1. electronic Submission of Medical Documentation (esMD) electronic Determination of Coverage (eDoC) Home Health (HH) Face to Face (F2F) Encounter
Thank you very much for making time to participate in the esMD electronic Determination of Coverage (eDoC) Home Health User Story Community Meeting. This is the 2nd Launch of the HH User Story. This CMS Initiative is being developed through esMD as an S&I Workgroup under ONC. esMD supports CMS in continuing to facilitate Medicare Provider / Supplier transition from paper to electronic structured Medical Documentation in addressing Medicare FFS Payment Error. We will also touch base on other workgroups we interface with, Pilot Projects that have launched, electronic submission of Medical Documentation, esMD Timelines, and Author of Record. We will also provide additional references and resources for your use.
August 5, 2015

2. Welcome and Introductions
Melanie Combs-Dyer, RN
Deputy Director, CMS / OFM / Provider Compliance Group
Dan Kalwa
Health Insurance Specialist, CMS / OFM / Provider Compliance Group
LT Melanie Edwards
Health Insurance Specialist CMS / OFM / Provider Compliance Group
Robert Dieterle,
Initiative Coordinator
Sweta Ladwa, MPH
Project Manager – Epidemiology
ESAC, Inc
Mark D Pilley, MD AAFP, AADEP, ABQAURP
Medical Director
StrategicHealthSolutions, LLC 2

3. Agenda Opening Remarks Introduction to esMD S&I Initiative
HH F2F Encounter Use Case Presentation
Questions & Answers
Closing Remarks
Here is an overview of today’s agenda. 3

4. Standards & Interoperability (S&I) Framework
Why use the S&I Framework?
It is a robust, repeatable process that will help improve interoperability and adoption of standards and health information technology.
The S&I Framework will streamline execution of the Data Segmentation initiative across the solution development lifecycle
Standards and interoperability, S&I Framework, under ONC is very robust, repeatable process that'll help to improve interoperability and the adoption of standards of health information technology in the exchange of information in the medical documentation. The S&I Framework will streamline the execution of the data segmentation initiative across the solution development life cycle which is the next slide, 4

5. Solution Development Lifecycle
eDoC Phase
Details
Charter
Challenge statement
Timelines and milestones
Goals and outcomes
Use Case
Create Use Case and User Stories
Actors and roles
Activity and Sequence diagrams
Dataset Requirements
Risks, Issues and obstacles
Sub-workgroup effort
Structured data requirements
Templates for data capture
Decision support
Standards Harmonization
Identify candidate standards
Create data model(s)
Map data model(s) to candidate standard(s)
Identify gaps, barriers and obstacles
Work with SDOs to address gaps
This is our development life cycle. The S&I initiative phases are on the left-hand side. And you can see, there is a (step by step) process of pre-discovery, discovery implementation, and in launching pilot projects and then evaluate on those pilot projects for effectiveness and lessons learned.
The Solution Development Lifecycle of electronic determination of coverage (eDoC) is one of the esMD WG phases under the S&I Initiative. The esMD workgroup initially completed a charter which provides guidance in developing a use case. Once the use case is developed the next step is to reach consensus through harmonization and the identification of specific categories of clinical information that is cross walked to Standardized structured data, such as HL7. This provides implementation guidance for the formation of pilot projects to test, evaluate, modify, and implement the use case.
Today is the Launch of the HH use case. In future meetings we will continue to concentrate the necessary details of user story. We will define the actors or providers that have specific roles and develop a workflow of the activities in a sequence diagram(s). We identify categories of clinical information that can be cross walked to structured data which can be used to develop structured documents for electronic submission of those documents to the payer upon request. We identify risk issues for those risks and obstacles that need to be addressed. The esMD sub workgroup focus on efforts to develop structured data requirements, templates for data capture, and the assistance support.
Implementation Guidance & Piloting
Create implementation guide(s)
Identify pilot participants
Develop pilot / demonstration plan
Evaluate success
Modify Implementation guide(s) as required 5

