High Intensity Care Management November 4, 2014 Webinar

Additional 2014 Clinical Model Elements The following elements of the clinical model cannot be tracked/measured via the claims system, but are identified as important goals within the clinical model. Physician Organizations should track these metrics. Metrics will be discussed at joint meetings, in addition, Physician Organizations may be asked to submit data to BCBSM. Clinical Model Goal Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact) Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months Quarterly review/update of care plan for engaged patients Hospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient needs SNF to home transition initial contact within 24-48 hours of discharge for engaged patients SNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs

Comprehensive Clinical Model Phase 1 Launch 10-1-14 Full Launch 4-1-15 HICM Common Clinical Model Components Subset of Core Model Core Model Comprehensive Clinical Model 1.24/7 phone access to clinical decision-maker with electronic access to pt record ● 2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority for July 1, 2014 start 3. In-home health care assessment by PCP, NP, or PA for homebound 4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments 5. Patient-specific comprehensive care plan (updated at least quarterly) 6. Care management team includes pharmacist and nutritionist 7. Access to in-home PT and OT 8. Care transitions management – Hospitals 9. Care transitions management – SNFs 10. Access to palliative care team 11. Access to hospice 12. Transportation for non-emergent medical visits and Rx 2016 13. Remote patient monitoring (weight, BP, glucose) 14. Standardized staff training 15. Review of all patients on monthly patient lists, common outreach script (2nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list

Medicare Advantage STAR Recognition Program

Medicare STAR Ratings The CMS star rating program is a pay-for-performance program for Medicare Advantage plans Plans will now receive revenue based on outcomes and the quality of their performance The higher the quality ranking, the higher the payments and the more competitive the plan is in the marketplace This is an attempt by CMS to create a new paradigm to bend the cost curve

What’s Measured STAR ratings measure a Plan’s performance in delivering quality outcomes STAR ratings are based on 53 key quality measures (36 related to Medicare and 17 related to prescription drug coverage) across the five following domains (subset of HEDIS measures)

What do CMS STARS Rating Measure Staying Healthy: screenings, tests, and vaccines Managing chronic (long term) conditions Ratings of health plan responsiveness and care Member complaints, problem getting services, and choosing to leave the plan Health plan customer service

What’s It Look Like Clinical quality and outcomes HEDIS Plan administrative performance and compliance Member assessment of their health (Health Outcomes Survey) Member perceptions of Plan, providers and care CAHPS

2014 Provider Outreach Activities Diagnosis coding education where DDDS is not part of practice HEDIS/STARS for all targeted providers Activities include: Address and close HEDIS/STARS treatment opportunity gaps Address and close Enterprise and BCNA risk adjustment diagnosis gaps

2014 Provider Outreach Activities Activities include: Support HEB education and sign-up Support provider staff on scheduling member appointments Provide education to providers Provide reference tools and materials to providers Retrieve medical records related to treatment opportunity gaps if necessary

2014 Provider Outreach Activities Activities include: Retrieve medical records for BCNA risk adjustment diagnosis gaps, BCNA only Complete focus-driven activities as specified Report on outreach activities completed by practice unit/providers

Provider Recognition Program BCN

Claims Coding Reference Measure Codes Adults’ Access to Preventive/ Ambulatory Health Services (AAP) CPT® codes to identify preventive/ ambulatory health services: Office or other outpatient services: 99201-99205, 99211-99215, 99241-99245 Home services: 99341-99345, 99347-99350 Nursing facility care: 99304- 99310, 99315, 99316, 99318 Domiciliary, rest home or custodial care services: 99324-99328, 99334-99337 Preventive medicine: 99381- 99387, 99391-99397, 99401- 99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, S0620, S0621 Ophthalmology and optom­etry: 92002, 92004, 92012, 92014 General medical examination: ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Adult Body Mass Index (ABA) Assessment CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 HCPCS: G0402, G0438, G0439 ICD-9-CM Codes to identify BMI: V85.0-V85.5 Exclusions: Members with a diagnosis of pregnancy in the measurement year or the year prior to the measurement year. ICD-9-CM: 630-679, V22, V23, V28 Breast Cancer Screening (BCS)

