patient volume for meaningful use richard kashinski meaningful use national business analyst dnc...

Patient Volume forMeaningful Use

Richard KashinskiMeaningful Use National Business Analyst

DNC (Contractor) for  U.S. Indian Health Service OIT

Last Updated: October 18, 2011

Today’s Objectives

• Previous Patient Volume Report

• Patient Volume Reports for Eligible Professionals

• Patient Volume Reports for Eligible Hospitals

REC Report

• The first Patient Volume Reports, created for the RPMS Third Party Billing package, were released August, 2011

• These reports replace any reports you may have previously been using to calculate your patient volume

How is Patient Volume used for Meaningful Use

• EPs and EHs who want to participate in the Medicaid EHR Incentive program must show they serve a significant Medicaid or Needy Individual Population.

• The Patient Volume Report shows they have achieved minimum thresholds for participating.

ELIGIBLE PROFESSIONALS

Eligible Professionals for Medicaid

• Doctors of Medicine• Doctors of Osteopathy• Dentists• Nurse Practitioners• Certified Nurse Midwives• Physician Assistants (PA)

– When working at an FQHC/RHC/Tribal clinic that is lead by a PA

Eligible Professionals for Medicaid

• Not Hospital Based– 90% or more of their covered professional services

must not be in either an inpatient or emergency room (Place of Service codes 21 or 23) of a hospital

• Eligibility determined by law– List was created by Congress

Eligible Professionals: MedicaidPatient Volume Threshold

Eligible Professional (EP)

If EP does not practice predominantly at

FQHC/RHC/Tribal: Minimum Medicaid Patient

Volume Thresholds

If EP does practice predominantly at

FQHC/RHC/Tribal: Minimum Needy Individual Patient Volume Thresholds

Physicians 30% 30%

Pediatricians 20% 30%

Dentists 30% 30%

Certified Nurse-Midwives

30% 30%

NPs 30% 30%

PAs practicing at an FQHC/RHC/Tribal that is led by a PA

N/A 30%

Eligible Professionals: Medicaid Patient Volume Calculation

• 3 main options for calculating patient volume• Individual EP Calculation (Patient Encounter)• Group Calculation• Patient Panel*

• State picks from these or proposes new method for review and approval by CMS

• If CMS approves a method for one state, it may be considered an option for all states

*Will NOT be included in the RPMS Third Party Billing Patient Volume Reports.

Eligible Professionals: Patient Volume Report

• Sites using RPMS Third Party Billing– Can run Patient Volume Reports.

• Individual and Group Patient Volume percentages

• Sites using COTS products– Patient volume logic will be shared

Eligible Professionals & Medicaid: Medicaid Encounter

• For calculating Medicaid patient volume, a “Medicaid encounter” means services rendered to an individual on any one day where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for all or part of:

• The service; or

• Their premiums, co-payments, and/or cost-sharing

• In RPMS when a patient is seen by more than one provider, but only one provider receives payment, all encounters on that day will be counted as paid Medicaid encounters.

Eligible Professionals: Medicaid Individual EP Calculation

Individual EP Calculation: Medicaid

Total Medicaid patient encounters for the EP in any representative

continuous 90-day period in the preceding calendar year

Total patient encounters for the EP in that same 90-day period

*100

Eligible Professionals: Medicaid Group Practice Calculation

Group Practice Calculation: Medicaid

Total Medicaid patient encounters for the entire clinic/group practice in any

representative continuous 90-day period in the preceding calendar year

Total patient encounters for the entire clinic/group practice in that same 90-day

period

*100

To Use the Group Practice Calculation

1. The Group Practice patient volume must be appropriate for the EP (e.g., if an EP ONLY sees Medicare, commercial or self-pay patients, this is not an appropriate calculation).

2. There is an auditable data source to support the clinic’s patient volume determination.

3. The practice and EPs must use one methodology in each year (i.e. clinics could not have some EPs using individual patient volume while others use the group practice volume).