6. Improper Payment Medical Documentation Requests are sent by:
Medicare receives 4.8 M claims per day.
CMS’ Office of Financial Management estimates that each year
the Medicare FFS program issued more than $45.8 B in improper payments (error rate 2014: 12.7%).
the Medicaid program issued more than $29.3 B in improper payments (error rate 2014: 6.7%).
Most improper payments can only be detected by a human comparing a claim to the medical documentation.
Medical Documentation Requests are sent by:
Medicare Administrative Contractors (MACs) Medical Review (MR) Departments
Comprehensive Error Rate Testing Contractor (CERT)
Payment Error Rate Measurement Contractor (PERM)
Medicare Recovery Auditors (formerly called RACs)
Claim review contractors issue over 1.8 million requests for medical documentation each year.
Claim review contractors currently receive most medical documentation in paper form or via fax.
Medicare and Medicaid issue billions of dollars in improper payments every year. The majority of payment error is due to insufficient documentation of clinical information, incorrect coding, and absence of a valid signature confirming Author of Record. The esMD Initiative is focused on promoting providers to improve Medical Documentation workflow directed at reducing payment error. Better documentation that substantiates accurate clinical information that can be submitted electronically to CMS Review and Audit Contractors through the esMD Gateway.
CMS hires Review / Audit Contractors to help find improper payments. Physicians, Nurses and other clinicians at the review contractors identify improper payments when comparing the claim to the medical documentation created by the provider at the time of service.
Hospitals, Physician Offices, Home Health providers, and other providers receive many requests for patient’s medical records every year from Medicare and Medicaid Review Contractors.
Medicare receives about 4.8 million claims per day. In 2013, Medicare fee-for-service program was estimated to issue more than $36.0 billion of improper payments. That's about a 10.1 percent error rate. Medicaid program was found to have about $14.4 billions of improper payments in 2013.

7. Improper Payment
Table B3: Top 20 Service Types with Highest Improper Payments: Part A Excluding Inpatient Hospital PPS Service Type Billed to Part A excluding Inpatient Hospital PPS (Type of Bill)
Projected Improper 95% Type of Error
Improper Payment Confidence No Insufficient Medical Incorrect
Payments Rate Interval Doc Doc Necessity Coding Other
Home Health $9,395,609, % % % % % 8.9% % 0.6%
Hospital Opt $3,450,750, % % % % % 1.6% % 0.2%
SNF Inpatient $2,451,703, % % - 8.7% % % 3.3% % 6.7%
Hosp Inpt (Part A) $1,345,286, % % % % % 50.6% % 1.9%
Clinic ESRD $1,168,927, % % % % % 2.3% % 0.3%
Nonhosp hospice $471,100, % % - 6.1% % % 27.5% % 2.6%
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
The Supplementary Appendices for the
Medicare
Fee-for-Service
2013 Improper Payment Rate Report
This slide shows improper payments for Part A services excluding inpatient hospital services for This report came out in November As you can see at the top of the list is Home Health Services, with a projected improper payments of $3.091 billion. That's 17.3 percent of this particular improper payment rate. This report is published by the CERT.

8. esMD Background Phase 1: Phase 2: Before esMD: Provider 8 electronic
Healthcare payers frequently request that providers submit additional medical documentation to support a specific claim(s). Until recently, this has been an entirely paper process and has proven to be burdensome due to the time, resources, and cost to support a paper system.
Review Contractor
Provider
Request Letter
Paper Medical Record
Phase 1:
Doc’n Request Letter
electronic
Phase I of esMD was implemented in September of It enabled Providers to send Medical Documentation electronically
This slide provides a high level overview background of esMD Initiative. The initiative before Phase 1 went into effect was what we traditionally knew as the paperwork flow, the paper trail, the USPS request for documentation in support of services that were built and sending of paper documentation by USPS to the review contractor for a review.
Phase 1 went into effect in September 2011, with the continuance of the paper request for documentation but with the capabilities and availability for providers to send documents electronically through the esMD gateway. This was a viable option and today, it's a growing option.
Phase 2 is the ability to send electronic medical documentation request and to receive electronic medical documentation in response to that request by the payer, followed by sending the requested Medical Documentation electronically back to the Medicare Contractor through the esMD Gateway. We hope to see Phase 2 implemented in the near future, exactly when is not known. .
The ONC S&I Framework Electronic Submission of Medical Documentation (esMD) initiative is developing solutions to support an entirely electronic documentation request.
electronic
Phase 2: 8

9. esMD Process Flow
The overall esMD process can be divided into three steps:
A provider registers with a payer to receive electronic medical documentation requests (eMDRs)
1. Register to Receive eMDRs
A payer sends an eMDR to a registered provider
2. Send eMDRs
A provider electronically sends medical documentation to a payer in response to an eMDR
3. Send Medical Documentation
This slide gives you a basic high level overview of Phase 2 or the electronic Medical Documentation Request. Providers would opt to request to receive electronic medical documentation request, the eMDR, and would receive those eMDRs from Medicare FFS Contractor and then in response, send back to the medical documentation in electronic form.
esMD Phase 2
esMD Phase 1 9

