes w/ peripheral circulatory disorder (Type I, Uncontrolled) Atherosclerosis of native arteries, extremities w/ ulceration Ulcers of the plantar surface, midfoot (except pressure ulcers), unspecified 682.7Cellulitis, foot, except toes

31 © Ingenix, Inc. 31 Underlying Disease – Diabetes Mellitus  Be Specific – Coding mistakes can be costly If the same scenario was documented as:  Example: –“Type I uncontrolled diabetes with atherosclerosis of the plantar surface of left midfoot with associative ulcerative cellulitis” Diabetes without Complications Atherosclerosis of native arteries, extremities w/ ulceration Ulcers of the plantar surface, midfoot (except pressure ulcers), unspecified 682.7Cellulitis, foot, except toes No cause and effect relationship established With this example, there is nothing indicating that the atherosclerosis of the lower extremities was due to the diabetes.

32 © Ingenix, Inc. 32 Peripheral Vascular (Arterial) Disease

33 © Ingenix, Inc. 33 Vague Vascular Codes:  – Peripheral Vascular Disease, Unspecified  – Vascular Disease (Circulatory Disorder), Unspecified  – Atherosclerotic Vascular Disease, Unspecified Be Specific – Identify the Problem

34 © Ingenix, Inc. 34 Recommended language: –PAD / PVD - Peripheral arterial disease, peripheral vascular disease, and claudication are coded to It is important to note that this code excludes atherosclerosis of the arteries of the extremities. –Atherosclerosis - of native arteries of the extremities, Category 440, is further classified as such: – With intermittent claudication – With rest pain – With ulceration (see ulcer coding rules) – With gangrene – Unspecified Documentation & Coding PAD / PVD

35 © Ingenix, Inc. 35 Recommended language: Peripheral Vascular diseases as a result of atherosclerosis of extremities:  Atherosclerosis of Native arteries of the Extremities (440.2x). –For coding purposes, the physician must document that the PVD is due to atherosclerosis (ASPVD) before a code from may be assigned. 2 –Further specification is needed for specific coding if the physician documents vague diagnoses as peripheral vascular disease or intermittent claudication. 1 1 Coding Clinic, 1992, 4 th Q, page M Health Information Systems (2008, April). Coding for peripheral vascular disease. In, For The Record, Vol. 20 No.8 p. 28. Retrieved March 10, 2009 from: Documentation & Coding PAD / PVD

36 © Ingenix, Inc. 36 Documentation & Coding PAD / PVD When Assigning Atherosclerosis of Arteries of the Extremities 440.2X Patients documented as atherosclerosis with intermittent claudication due to atherosclerosis are coded to If claudication is documented without mention of atherosclerosis, only code Patients documented as atherosclerosis with neither gangrene nor ulceration, but with rest pain are coded to If rest pain is documented without mention of atherosclerosis, only code All patients documented as atherosclerosis without gangrene, but with ulceration are coded to If ulceration is documented without mention of atherosclerosis, only code All patients documented as atherosclerosis with gangrene are coded to If gangrene is documented without mention of atherosclerosis, only code Recommended language: Ulcers: Codes from Subcategory 707.1x (Ulcer of lower limb) should be assigned in addition to or

37 © Ingenix, Inc. 37 Rules of Coding PAD / PVD: Ischemic Ulcers  Subcategory 707.1x Ulcer of lower limbs, except pressure ulcer ▪ First : Code any underlying or causal condition Example: – Atherosclerosis of Extremities w/ Ulceration x – Diabetic PVD with Ulceration … or x – Diabetic Ulcers, Unspecified ▪ Second: Code associative ulcers to the highest level of specificity Example: – Ulcer of lower limb, unspecified – Ulcer of thigh – Ulcer of calf – Ulcer of ankle – Ulcer of heel and mid-foot – Ulcer of other part of foot – Ulcer of other part of lower limb

38 © Ingenix, Inc. 38 Chronic Ulcers of Skin Others of importance  Chronic ulcer of other specified sites  Chronic ulcer of unspecified site –  Venous stasis ulcers (leg): –with varicose veins (any part or unsp. site) – –chronic venous insufficiency, NOS, without varicose veins (use additional code for any associated ulceration ) –with varicose veins and inflammation or infection (any part or unsp. site) – Rules of Coding PAD / PVD: Other Ulcers

39 © Ingenix, Inc. 39 Recommended language to avoid:  Diagnostic statements that do not impact severity adjustment as they are default coded to 440.9: (Atherosclerosis - generalized and unspecified) –Arteriosclerotic (vascular) disease (440.9) –Generalized arteriosclerosis (440.9) –Arteriosclerotic endarteritis (440.9) –Arteriosclerosis obliterans (440.9) –Arteriosclerosis with calcification (440.9) PAD Documentation & Coding – (Generalized & Unspecified)

40 © Ingenix, Inc. 40 Recommended language : Vascular diseases often occur as a manifestation of diabetes:  Diabetic Peripheral Circulatory Disorders (250.7X and ) –If the PVD is due to diabetes mellitus, codes 250.7x and would be assigned. (Not 443.9) –Provide the appropriate linkage for the diabetes with Peripheral Circulatory Manifestations (250.7x) Documentation & Coding PAD / PVD – (Diabetic PVD)