Claims Coding Reference Measure Codes Annual Monitoring for Patients on Persistent Medications (MPM) Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics:   Drug serum concentration for serum potassium: CPT®: 80051, 84132 Drug serum concentration for serum creatinine: CPT®: 82565, 82575 Drug serum concentration for blood urea nitrogen: CPT®: 84250, 84525 *Drug serum concentration for Digoxin: CPT®: 80162 Monitoring for Anticonvulsants: Drug serum concentration for phenobarbital: CPT®: 80184 Drug serum concentration for carbamazepine: CPT®: 80156, 80157 Drug serum concentration for phenytoin: CPT®: 80185, 80186 Drug serum concentration for valproic acid and divalproex sodium: CPT®: 80164 Lab panel codes: CPT®: 80047, 80048, 80050, 80053, 80069

Claims Coding Reference Measure Codes Breast Cancer Screening (BCS) CPT®: 77055-77057 HCPCS: G0202, G0204, G0206 ICD-9-PCS: 87.36, 87.37 Exclusions: Members with a bilateral mastectomy. Any of the following meet criteria for bilateral mastectomy: Bilateral mastectomy ICD-9: 85.42, 85.44, 85.46, 85.48 Unilateral mastectomy CPT®: 19180, 19200, 19220, 19240, 19303-19307 ICD-9-PCS: 85.41, 85.43, 85.45, 85.47 Two unilateral mastectomies *50 and 09950 modifier codes indi­cate the procedure was bilateral and performed during the same operative session. Cholesterol Management for Patients with Cardiovascular Conditions (CMC) CPT®: 80061, 83700, 83701, 83704, 83721 Plus CPT® II: 3048F, 3049F, 3050F

Claims Coding Reference Measure Codes Colorectal Cancer Screening (COL) FOBT Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013: CPT®: 82270, 82274 HCPCS: G0328 Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013: CPT®: 45330-45335, 45337-45342, 45345 HCPCS: G0104 ICD-9-PCS: 45.24 Colonoscopy between 1/1/2004 and 12/31/2013: CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 HCPCS: G0105, G0121 ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, 45.43 AND/OR Chart documentation of previously performed colorectal cancer screening tests. Exclusions: Members with a history of either of the following: Colorectal cancer HCPCS: G0213-G0215, G0231 ICD-9-CM: 153, 153.0-153.9, 154.0, 154.1, 197.5, V10.05 Total colectomy CPT®: 44150-44158, 44210-44212 ICD-9-PCS: 44.80-45.83 Claims Coding Reference

HEDIS Coding Reference Measure Codes Comprehensive Diabetes Care (CDC) – Eye Exam CPT®: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 CPT® II codes: 2022F, 2024F, 2026F, 3072F HCPCS codes: S0620, S0621, S0625, S3000 Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: 256.4 A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0 HEDIS Claims Coding Reference

HEDIS Claims Coding Reference Measure Codes Comprehensive Diabetes Care (CDC) – HbA1c CPT®: 83036, 83037 PLUS CPT® II: 3044F, 3045F, 3046F Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: 256.4 A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0 Comprehensive Diabetes Care (CDC) – LDL-C CPT®: 80061, 83700, 83701, 83704, 83721 PLUS CPT® II: 3048F, 3049F, 3050F

HEDIS Claims Coding Reference Measure Codes Comprehensive Diabetes Care (CDC) – Nephropathy Screening CPT®: 82042, 82043, 82044, 84156 PLUS CPT® II: 3060F, 3061F, 3066F, 4010F ICD-9-CM: 250, 403-405, 580-588, 753, 791 Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: 256.4 A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) ICD-9-CM codes to identify rheumatoid arthritis: 714.0, 714.1, 714.2, 714.81 HCPCS codes to identify pharmacy claims for DMARD in the measurement year: J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310 Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) COPD: Chronic bronchitis: 491 Emphysema: 492 COPD: 493.2, 496   CPT® codes to identify spirometry testing: 94010, 94014-94016, 94060, 94070, 94375, 94620

HEDIS Claims Coding Reference Measure Codes Osteoporosis Management in Women Who Had a Fracture (OMW) Codes to identify bone mineral density test: CPT®: 76977, 77078-77083, 78350, 78351 HCPCS: G0130 ICD-9-CM: 88.98 AND/OR pharmacy claims for osteoporosis drug therapy: HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488

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