4. The clinic/group practice uses the entire practice or clinic’s patient volume and does not limit it in any way.

5. If EP works inside & outside of the clinic/practice, only those encounters associated with the clinic/practice are included, not the EP’s outside encounters.

Eligible Professionals & Medicaid: Needy Patient Encounter

• For calculating needy individual patient volume, a “Needy Patient” encounter means services rendered to an individual on any one day where:• Medicaid or CHIP (or a Medicaid or CHIP demonstration project

approved under section 1115 of the Act) paid for all or part of:• The service; or• Their premiums, co-payments, and/or cost-sharing; or

• The services were furnished at no cost; or• The services were paid for at a reduced cost based on a sliding

scale determined by the individual’s ability to pay

• In RPMS Medicaid and CHIPs visits will be calculated. Sites will have to calculate additional encounters of other needy types and add them to the RMPS Patient Volume Report values.

Eligible Professionals: Medicaid Needy Individual EP Calculation

Individual EP Calculation: Needy Individual

Total Needy Individual patient encounters for the EP in any representative continuous 90-day period in the preceding calendar year

Total patient encounters for the EP in that same 90-day period

*100

Eligible Professionals: Medicaid Needy Group Practice Calculation

Group Practice Calculations: Needy Individual

Total Needy Individual patient encounters for the entire clinic/group practice in any representative continuous 90-day period

in the preceding calendar year

Total patient encounters in that same 90-day period

*100

ELIGIBLE HOSPITALS

Eligible Hospitals

• Acute Care Hospitals – Including Cancer and Critical Access Hospitals where

the average length of stay is 25 days or fewer– All I/T/U hospitals qualify as Acute Care Hospitals

• Children’s Hospitals – CMS Certification Number (CCN) in the 3300-3399

series

Eligible Hospital: Medicaid Patient Volume Threshold

Eligible Hospitals Minimum Medicaid Patient Volume threshold

Acute care hospitals, including Critical Access Hospitals

10%

Eligible Hospital: Medicaid Patient Volume Calculation

• One option for calculating patient volume• Medicaid Encounters

• Each state can use this method or propose a new method for review and approval by CMS

• If CMS approves a method for one state, it may be considered an option for all states

Eligible Hospitals: Patient Volume Reports

• Sites using RPMS Third Party Billing– Can run Patient Volume Reports.

• Hospital/ER Patient Volume percentages

• Sites using COTS products– Patient volume logic will be shared

Eligible Hospital: Medicaid Encounter Definition

• For calculating Medicaid patient volume, a “Medicaid encounter” means services rendered to an individual where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of:

• Service per inpatient discharges, • Premiums, co-payments, and/or cost-sharing per inpatient

discharge • Service in an emergency department* on any one day, or, • Their premiums, co-payments, and/or cost sharing in an

emergency department* on any one day.

*An emergency department must be part of the hospital under the qualifying CCN.

Eligible Hospital: Medicaid Patient Volume Calculation

Hospital Medicaid Patient Volume Calculation

Total Medicaid encounters (hospital discharges/ER visits) in any

representative continuous 90-day period in the preceding fiscal year

Total encounters (hospital discharges/ER visits) in the

same 90-day period

*100

IHS Meaningful Use: Contact Information

• Chris Lamer, Meaningful Use Project Lead, IHS (615) 669-2747 Chris.Lamer@ihs.gov

• Cathy Whaley, Meaningful Use Project Manager, DNC(520) 622-2069Catherine.Whaley@ihs.gov

• Cecelia Rosales, Meaningful Use National Team Lead (505) 248-4359 Cecelia.Rosales@ihs.gov

• Richard Kashinski, Meaningful Use Business Analyst(505) 248-4910

Richard.Kashinski@ihs.gov

Questions?

Sign up for the MU Listserv!

More questions, contact us at:MeaningfulUseTeam@ihs.gov

Training Database Navigation

• Type CORE• Type TPB• Type RPTP• Type MURP• Type MUPV