claims based outcomes reporting “or” - audiofly · 2012-11-29 · claims based outcomes...
TRANSCRIPT
Claims Based Outcomes Reporting“CBOR”
Michael Stevenson, MBA, PTDirector, Product Management
Section 3005(g) of the MCTRJCA requires CMS to implement, beginning on January 1, 2013,
“. . . a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Act. Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.”
The Other Shoe Has Dropped
WHO
Medicare Part B (p. 227)
All areas of outpatient therapy services including hospitals, CAH, CORF, private practice, home health (after A benefit), SNF, etc.
WHEN
Time Line (p. 277)
Test Period: January 1 – July 1
Payment Rejection after July 1
CBOR
HOW
Must use Outcomes Measures that map to a 7 point scale
AM-PAC, FOTO, OPTIMAL, NOMS recommended by CMS in IOM
IOM provision of the Benefits Policy Manual, Chapter 15, Section 220.3C “Documentation Requirements for Therapy Services.”
14 new G-codes sets
11 Functional G-codes (7 of those SLP)
3 ‘other’, one for each discipline
7 Impairment Limitation Restriction Modifiers
CBOR
Eval/Re-eval Goal Discharge
PT/OT
Mobility: Walking & Moving Around G8978 G8979 G8980
Changing & Maintaining Body Position G8981 G8982 G8983
Carrying, Moving & Handling Objects G8984 G8985 G8986
Self Care G8987 G8988 G8989
Other PT/OT Primary Functional Limitation G8990 G8991 G8992
Other PT/ OT Subsequent Functional Limitation G8993 G8994 G8995
SLP
Swallowing G8996 G8997 G8998
Motor Speech G8999 G9157 G9158
Spoken Language Comprehension G9159 G9160 G9161
Spoken Language Expression G9162 G9163 G9164
Attention G9165 G9166 G9167
Memory G9168 G9169 G9170
Voice G9171 G9172 G9173
Other SLP Functional Limitation G9174 G9175 G9176
G-codes and ModifiersImpaired Limitation
Restriction (% Impaired)
CH 0%CI 20 ≤ 1%
CJ 40≤ 20%CK 60≤ 40%
CL 80≤ 60%CM 100≤ 80%
CN 100%
0% Impaired
20% Impaired
40% Impaired
60% Impaired
80% Impaired
100% Impaired
Mo
dif
ier
Scal
e
Functional G-codes
Only code the primary functional deficit. (p. 246)
If you resolve primary and move to a secondary functional deficit, new G codes must be applied. (p. 246)
If using a composite score instrument, code as ‘other functional impairment’ (FOTO, AM-PAC) (p. 244)
Goal G-Code Modifiers
Intended to be Long Term, Episodic, or Discharge Goal, not short term goal (p. 261)
If you switch to subsequent functional area, you must reset goal codes
Coding Details
In summary, we maintain that claims-based reporting should occur at the outset of therapy episode, on or before every 10 treatment days throughout the course of therapy, and at the time of discharge from therapy. Additionally, functional reporting is also required at the time the beneficiary’s condition changes significantly enough to clinically warrant a re-evaluation such that a HCPCS/CPT code for a re-evaluation or a repeat evaluation is billed.
(Page 273)
Reporting Frequency
• Current G-code w/ modifier
• Goal G-code w/ modifierEval
• Current G-code w/ updated modifier
• Goal G-code w/ modifier (updated)Every 10th Visit
• Discharge G-code w/ modifier
• Goal G-code w/modifierFinal Visit
• New Current G-code w/ modifier
• New Goal G-code w/modifierChanging Primary
Condition
G-code Steps
“We are finalizing the proposed requirement that the G-codes and related modifiers must be documented in the beneficiary’s medical record.” p. 275
This includes functional status, goal, and discharge G codes according to the schedule published in earlier slides.
Documentation
For each line on the institutional claim submitted by hospitals, SNFs, rehabilitation agencies, CORFs and HHAs, a charge of one penny, $0.01, can be added.
For each line on the professional claim submitted by private practice therapists and physician/NPPs, a charge of $0.00 can be added.
A Penny For Your Trouble
To continue market leadership, MediServe developed the web-based data collection tool for the DOTPA program.
MedPAC suggested that “CMS consider developing an instrument that collects the necessary information that would allow Medicare to categorize beneficiaries by condition and severity in order to pay appropriately” and pointed to the “Reason for Therapy” form used in the DOTPA study as a starting point, noting that it is “concise, easy to assess and document for clinicians, and collects information on function and limitations across three therapy disciplines.” (p. 259)
A Look Ahead
SOLUTION IDEAS
PLEASE MUTE YOUR PHONEI WILL BE TURNING ON ALL
THE MICROPHONES
1. Map / update ICF-based functional problem list to CMS list.
2. Modify Problem List / Goal branch 1. Ask ‘level of impairment after choice of functional area,’
(Selection list of modifiers)
2. Allow free text goal description
3. Prompt for goal setting. (Selection List of modifiers)
3. Create 294 charge code definitions (one for each combination of G-code and modifier.)
4. In this configuration, the PRIMARY FUNCTIONAL IMPAIRMENT MUST BE DOCUMENTED FIRST. When branch loops on itself, the alternative problems will not be mapped to charge codes w/ modifiers.
How To Handle This In MediLinks
MCCS: MediLinks Content Configuration Services
Identifying outcomes measures with scales than can be mapped to the 7 points scale
What would we do with this in ML?
How would we know which scales mapped to which functional area?
What if more than one scale was used?
Developing conversions to 7 point scales
Update website with mappings and coding guidance
Secondary Projects
Pick a standardized assessment for all patients (AM-PAC)
AM-PAC score and converted modifier scale can be auto-populated in to problem / goals branch.
Branch can use conditional response to map to proper charge code choice with proper modifier to remove therapist error.
This solution can only tolerate a predetermined use of one outcomes scale.
Alternate Configuration
Evaluation Branch Workflow
Select Primary Impairment
Select Primary Impairment
ModifierEnter Goal
Select Goal Modifier
Go to Additional Problem / Goals
Branches
Progress Summary Branch Workflow
Do you want to Update or DC Primary
Impairment
Select Primary
Impairment
Select Primary Impairment
Updated Modifier
Confirm / Update
Goal
Select Goal
Modifier
Enter Problem Update
Select Primary
Impairment
Enter Problem Update
Select Primary Impairment
Discharge Modifier
Confirm / Update
Goal
Select Goal
Modifier
Select whether Subsequent Functional Limitation needs
to be set
Update
Discharge
Subsequent
Select Subsequent Impairment
Select Subsequent Impairment
Modifier
Enter Goal
Select Goal
Modifier
Go to Additional Problem / Goals
Branches
Discharge Summary Branch Workflow
Select Primary or Subsequent
Impairment
Enter Problem Update
Select Primary Impairment
Discharge Modifier
Confirm / Update Goal
Select Goal Modifier
Go to Additional Problem / Goals
Branches
Operational Challenges?
Identify patients missing G-codes (How do we know they need them? How is Medicare defined?)
Identify when Subsequent impairments are created without Discharge scores for Primary impairment
Identify patients with impairment G-codes, but missing Goal Codes
Patients show are on their 10th visit today and needing G-codes. Report initially, future Task List or Appointment Alert?
Discharged Patients missing Discharge G-codes / Discharge Goal codes
Reports
Charge master by locationIs anyone configuring ‘duplicate’ charge definitions based on location?
Considerations
Final selection on solution proposals
Another webinar to demonstrate final content
Establish delivery timeframes
Next Steps
Thank You