1. High Intensity Care Management November 4, 2014 Webinar

2. 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 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

3. Comprehensive Clinical Model
Phase 1 Launch
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

4. Medicare Advantage STAR Recognition Program

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. Provider Recognition Program
BCN

13. 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: , ,
Home services: ,
Nursing facility care: , 99315, 99316, 99318
Domiciliary, rest home or custodial care services: ,
Preventive medicine: , , , 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®: , , , , , , , , 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: , V22, V23, V28
Breast Cancer Screening (BCS)

14. 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

15. Claims Coding Reference
Measure
Codes
Breast Cancer Screening (BCS)
CPT®:
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,
ICD-9-PCS: 85.41, 85.43, 85.45, 85.47
Two unilateral mastectomies
*50 and 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, Plus
CPT® II: 3048F, 3049F, 3050F

16. 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®: , , 45345
HCPCS: G0104
ICD-9-PCS: 45.24
Colonoscopy between 1/1/2004 and 12/31/2013:
CPT®: , 44397, 45355, , 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, , 154.0, 154.1, 197.5, V10.05
Total colectomy
CPT®: ,
ICD-9-PCS:
Claims Coding Reference

17. HEDIS Coding Reference
Measure
Codes
Comprehensive Diabetes Care (CDC) – Eye Exam
CPT®: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , ,
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: , 251.8, 648.8, , 962.0
HEDIS Claims Coding Reference

18. HEDIS Claims Coding Reference
Measure
Codes
Comprehensive Diabetes Care (CDC) – HbA1c
CPT®: 83036, 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: , 251.8, 648.8, , 962.0
Comprehensive Diabetes Care (CDC) – LDL-C
CPT®: 80061, 83700, 83701, 83704, PLUS
CPT® II: 3048F, 3049F, 3050F

19. HEDIS Claims Coding Reference
Measure
Codes
Comprehensive Diabetes Care (CDC) – Nephropathy Screening
CPT®: 82042, 82043, 82044, PLUS
CPT® II: 3060F, 3061F, 3066F, 4010F
ICD-9-CM: 250, , , 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: , 251.8, 648.8, , 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,
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, , 94060, 94070, 94375, 94620

20. HEDIS Claims Coding Reference
Measure
Codes
Osteoporosis Management in Women Who Had a Fracture (OMW)
Codes to identify bone mineral density test:
CPT®: 76977, , 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

21. Open Discussion