41 © Ingenix, Inc. 41 Recommended language : Vascular diseases of other and unspecified types of PAD / PVD:  Other Peripheral Vascular Disease (PVD), Unspecified (443.9) –Peripheral arterial disease, peripheral vascular disease, and claudication are coded to ▪ It is important to note that this code excludes atherosclerosis of the arteries of the extremities ( – ). –This code is assigned if there is no additional documentation regarding the type of manifestation of PVD / PAD. Documentation & Coding PAD / PVD – (Other & Unspecified)

42 © Ingenix, Inc. 42 DM Coding Concepts See Provider Tool Book Underlying Diseases & Manifestations

43 © Ingenix, Inc. 43 Underlying Disease – Diabetes Mellitus  Coding of Underlying Disease (Etiology) and Manifestation Code both the etiology (underlying disease) and the manifestation of the disease. The underlying disease is coded first. Both the underlying disease and the manifestation are in the present tense. ICD-9 states," the most commonly used etiology/manifestation combinations are the codes for Diabetes Mellitus” 250.XX, [XXX.XX]. 1 1 The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2008, October). ICD-9-CM official guidelines for coding and reporting. Retrieved August 13, 2010, from Department of Health and Human Services (DHHS) Web site:

44 © Ingenix, Inc. 44 Underlying Disease – Diabetes Mellitus is over-reported  Diabetes Mellitus, code without mention of complication is appropriate at times.  However, if complications exist, code to the specific complications and manifestations.

45 © Ingenix, Inc. 45 Underlying Disease: Make The Connection  The documentation MUST make the connection.  Document and code to the specific complications and manifestations in the chart.  In order to code a disease or condition as a manifestation of DM: –it must be stated that the disease or condition is diabetic or due to Diabetes. (The Coding Clinic, Third Quarter 1991, pages 7-8)

46 © Ingenix, Inc. 46 Diabetes Controlled/Uncontrolled  The documentation must indicate the status of the diabetes.  Poorly controlled or poor control is vague terminology and does not necessarily indicate uncontrolled blood glucose levels.  Out-of-control or uncontrolled DM is coded only when the physician specifically documents this status. Example: Type II Diabetic PVD, poorly controlled –(250.70) and (443.81) Type II Diabetic PVD, uncontrolled –(250.72) and (443.81)

47 © Ingenix, Inc. 47 Importance of Specific Coding  What System is being Affected? –250.4XDiabetes with renal manifestations –250.5X Diabetes with ophthalmic manifestations –250.6XDiabetes with neurological manifestations –250.7XDiabetes with peripheral circulatory disorders –250.8XDiabetes with other specified manifestations –250.9XDiabetes with unspecified complications

48 © Ingenix, Inc. 48 Diabetes Coding Tool

49 © Ingenix, Inc. 49 Diabetes w/ Peripheral Circulatory & Other Manifestations Review: “ Diabetic PVD ” vs. “ Diabetic atherosclerosis of L-extr with associative ulcers ” See DM Coding Tool

50 © Ingenix, Inc. 50 Diabetes w/ Peripheral Circulatory & Other Manifestations This represents Diabetes “Associated” with Peripheral Circulatory Disorders 250.7x is hierarchical to 250.8x and therefore places the MA member into a higher risk category for expected resource allocation This represents Diabetes “Associated” with Other Specified Manifestations See DM Coding Tool

51 © Ingenix, Inc. 51 Diabetes w/ Peripheral Circulatory & Other Manifestations This represents diabetic PVD unspecified or specified types of atherosclerotic PVD of lower extremities “Diabetic” (atherosclerosis) of lower extremities (440.23) with ulcerations (701.x) is coded with 250.7x 250.7X X 3 Total Codes =+ See DM Coding Tool

52 © Ingenix, Inc. 52 Diabetes w/ Peripheral Circulatory & Other Manifestations This represents Diabetic PVD “unspecified atherosclerotic cause” The proper code for “Diabetic” PVD, “Unspecified” is (Not 443.9) See DM Coding Tool

53 © Ingenix, Inc. 53 Specificity Makes a Difference! “Diabetic” PVD (unspecified atherosclerotic cause) (Unspecified) “Diabetic” PVD (atherosclerosis) of lower extremities, with ulcers (440.23) and (707.1x) (Specified) Documenting and coding more specifically places the member in a higher risk category for expected resource allocation See DM Coding Tool

54 © Ingenix, Inc. 54 Specificity Makes a Difference! Note: Assign 250.8x when “diabetic” ulcers are not due to atherosclerosis See DM Coding Tool Example: “Diabetic PVD with Ulcers”

55 © Ingenix, Inc. 55 Specificity Makes a Difference! Note: Assign 250.8x when “diabetic” ulcers are not due to atherosclerosis See DM Coding Tool Example: “Diabetic PVD with Diabetic Ulcers”

56 FYI #2 Presented By Pam Holt

57 © Ingenix, Inc. 57 Patients “At Risk” for PAD  Ingenix can provide a report for your patients that are “At Risk” for PAD –Ad Hoc (not available on InSite) –Request through your Ingenix Market Consultant

58 © Ingenix, Inc. 58 User Group Feedback Survey  We want your feedback!  Survey is to be sent immediately after this call

59 © Ingenix, Inc. 59 Question and Answer


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