10. Electronic Determination of Coverage (eDoC)
Underlying Challenge:
Enable provider capture of documentation and benefit determination based on payer rules
Secure exchange of templates, decision support, and documentation between payers, providers, Home Health Agency and beneficiary
Scope:
Focus on defining the use case, user stories and requirements supporting a standards-based architecture
Reuse of existing S&I Initiative efforts where possible
Creation of structured data capture templates and supporting exchange standards
HH F2F Encounter as Use Case
Outcome:
Successful pilot of templates, decision support, information exchange standards over standard secure transactions for the purpose of determining coverage
Validation with use case for HH F2F Encounter
This is a basic overview of the Underlying Challenges, Scope, and Outcomes the esMD Initiative is focused on achieving.
In terms of our challenges, we hope to enable the provider to capture the documentation to benefit determination of coverage based on payer rules. This allowing the physician to find the appropriate clinical information that substantiates the face-to-face encounter occurred supporting certificate of HHS. This allows the provider to put together a document that has good information for benefit coverage. Secure exchange of the clinical information in the Medical Documentation allows decisions support and sending of documentation between payers, providers, home health agencies and the beneficiary.
The scope is defining the use case, the user stories, the requirements supporting the standards-based architecture for the medical documentation; reuse of existing S&I initiative efforts were impossible, and creation of structured documentation using the clinical information identified in the templates and supporting exchanged standards; Home Health face-to-face encounter as a use case; the outcome is a successful pilot of templates and decision support to the EMR systems; information exchange standards over standards of secured transactions for the purpose of determining coverage; and this also includes the possibility of a digital signature that is ascribed to the document to validate Author of Record (AoR). This is the use case for face-to-face encounters. 10

11. eDoC General Workflow HH F2F Encounter
Patient
LCMP/
Therapist/
Specialist
Physician/
Non-Physician Provider
Home Health Agency
This slide depicts the general workflow. This is a busy slide. It points out that the patient is going to be at the top of the pinnacle of the workflow and is the focus of coverage of provider services. Physician and non-physician providers are involved. As per the policy language, the physician must document the face-to-face encounter supporting certification of HHS. Non-physician providers are allowed to complete the face-to-face encounter itself but the completion of the F2F Encounter document is anticipated and expected to be by performed by the physician.
There is interchange between the home health agency as indicated on the right side of this slide. There is sometimes a need to involve other specialists like a physical therapist, occupational therapist, or even a physiatrist on occasions. There's exchange of the information through the health information handler (HIH) or directly to the esMD electronic gateway through CONNECT. The occupational therapist and physical therapist themselves are not considered allowed non-physician providers. They do provide information that physicians can use n understand their patients' functional limitations, capacities, risk and tolerances.
Templates and Rules
Payer 11

12. Possible Documentation Processes for HHA Services (Scenario 1: Community Physician seeing Patient in the Office) 1
Has an in-person visit with physician
Beneficiary 2
90 days before or 30 days after the first HHA visit, documents the in-person visit in an office note in the medical record. Should include:
Homebound status of beneficiary
Need for skilled care
Ordering Physician 6
Signs/Dates
POC
Certification Statement 3
Writes Order for HHA services before first HHA visit
Fax or
Direct
Fax or
Direct
Fax or
Direct 4
Receives and Files:
In-person visit progress note
Order 7
Receives and File:
POC
Certification Statement 5
Drafts a
Plan of Care (POC)
HHA

13. Possible Documentation Processes for HHA Services (Scenario 2: Hospitalist seeing Patient in the Hospital)
Beneficiary 1
Has an in-person visit with physician 2
90 days before or 30 days after the first HHA visit, documents the in-person visit in Discharge Summary in the medical record. Should include:
Homebound status of beneficiary
Need for skilled care
Hospitalist 3
Writes Order for HHA services before first HHA visit 6
Signs/Dates
POC
Certification Statement
Fax or
Direct
Community Physician
Fax or
Direct 4
Receives and Completes
Discharge Summary (in-person visit)
Order for HH services 7
Receives and File:
POC
Certification Statement
HHA 5
Drafts a POC
Fax or
Direct

14. Related S&I Framework Initiatives
Description
Relationship
Transitions of Care (C-CDA)
Defines the electronic communication and data elements necessary for clinical information exchange to support transfers of care between providers and between providers and patients
Standards for the exchange of clinical information
Provider Directories
Defines transaction requirements and core data sets needed to support queries to provider directories to enable electronic health information exchange
Electronic endpoints for participants in eDoC
Structured Data Capture (SDC)
External template driven capture of structured data within the EHR
Templates and workflow to capture payer required information
esMD Author of Record
Standards for providing digital signatures to transactions and documentation.
Standards for Digital Signatures on transaction and documents
Direct
a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information
Utilize Direct as a transport mechanism between providers, payers and suppliers
These are related S&I Framework initiatives that esMD interfaces with. First one is transitions of care. This defines the electronic communication and standards necessary for clinical information exchange to support transfers of care between providers and between providers and patients. The relationship with esMD is in aplying standards for exchange of clinical information. And I believe it's this workgroup that has developed a plan of care and uses a particular form called the 485 form. This is not a CMS authorized form but one that is commonly used. CMS in not prescriptive and has not published a required form. The esMD HH F2F Use Case being developed will dovetail on to transitions of care.
Provider directories are the next line down or row down. This defines the transition requirements and core data sets needed to support queries to provider directories to enable electronic health information exchange. This will provide the electronic endpoints for participants in Electronic Determination of Coverage, or what we call eDoC.
The next related initiative is that of Structured Data Capture, SDC for short. This is an external template driven capture of structured data within the electronic health record. The relationship is with the Templates and workflow to capture payer required information. The next related initiative is the esMD Author of Record (AoR). This is the development of Standards for providing a digital signature that is identity proofed at a medium level across the federal bridge issued by a certifying authority or registered authority and relates to the standards for applying digital signatures on structured Medical Documents. If this could be implemented there's a potential we can reduce some of our payment error rate by as much as 20 to 30 percent and speed up turnaround times for medical review and audit determinations.
Direct is a transport system that provides a simple, secure, scalable standards-based way for participants to send authenticated, encrypted health information. This utilizes direct as a transport mechanism between providers, payers, and suppliers, and it can potentially used to sent electronic Medical Documentation to the esMD gateway. 14

15. eDoC Workgroup Structure
Charter
Use Case
Harmonization
Pilots
Sub-Workgroups
User Stories
Power Mobility Devices
Lower Limb Prostheses
Home Health Services
Structured Data
Determine documentation requirements
Evaluate appropriate clinical elements
Clinical Vocabularies
Define CCDA template
Documentation Templates
Define template requirements
Define template workflow
Define EHR data capture requirements
Specify storage requirements
Transport
ASC X12 275, 278, 277
Direct
CONNECT
This slide gives you overall workgroup structure for the esMD workgroups. As you can see, at the top, as outlined previously, a charter is first established followed by the use case, harmonization and pilots. Next are the Sub-workgroups: other use case stories are listed that are in the Pilot process at this time: power mobility devices (PMD), and Lower Limb Prosthetics (LLP).
Our third initiative is home health services (HHS). The structured data Sub-workgroup focuses on determining documentation requirements, evaluate appropriate clinical information, and clinical vocabularies. But we don't want to leave clinical information or categories of clinical information out of a document template. The physician may want and/or need to use specific clinical information in describing the patient’s presentation in the Medical Documentation available in defined clinical vocabularies.
The documentation templates Sub-workgoup will define requirements that define workflow and define EHR data capture. Transport systems are just that. That's how you send the bundled documentation electronically. ASC X12 275, 270, 277 through direct and connect into the esMD gateway.
Consolidated CDA
Structured Data Capture
esMD eDoC IGs 15

16. Home Health – Face to Face Encounter16

17. Patient Eligibility – Home Health Services (HHS)
Medicare's coverage and patient eligibility rules can be found at:
This is the Website link to Medicare’s coverage center regarding patient eligibility rules for Home Health benefits.

18. Prepayment – Post-Payment
Types of Review
Prepayment – Post-Payment
n Letters are sent to:
Home Health Provider
Illustrated is a map of the current Home Health and Hospice MACs currently performing Prepayment and Post-Payment review of Home Health claims regarding Medicare beneficiaries services. 18

19. Prepayment & Post-payment Decision Letters are sent to:
Home Health Provider 19

20. Structured Information HH F2F Encounter Documentation
Based on clinical template developed by CMS
Available at Systems/Computer-Data-and-Systems/Electronic-Clinical- Templates/HomeHealthHHElectronicClinicalTemplate.html
Suggested e-Clinical Template
and-Systems/Electronic-Clinical-Templates/Downloads/eclinicaltemplatev44.pdf
Supports
Data collection by Physician / NPP during HH F2F Encounter
Reporting of clinical information for coverage determination
Clinical decision support and automated determination of coverage
Clinical Information for Structured Medical Documentation of a Home Health (HH) Face to Face (F2F) Encounter has basis with the electronic Clinical Template developed by CMS which can be accessed using the listed Website links contained in this slide.
The electronic template supports data collection of clinical information for completing structured Medical Documentation by the evaluating Physician or Non-Physician Provider obtained during the HH F2F encounter substantiated the need for Homebound HH services while also providing clinical decision support and automated or electronic determination of coverage. 20

21. Components of HH F2F Encounter e-Clinical Template
Chief Complaint
History of Present Illness
Past Medical History
Past Surgical History
Allergies/Current Medications
Review of Systems
Objective Findings
Assessment
Plan/Orders
Homebound Status
Physician or Treating Practitioner’s (NPP) Information
Completed, Signed and Dated Certification for HH services
Components focused on data to support coverage of home health services under the Medicare Benefit
Listed on this slide are the general sections of the HH F2F eClinical Template.
Chief Complaint
History of Present Illness
Past Medical History
Past Surgical History
Allergies/Current Medications
Review of Systems
Objective Findings
Assessment
Plan/Orders
Homebound Status
Physician or Treating Practitioner’s (NPP) Information
Completed, Signed and Dated Certification for HH services
These Components focus on providing necessary information to be available for the evaluating provider in collecting and documenting sufficient data to support coverage of home health services under the Medicare Benefit. 21

22. Evaluation Process for HH F2F Encounter e-Clinical Template
Examination of individual clinical elements for each section of the template
Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)
Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components
Develop Templated CDA based on consensus and best practices
The esMD Use Case for the HH F2F Encounter eClinical Template will:
Exam individual clinical elements for each section of the template
Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)
Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components
Develop a Templated CDA based on consensus and best practices 22

23. Call for Public Participation
As an S&I Initiative, esMD is requesting public participation and input to identify and assess existing standards and define requirements
Targeted Participants:
Medicare, Medicaid, and Commercial Payers
Providers, Provider Organizations
Service suppliers (e.g. DMEs)
Health Information Handlers (HIHs)
HIT/EHR Vendors and Vendor Associations
State HIEs, HIE Vendors
SDOs
CAQH CORE
Others with Expertise/Interest in Coverage Determination, Structured Documentation, Decision Support, and Pre-authorization,
The esMD S&I Initiative invites and welcomes public participation and input in identifying and assessing existing standards and define requirements for this Use Case. Targeted Participants include but are not limited to those listed on this slide. 23

24. Summary Payer interaction with providers for determination of coverage
eDoC workgroup identifies Best Practice for:
Payer interaction with providers for determination of coverage
Developing, delivering and using structured documentation templates to support coverage determination
Addressing Author of Record requirements
Secure electronic communication between payers, provider, suppliers and beneficiaries
Creating implementation guides for payers and providers for all required eDoC processes and transactions
The electronic Documentation of Coverage workgroup identifies Best Practice for:
Payer interaction with providers for determination of coverage
Developing, delivering and using structured documentation templates to support coverage determination
Addressing Author of Record requirements
Secure electronic communication between payers, provider, suppliers and beneficiaries
Creating implementation guides for payers and providers for all required eDoC processes and transactions 24

25. Next Steps
The electronic Determination of Coverage Workgroup is open for anyone to join. This community will meet weekly by webinar and teleconference from 1:00 to 2:00 pm ET on Wednesday see S&I Framework calendar for webinar information:
Information on how to join the Community can be found on the electronic submission of Medical Documentation (esMD) page:
In order to ensure the success of eDoC and the subsequent pilots, we encourage broad and diverse participation from the community. Wide community participation will ensure that the standards reflect technology that is useable across the industry and that it meets the needs of all stakeholders.
This is your chance to have an impact on the evaluation and selection of standards and the creation of implementation guides for the electronic Determination of Coverage. 25

26. References
Links
esMD Initiative:
esMD Program:
CMS Electronic Clinical Template Program: 26

27. References Links Progress Note and Guidance – Electronic HH Template:
Home Health Paper Clinical Template: 27

28. Contact Information
Contact Information Robert Dieterle – esMD Initiative Coordinator Dan Kalwa – CMS Melanie Edwards – CMS Mark Pilley – Co Lead Sweta Ladwa – Co Lead 28

29. 29